Brain Advance Access originally published online on June 30, 2009
Brain 2009 132(8):2265-2276; doi:10.1093/brain/awp169
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Longitudinal study of intraneural perineurioma—a benign, focal hypertrophic neuropathy of youth
1 Department of Neurology, Mayo Clinic Rochester, MN 55905 USA 2 Department of Radiology, Mayo Clinic Rochester, MN 55905 USA 3 Department of Neurosurgery, Mayo Clinic Rochester, MN 55905 USA 4 Department of Neurology, Mayo Clinic Scottsdale, AZ 85259 USA
Correspondence to: P. James B. Dyck, MD, Mayo Clinic, Department of Neurology, 200 1st St. SW, Rochester, MN 55905, USA E-mail: dyck.pjames{at}mayo.edu
The natural history of intraneural perineurioma has been inadequately studied. The aim of this study was to characterize the clinical presentation, electrophysiologic and imaging features and outcome of intraneural perineurioma. We ask if intraneural perineurioma is a pure motor syndrome that remains confined to one nerve and should be treated by surgical resection. We examined the nerve biopsies of cases labelled perineurioma and selected those with diagnostic features. Thirty-two patients were identified; 16 children and 16 adults; 16 males and 16 females. Median age of onset of neurological symptoms was 14 years (range 0.5–55 years) and median age at evaluation was 17 years (range 2–56 years). All patients had motor deficits; however, mild sensory symptoms or signs were experienced by 27 patients; ‘prickling’ or ‘asleep numbness’ in 20, mild pain in 13 and sensory loss in 23. The sciatic nerve or its branches was most commonly affected in 15, followed by brachial plexus, radial nerve and ulnar nerve (four each). Magnetic resonance imaging demonstrated nerve enlargement (29/32), T1 isointensity (27/32), T2 hyperintensity (25/32) and contrast enhancement (20/20). Diagnoses were made based on targeted biopsy of the focal nerve enlargement identified by imaging. Neurological impairment was of a moderate severity (median Neuropathy Impairment Score was 12 points, range 2–49 points). All patients had focal involvement with 27 involving one nerve and five involving a plexus (one bilateral). Long-term follow-up was possible by telephone interview for 23 patients (median 36 months, range 2–177 months). Twelve patients also had follow-up neurologic evaluation (median 45 months, range 10–247 months). The median Neuropathy Impairment Score had changed from 12.6 to 15.4 points (P = 0.19). In all cases, the distribution of neurologic findings remained unchanged. Median Dyck Disability Score was 3 (range 2–5) indicating a mild impairment without interfering with activities of daily living. Ten patients judged their symptoms unchanged, nine slightly worse and four slightly better. We conclude intraneural perineurioma is a benign hypertrophic (non onion bulb) peripheral nerve tumour that presents insidiously in young people and is motor predominant with mild sensory involvement. It is most often a mononeuropathy, but a plexopathy can occur. Diagnosis of this condition requires clinical suspicion, imaging, targeted fascicular biopsy of the lesion and expertise of nerve pathologists. As these tumours are static or slowly progressive, remain confined to their original distribution and have low morbidity, they probably should not be resected routinely. Because intensive evaluation is needed for diagnosis, intraneural perineurioma is probably under-recognized.
Key Words: perineurioma; peripheral neuropathy; nerve sheath neoplasm; localized hypertrophic neuropathy; sciatic neuropathy
Abbreviations: CIDP, Chronic inflammatory demyelinating polyneuropathy; CSF, cerebrospinal fluid; DDS, Dyck disability score; EMA, epithelial membrane antigen; EMG, electromyography; IN, intraneural; IRB, institutional review board; MRI, magnetic resonance imaging; mRS, modified Rankin scale; NCS, nerve conduction studies; NIS, Neuropathy Impairment Score; NSC, Neuropathy Symptoms and Change; QST, quantitative sensory testing; SNAP, sensory nerve action potential
Received April 4, 2009. Revised May 5, 2009. Accepted May 18, 2009.