Showing MRI images of an 82-year-old woman with partial motor seizures afecting her face.
3. Multiple myeloma
4. None of the above
T1W MR image shows a right dural-based, extra-axial, frontoparietal mass (red arrows) and intraparenchymal edema (green asterisk) on FLAIR sequence. The mass enhances markedly on T1W gadolinium-enhanced imaging and shows a dural tail (yellow arrows) There is thickening of the inner table wall (white arrow).
Conclusion: Extra-axial homogenous enhancing mass with associated thickening of the inner table wall, medial displacement of the cortex, and dural enhancement
Final diagnosis: WHO Grade II Meningioma
The differential diagnosis of extra-axial cranial masses should include meningiomas, metastatic tumors, multiple myeloma, lymphoma, chloroma, Rosai-Dorfman disease, and sarcoidosis.
Meningiomas are the most common nonglial primary tumors of the central nervous system and the most common extra-axial neoplasms, accounting for approximately 15% of all intracranial tumors.
The typical meningioma is a homogeneous, hemispheric, markedly enhancing extra-axial mass. The dural tail sign on gadolinium MR images refers to a thickening of the enhanced dura that simulates a tail extending from the mass. It appears in 60-72% of meningiomas, but it can also be seen in other dural-based masses (lymphoma, metastasis, chloroma, sarcoidosis, plasmacytoma, neurinoma). Meningiomas may be associated with hyperostosis.
71-year-old woman with multiple myeloma who presents with ataxia.
MR images show a left extra-axial mass with intermediate signal on T1W and FLAIR images, and homogeneous increased signal on gadolinium-enhanced images (blue arrows). T1W images show focal low signal intensity of the infiltrated bone marrow adjacent to the mass (yellow arrows)
72-year-old man diagnosed of squamous cell lung carcinoma with right hemiparesis.
MR images show a left frontal extra-axial, dural-based mass (green arrows), with intermediate signal on T1W and FLAIR sequences, homogeneous enhancement on gadolinium-enhanced images, and linear dural enhancement (orange arrows). Adjacent intraparenchymal edema is better demonstrated on FLAIR images as an area of increased signal (asterisk).
Follow Dr. Pepe’s advice:
- Meningiomas are the most common extra-axial neoplasms.
- Typical meningiomas present as markedly enhancing extra-axial masses. The dural tail sign, although non-specific, is found in 60% of them.
- Differential diagnosis should include metastatic tumors, multiple myeloma, lymphoma, chloroma, Rosai-Dorfman disease, and sarcoidosis.
1-Patterns of Contrast Enhancement in the Brain and Meninges. RadioGraphics 2007; 27:525–551.
2-Magnetic resonance imaging of meningiomas.Semin Ultrasound CT MR. 1992 Jun;13(3):154-69.
Case presented by Laura Oleaga, MD