Acute carpal tunnel syndrome due to a hemangioma of the median nerve

Hemangioma of the median nerve presenting as acute carpal tunnel syndrome is unusual A-18- year old male presented with severe incapacitating pain of sudden onset of left forearm and hand after manual field work. There was swelling on volar aspect of forearm, with hyperalgesia in the median nerve distribution. The fingers and wrist were inmarked flexion and the patient did not allow wrist and finger extension. X-rays were within normal limits. An emergency volar carpal ligament release revealed, haematoma about 100 ml with numerous vessels encircling the median nerve. Histopathology of lesion turned out to be a cavernous hemangioma. Post operatively patient had full recovery.

Hemangioma of the median nerve presenting as acute carpal tunnel syndrome is unusual A-18-year old male presented with severe incapacitating pain of sudden onset of left forearm and hand after manual field work. There was swelling on volar aspect of forearm, with hyperalgesia in the median nerve distribution. The fingers and wrist were inmarked flexion and the patient did not allow wrist and finger extension. X-rays were within normal limits. An emergency volar carpal ligament release revealed, haematoma about 100 ml with numerous vessels encircling the median nerve. Histopathology of lesion turned out to be a cavernous hemangioma. Post operatively patient had full recovery.
Acute Carpal tunnel syndrome, hemangioma, median nerve hronic carpal tunnel syndrome (CTS) is a unique entity in that it is the most common entrapment neuropathy encountered in neurosurgical practice. A thorough search of the literature has revealed that till now two cases of chronic CTS due to hemangioma involving the neurovascular structures in the wrist and forearm have been reported.
We are reporting here a case of hemangioma of the median nerve with a presentation of acute CTS.

CASE REPORT
In May 1996, a young manual laborer of 18 years presented with agonizing pain in his left forearm and hand for the past two days. Patient developed this pain after having exerted during manual fieldwork. Pain was sudden in onset, severe and incapacitating, not responding to normal. An MRI could not be performed as the facilities C analgesics. A diffuse, nonreducible swelling was present on the volar aspect of the forearm [ Figure 1]. No pulsations were present, local temperature was raised. Fingers and wrist were in marked flexion and the patient did not allow wrist and finger extension. There was hyperalgesia in the median nerve distribution. There was no wasting of the thenar muscles or history of paresthesias at night suggestive of a chronic cause. Regional lymph nodes were not enlarged. Routine investigations and chest X-ray were were not available at that time. Carpal pillars projection showed no bony abnormality. An emergency surgery was done under tourniquet and volar carpal ligament was released. Intraoperative findings showed hematoma about 100cc along with numerous vessels encircling the median nerve and intermingled within the substance of the median nerve. No definite plane of cleavage could be found and we were not able to resect the lesion and the mass was left inside after taking a microbiopsy.
Histopathology proved it to be a cavernous hemangioma. Postoperatively patient showed full recovery of functions with normal sensations although he had to change his job old woman. Our case differs from the others reported so congenitally small carpal canals. It occurs in middle-aged far in that the patient is an adolescent male who had an obese women. It is usually bilateral and may occur due to acute presentation of CTS and the mass was left in situ as increase in canal contents, decreased canal size, no plane of cleavage could be found. In our ten year followneuropathic inflammatory conditions and conditions due up he has had no recurrence of symptoms or thenar wasting to altered fluid balance. Hamartomas involving the till date although he had to change his profession from a peripheral nerves were first described in 1953 by Mason,1 manual worker to a vendor to avoid recurrence of mostly involving the median nerve in the forearm and wrist symptoms due to traumatic rupture of vessels in the and usually presenting as chronic CTS. Acute CTS may hemangioma. occur consecutive to hamate and triquetral fractures, 2 acute metacarpal osteomyelitis 3 compression by anomalous Whenever a patient presents with s/s of acute CTS the flexor digitorum superficialis, 4 after internal fixation of possibility of a hemangioma involving the median nerve secondary to pyogenic infections, 5 classical should be kept in mind in the differential diagnosis. Surgery hemophilia, 6 von Willebrand's disease 7 oral anticoagulant can be limited to decompression only if a plane of cleavage distal radial fractures, 9 filarial infections, 10 cannot be found. If symptoms recur or progress later, total thrombosed persistent median artery, 11 idiopathic tumoral resection and grafting may then be carried out, although calcinosis, 12 decompression sickness, 13 Hansen's disease, 14 the results are not satisfactory 22 peritendinitis calcarea, 15 pseudogout, 16 scaphoid pseudoarthroses. 17 Bilateral cases may occur due to human Tenosynovitis is not a part of the pathophysiological process of chronic CTS such as thenar wasting, trophic changes, night pain and paresthesias in median nerve distribution may not be present.
To the best of our knowledge only two cases of chronic CTS due to a hemangioma involving the neurovascular structures in the wrist and forearm have been reported. Although 44 cases of fibrolipomatous hamartomas involving peripheral nerves have been reported, nearly half of them by Silverman and Enzinger, 19 41 involved the median nerve, two in the ulnar nerve, 20 one in an unidentified nerve on the extensor surface of the proximal forearm and one in a case of macrodactyly. 21