Dural-based Masses, Multiple



Dural-based Masses, Multiple


Miral D. Jhaveri, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Meningioma (Multiple Meningiomatosis)


  • Metastases, Meningeal


  • Subdural Hematomas, Chronic


Less Common



  • Neurosarcoid


  • Neurofibromatosis Type 2


  • Lymphoma, Metastatic, Intracranial


Rare but Important



  • Extramedullary Hematopoiesis


  • Langerhans Cell Histiocytosis


  • Erdheim-Chester Disease


  • Rosai-Dorfman Disease


  • Epidural Hematoma


  • Myeloma


  • Leukemia


  • Tuberculosis


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • > 95% multiple dural-based masses are either meningiomas or metastases


Helpful Clues for Common Diagnoses



  • Meningioma (Multiple Meningiomatosis)



    • 1-9% of imaged meningioma cases


    • Most occur in women


    • Can occur in absence of NF2


    • MRS: Characteristic alanine peak


  • Metastases, Meningeal



    • Skull often but not always infiltrated


    • Multifocal > solitary lesions


    • NECT, bone algorithm, for osseous evaluation


    • MR C+ if dural, scalp involved


    • Often known extracranial primary neoplasm



      • Prostate, breast, neuroblastoma


  • Subdural Hematomas, Chronic



    • Remote trauma history


    • NECT



      • Varying density


      • Fluid-fluid levels


      • Less common: Calcification of inner membranes


    • MR



      • T1 C+ thick, enhancing, dural membranes


      • ± Foci of old hemorrhage


Helpful Clues for Less Common Diagnoses



  • Neurosarcoid



    • Multifocal, dural-based foci


    • Presence of associated leptomeningeal enhancement additional clue


    • Other findings



      • Abnormal CXR


      • Increased erythrocyte sedimentation rate (ESR) & serum angiotensin converting enzyme (ACE)


  • Neurofibromatosis Type 2



    • Multiple inherited schwannomas, meningiomas, & ependymomas


    • Best diagnostic clue: Bilateral vestibular schwannomas


    • Schwannomas on cranial nerves and spinal nerve roots


    • Only 10% of patients with multiple meningiomas have NF2


  • Lymphoma, Metastatic, Intracranial



    • Multiple or solitary dural mass mimicking meningioma


    • 10-30% of patients with systemic lymphoma may develop secondary CNS involvement



      • Parenchymal > dural involvement


Helpful Clues for Rare Diagnoses



  • Extramedullary Hematopoiesis



    • Found in patients with chronic anemias or marrow depletion


    • Smooth homogeneous dural-based masses


    • Mimics subdural hematoma on NECT


    • Isointense with brain on T1WI, hypointense on T2WI


    • Enhances strongly, homogeneously


    • May show osseous findings of underlying disease


    • Confirm with Tc-99m-sulfur colloid scan


  • Langerhans Cell Histiocytosis



    • Well-defined lytic skull lesion with “beveled edges”


    • Associated dural & scalp soft tissue masses common


    • Patients often present with diabetes insipidus



      • Thick, enhancing infundibulum


      • Absent posterior pituitary bright spot


  • Erdheim-Chester Disease



    • Non-Langerhans type histiocytosis



    • Affects multiple organs (including long bones, skin, lung, soft tissue)


    • Histiocytic infiltration of long bone metaphyses



      • Manifests as sclerotic appearance on conventional radiographs


    • Dural mass lesions most common



      • Falx cerebri, tentorium, sella/parasellar regions


      • Biopsy essential for diagnosis


    • May involve brain parenchyma


  • Rosai-Dorfman Disease



    • Sinus histiocytosis with massive lymphadenopathy


    • Propensity to arise from the base of the skull, parasellar region, orbit


    • May resemble multiple meningiomatosis, sarcoid


    • CNS Rosai-Dorfman disease has definite male predominance


    • Dural-based, extra-axial enhancing masses most common finding


    • May infiltrate brain with striking perilesional cerebral edema


    • Biopsy essential for diagnosis


  • Epidural Hematoma



    • Trauma history


    • < 5% multiple/bilateral


    • NECT (acute phase)



      • Hyperdense biconvex extra-axial mass


      • 90-95% associated skull fracture


    • Does not cross sutures



      • May if sutural diastasis/fracture present


    • Can cross falx & tentorium


    • ± Underlying contusions of brain parenchyma


  • Myeloma



    • Dural-based masses with lytic skull lesions


    • Skeletal survey may be helpful


  • Leukemia



    • May present with or mimic hematoma


    • Homogeneously enhancing extra-axial tumor(s) in patient with known or suspected myeloproliferative disorder


  • Tuberculosis

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Aug 7, 2016 | Posted by in NEUROLOGY | Comments Off on Dural-based Masses, Multiple

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