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Sciatic Nerve Intraneural Hematoma
Clinical Images
Sciatic Nerve Intraneural Hematoma Hussam Abou-Al-Shaar1 and Mark A. Mahan2
Key words Hemorrhage - Intraneural hematoma - Sciatic nerve -
From the 1Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York; and 2Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA To whom correspondence should be addressed: Mark A. Mahan, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 129:170-171. https://doi.org/10.1016/j.wneu.2019.05.256 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
Intraneural hematomas are an uncommon cause of a focal mononeuropathy. When they do occur, it is usually in the setting of inherited or iatrogenic coagulopathies or as a consequence of injections targeting nerves. We report a man aged 68 years on warfarin therapy for a prior pulmonary embolism who presented with a 6-month history of progressive weakness of knee flexion and ankle movement, excruciating pain, and dense numbness in his posterior left thigh and below the knee, consistent with a severe high sciatic palsy. Imaging depicted a contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve in the thigh, which was radiologically interpreted as a hip arthroplasty-associated pseudotumor. The patient underwent surgical exploration, which revealed a thick hemorrhagic pseudocompartment within the sciatic nerve. The histopathologic diagnosis was consistent with chronic hemorrhage. These impressive lesions should be included in the differential diagnosis of nerve masses.
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION A man aged 68 years on warfarin therapy for a prior pulmonary embolism presented to the neurosurgery clinic with a vague 6month history of progressive weakness, excruciating pain, and dense numbness in
his posterior left thigh and below the knee. His prior medical history was notable for bilateral total hip arthroplasties 5 years previously and numerous piriformis-region injections. Initial neurologic examination demonstrated a severe high sciatic palsy, with weakness of left knee flexion and ankle
Figure 1. (A,B) Magnetic resonance imaging depicting a contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve. Axial T2-weighted fat-saturated image (A) demonstrates an ovoid mass with apparent fascicles on the anterior/deep surface of the mass (thin arrow), with similar appearance on coronal T2-weighted fat-saturated image (B) with hyperintensity within the mass suggestive of late subacute
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dorsi- and plantar-flexion. Magnetic resonance imaging depicted a 23-cm contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve in the thigh, with the appearance of hemosiderosis or metallosis and possible origin from the acetabular component of the left hip
hematoma (open arrow) and adjacent tissue edema (solid grey arrow). (C) Thick hemorrhagic pseudocompartment was evident within the sciatic nerve intraoperatively. Branches to the hamstring muscles were identified and marked with vessel loops. (Reproduced with permission from the Department of Neurosurgery, University of Utah.)
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.256
CLINICAL IMAGES HUSSAM ABOU-AL-SHAAR AND MARK A. MAHAN
prosthesis, interpreted as consistent with hip arthroplasty pseudotumor (Figure 1A,B). During surgical exploration for decompression to reduce pain and facilitate potential neurologic recovery, a thick hemorrhagic pseudocompartment was found within the sciatic nerve (Figure 1C), with blood of various ages extending from the ischial tuberosity to the knee. Histopathological examination revealed the contents of the mass were hemorrhage and fibrin, with the cyst wall demonstrating dense fibrous tissue, pigment-laden macrophages, multinucle-
SCIATIC NERVE INTRANEURAL HEMATOMA
ated giant cells, and lymphohistiocytic inflammation. The histologic diagnosis was consistent with chronic hemorrhage, not an inflammatory pseudotumor. Intraneural hematomas are uncommon but have occurred in the setting of inherited or iatrogenic coagulopathies, especially in the setting of injections targeting nerves. The patient continued to have sympathetic mediated vasodilation of the distal lower extremity, neuropathic pain, and impoverished recovery of foot plantar flexion at 4-year follow-up.
WORLD NEUROSURGERY 129: 170-171, SEPTEMBER 2019
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 April 2019; accepted 30 May 2019 Citation: World Neurosurg. (2019) 129:170-171. https://doi.org/10.1016/j.wneu.2019.05.256 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
171
Sciatic Nerve Intraneural Hematoma Hussam Abou-Al-Shaar1 and Mark A. Mahan2
Key words Hemorrhage - Intraneural hematoma - Sciatic nerve -
From the 1Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York; and 2Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA To whom correspondence should be addressed: Mark A. Mahan, M.D. [E-mail: [email protected]] Citation: World Neurosurg. (2019) 129:170-171. https://doi.org/10.1016/j.wneu.2019.05.256 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com
Intraneural hematomas are an uncommon cause of a focal mononeuropathy. When they do occur, it is usually in the setting of inherited or iatrogenic coagulopathies or as a consequence of injections targeting nerves. We report a man aged 68 years on warfarin therapy for a prior pulmonary embolism who presented with a 6-month history of progressive weakness of knee flexion and ankle movement, excruciating pain, and dense numbness in his posterior left thigh and below the knee, consistent with a severe high sciatic palsy. Imaging depicted a contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve in the thigh, which was radiologically interpreted as a hip arthroplasty-associated pseudotumor. The patient underwent surgical exploration, which revealed a thick hemorrhagic pseudocompartment within the sciatic nerve. The histopathologic diagnosis was consistent with chronic hemorrhage. These impressive lesions should be included in the differential diagnosis of nerve masses.
1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
INTRODUCTION A man aged 68 years on warfarin therapy for a prior pulmonary embolism presented to the neurosurgery clinic with a vague 6month history of progressive weakness, excruciating pain, and dense numbness in
his posterior left thigh and below the knee. His prior medical history was notable for bilateral total hip arthroplasties 5 years previously and numerous piriformis-region injections. Initial neurologic examination demonstrated a severe high sciatic palsy, with weakness of left knee flexion and ankle
Figure 1. (A,B) Magnetic resonance imaging depicting a contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve. Axial T2-weighted fat-saturated image (A) demonstrates an ovoid mass with apparent fascicles on the anterior/deep surface of the mass (thin arrow), with similar appearance on coronal T2-weighted fat-saturated image (B) with hyperintensity within the mass suggestive of late subacute
170
www.SCIENCEDIRECT.com
dorsi- and plantar-flexion. Magnetic resonance imaging depicted a 23-cm contiguous cystic mass of mixed T1 and T2 intensities involving the left sciatic nerve in the thigh, with the appearance of hemosiderosis or metallosis and possible origin from the acetabular component of the left hip
hematoma (open arrow) and adjacent tissue edema (solid grey arrow). (C) Thick hemorrhagic pseudocompartment was evident within the sciatic nerve intraoperatively. Branches to the hamstring muscles were identified and marked with vessel loops. (Reproduced with permission from the Department of Neurosurgery, University of Utah.)
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2019.05.256
CLINICAL IMAGES HUSSAM ABOU-AL-SHAAR AND MARK A. MAHAN
prosthesis, interpreted as consistent with hip arthroplasty pseudotumor (Figure 1A,B). During surgical exploration for decompression to reduce pain and facilitate potential neurologic recovery, a thick hemorrhagic pseudocompartment was found within the sciatic nerve (Figure 1C), with blood of various ages extending from the ischial tuberosity to the knee. Histopathological examination revealed the contents of the mass were hemorrhage and fibrin, with the cyst wall demonstrating dense fibrous tissue, pigment-laden macrophages, multinucle-
SCIATIC NERVE INTRANEURAL HEMATOMA
ated giant cells, and lymphohistiocytic inflammation. The histologic diagnosis was consistent with chronic hemorrhage, not an inflammatory pseudotumor. Intraneural hematomas are uncommon but have occurred in the setting of inherited or iatrogenic coagulopathies, especially in the setting of injections targeting nerves. The patient continued to have sympathetic mediated vasodilation of the distal lower extremity, neuropathic pain, and impoverished recovery of foot plantar flexion at 4-year follow-up.
WORLD NEUROSURGERY 129: 170-171, SEPTEMBER 2019
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 2 April 2019; accepted 30 May 2019 Citation: World Neurosurg. (2019) 129:170-171. https://doi.org/10.1016/j.wneu.2019.05.256 Journal homepage: www.journals.elsevier.com/worldneurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved.
www.journals.elsevier.com/world-neurosurgery
171