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Clinical Problem Solving: Radiology
October 2005

Radiology Quiz Case 4: Diagnosis

Author Affiliations
 

R. NICKBRYANMDPATRICIA A.HUDGINSMD

Arch Otolaryngol Head Neck Surg. 2005;131(10):928. doi:10.1001/archotol.131.10.928

Verocay1 is credited with first describing a nerve tumor as a special entity in 1910. The schwannoma arises from schwann cells, as does the neurofibroma.2 Typically, 25% to 45% of all extracranial schwannomas occur in the head and neck region.3 The reported sites of origin of cervical schwannomas are cranial nerves IX to XII, the cervical plexus, the sympathetic chain, and the brachial plexus. Primary tumors of the brachial plexus are unusual. In 1987, Lusk et al4 reviewed 147 cases that had been published since 1886. Symptoms of numbness, paresthesia, and shooting pain radiating into the upper extremity on palpation are characteristic of the benign neural tumors of the brachial plexus, as in our case. The diagnosis can be suggested by the results of fine-needle aspiration before definitive surgical treatment is undertaken, also as in this case. Fine-needle aspiration of the lesions can cause shooting pain or paresthesia that radiates into one of the upper extremities, a reaction that strongly suggests the diagnosis of brachial plexus schwannoma. Computed tomography usually shows that the lesion is isodense to the surrounding scalene musculature. Magnetic resonance imaging has a real advantage because of improved contrast between soft tissue structures. Schwannomas are visible as well-delineated masses with a low signal intensity on T1-weighted MRIs, a very high signal intensity on T2-weighted MRIs, and strong peripheral enhancement on postcontrast MRIs.5

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