Giant plexiform neurofibroma with hemorrhage in cranio-maxillofacial region as depicted on CT and MRI
© I. Holzapfel Publishers 2010
Received: 9 September 2009
Accepted: 5 January 2010
Published: 26 February 2010
Plexiform neurofibroma (PN) is a rare benign tumor and a special subtype of neurofibromatosis type 1 (NF1). Though the incidence is low, giant PN of the craniomaxillofacial region could result in severe hemifacial hypertrophy which is known as a typical manifestation of NF1 in young children. Here, we retrospectively reported a giant plexiform neurofibroma with hemorrhage in the cranio-maxillofacial region detected by CT and MRI. In addition, a brief review of the relevant literature is presented.
KeywordsPlexiform neurofibroma Hemorrhage CT MR
Neurofibromatosis is an autosomal dominant phakomatoses or neurocutaneous syndrome. Two distinct types of neurofibromatosis including neurofibromatosis type 1 (NF1) and neurofibromatosis type 2 (NF2) have been recognized according to the different clinical manifestations and genetic mutation. Plexiform neurofibroma (PN), a special subtype of NF1, is a rare, slow-growing benign tumor . Although previous study presented one case with PN in the craniomaxillofacial region, the entity with hemorrhage in this region on CT and MRI has not been described . We report here the radiological findings of a giant hemorraghic PN in the cranio-maxillofacial region to illustrate the usefulness of CT or MRI in making diagnosis.
A 21-year-old man presented with a mass on the right side of his face for 16 years, which had initially appeared as a small cutaneous protuberance with a size of 2 cm in diameter in the right zygomatic arch region. The mass gradually enlarged and involved the right scalp, eye and face, and the color turned darker and darker with time. No treatments were administered in the history. Nine days before admission, the lesion grew abruptly, which resulted in cosmetic impairment of right face accompanied by severe headache, and the proptosis of the right eye and loss of eyesight. No other first-degree relatives in his family were noted NF1 besides his grandmother with neurofibroma alongside of left eye.
NF1 is the most common type of neurofibromatosis and usually presented with involvement of bone, nervous system, soft tissues and skin . The mutated gene for NF1 has been located to chromosome 17q11.2 . PN is a special subtype of NF1 usually presented in childhood and 50% individuals have a positive family history as in the present case. Malformation is a common feature due to invasive growth of the tumor, with hyper-pigmentation of the overlying involved skin. In the present case, PN which arises from cranio-maxillofacial region may involve the five sensory organs malformation is observed as well as a dysplastic cranium. The rapid increase of the PN size due to subacute hemorrhage within the tumor caused the loss of eyesight is extremely rare in our report .
PN arises mainly from the peripheral nerves and represents a neoplasia of the nerve trunk or peripheral nerves and their nerve endings. The tumor consists of neuronal axons, Schwann cells, fibroblasts and peripheral nerves with mucinous degeneration are predominant manifestations under electron microscope. Hyperplasia of Schwann cells is more common with the typical network-like growth . PN consists of a proliferation of cells in the nerve sheath extending across the length of a nerve without a capsule and involving adjacent tissues . Treatment of giant PN is typically surgical and complete resection is often difficult due to the extensive growth of the tumor and residual apartment may develop malignant change .
Non-enhanced CT scan demonstrated a giant heterogeneous attenuation mass with extensive involvement of both the superficial and deep tissue within cranio-maxillofacial region. Hyper attenuation areas on CT were compatible with hemorrhage. MRI displayed a heterogeneously hypo-intense to iso-intense mass on T1-weighted MRI which was hyper-intense on T2-weighted images compatible with a cyst-like appearance with subacute hemorrhage and mucinous degeneration. Heterogeneous enhancement suggests multiple components along with abnormal vessels involving the neurovascular bundle [9, 10].
Both CT and MRI can disclose the internal features of the tumor and the invasion of the surrounding tissues. In addition, the entire lesion can be clearly displayed in multiple planes using MRI and three-dimensional CT. SSD can reconstruct the profile of PN. MRI can effectively disclose the composition of the various soft tissues and the components of subacute hematoma such as hemosiderin. T2-weighted MRI has an advantage in differential diagnosis over CT .
In summary, we report a case of giant PN with hemorrhage in right cranio-maxillofacial region and its appearances on CT and MRI. The images can display the internal features of the mass, and relationship between the three-dimensional structure of the lesion and the neighboring structures. All findings could shed a light on the future surgical resection.
- Overdiek A, Feifel H, Schaper J, Mayatepek E, Rosenbaum T: Diagnostic delay of NF1 in hemifacial hypertrophy due to plexiform neurofibromas. No To Hattasu (Brain and Development) 2006,28(5):275–280.Google Scholar
- Wise JB, Patel SG, Shah JP: Management issues in massive pediatric facial plexiform neurofibroma with neurofibromatosis type 1. Head Neck 2002, 24: 207–211. 10.1002/hed.10001PubMedView ArticleGoogle Scholar
- Hersh JH: Health supervision for children with neurofibromatosis. Pediatrics 2008, 21: 633–642.View ArticleGoogle Scholar
- Cre'ange A, Zeller J, Rostaing-Rigattieri S, Brugie'res P, Degos JD, Revuz J, et al.: Neurological complications of neurofibromatosis type 1 in adulthood. Brain 1999, 122: 473–481. 10.1093/brain/122.3.473View ArticleGoogle Scholar
- Malagari K, Drakopoulos S, Brountzos E, Sissopulos A, Efthimidadou A, Hadjiyiannakis E, et al.: Plexiform neurofibroma of the liver: findings on MR imaging, angiography, and CT portography. AJR 2001, 176: 493–495.PubMedView ArticleGoogle Scholar
- Waggoner DJ, Towbin J, Gottesman G, Gutmann DH: Clinic-based study of plexiform neurofibromas in neurofibromatosis I. Am J Med Genet 2001, 9: 132–135.Google Scholar
- Aribandi M, Wood WE, Elston DM, Weiss DL: CT features of plexiform neurofibroma of the submandibular gland. AJNR 2006, 27: 126–128.PubMedGoogle Scholar
- Valeyrie-Allanore L, Ismaïli , Bastuji-Garin N, Zeller J, Wechsler J, Revuz J, et al.: Symptoms associated with malignancy of peripheral nerve sheath tumours: a retrospective study of 69 patients with neurofibromatosis 1. Br J Dermatol 2005, 153: 79–82. 10.1111/j.1365-2133.2005.06558.xPubMedView ArticleGoogle Scholar
- Lin J, Martel W: Cross-sectional imaging of peripheral nerve sheath tumors: characteristic signs on CT, MR imaging, and sonography. AJR 2001, 176: 75–82.PubMedView ArticleGoogle Scholar
- Bourgeois JM, Radhi J, Elden L, et al.: Plexiform neurofibroma of the submandibular salivary gland in a child. Can J Gastroenterol 2001, 15: 835–837.PubMedGoogle Scholar
- Fortman BJ, Kuszyk BS, Urban BA, Fishman EK: Neurofibromatosis type 1: a diagnostic mimicker at CT. Radiographics 2001, 21: 601–612.PubMedView ArticleGoogle Scholar