Dural metastases

Changed by Henry Knipe, 17 Jun 2016

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Dural or pachymeningeal metastases are a relatively common cause of dural masses, although they are less common than brain metastases and meningiomas. They can occur both within the spine and intracranially - this article is focussed on intracranial dural masses.

Clinical presentation

Patients may present with headache, fatigue, confusion and focal neurology such as contralateral motor and sensory changes or cranial nerve involvement ⁴. A significant number (~20%) may be clinically occult.

Pathology

There are four mechanisms by which intracranial dural metastases are thought to occur ²:

direct extension from skull metastases
retrograde seeding through the vertebral venous plexus
haematogenous seeding
lymphatic seeding

The primary malignancies that frequently cause dural metatases include (in descending order of frequency) ^1,2:

breast cancer
prostate cancer
lung cancer
head and neck cancers
haematological cancers
neuroblastoma

Radiographic features

MRI

Dural metastases may be diffuse or present as a focal mass. Typically multiple lesions. ~~Typical signal~~

Signal characteristics:

T1: typically iso/hypointense to adjacent cortex
T2: iso/hyperintense to adjacent cortex
T1C+: vivid enhancement ⁴
MRS
- choline/creatine ratio ⁵
- prominent lipid peak ⁵
- occasional lactate peak ⁵

Differential diagnosis

When mass like the differential diagnosis is essentially that of other dural masses particularly:

meningiomas: can look indistinguishable~~. dural~~; dural based mass with "dural tail"~~. hyperostosis~~, hyperostosis and ~~Calcification.~~calcification; MRS: increased alanine~~↑ and~~ peakand no lipid/lactate. peak
haemangiopericytoma: can look identical.; often has prominent T2 flow voids
CNS lymphoma dural involvement: diffusely enhancing dural mass, often multifocal, T2 low signal due to hypercellularity, no calvarial invasion.
gliosarcoma: rare~~. often~~; often with dural involvement~~. heterogeneously~~; heterogeneously enhancing parenchymal mass.
leukemia/myeloma.
CNS tuberculosis: strong ~~meningeal~~dural thickening and enhancement with basilar predominance~~, dural thickening. abnormail CXR, lab.~~; usually abnormal chest x-ray; more common endemic areas~~/immuncompromised~~ / immunocompromised patients
neurosarcoidosis: ~~sometimes:~~ multifocal dural based masses.; leptomeningeal enhancement~~. no~~; no skull involvement~~. abnormal CXR, lab (ACE,ESR, skin test).~~; abnormal chest x-ray and serum markers
chronic subdural ~~hemmorhage~~haemorrhage: trauma history, fluid-fluid levels~~. varying~~; varying density./intensity
extramedullary hematopoiesis: ~~chronic~~chronically anemic patients~~. smooth~~; smooth homogeneous dural based masses with strong homogeneous enhancement~~. T1 isointense with brain and T2↓. strong homogeneous enhancement. Tc-99m-sulfur colloid scan positive. ± underlying disease osseous findings~~

When more diffuse the differential also includes other causes of dural enhancement, and sometimes if thin or irregular, it may be difficult to distinguish pachymeningeal metastases from leptomeningeal metastases or other leptomeningeal processes.

~~-</ul><h4>Radiographic features</h4><h5>MRI</h5><p>Dural metastases may be diffuse or present as a focal mass. Typically multiple lesions. Typical signal characteristics:</p><ul>~~
+</ul><h4>Radiographic features</h4><h5>MRI</h5><p>Dural metastases may be diffuse or present as a focal mass. Typically multiple lesions.</p><h6>Signal characteristics</h6><ul>
~~-<a href="/articles/meningioma">meningiomas</a>: can look indistinguishable. dural based mass "dural tail". hyperostosis and Calcification. MRS: alanine↑ and no lipid/lactate.</li>~~
+<a href="/articles/meningioma">meningiomas</a>: can look indistinguishable; dural based mass with "dural tail", hyperostosis and calcification; MRS: increased alanine peakand no lipid/lactate peak</li>
~~-<a href="/articles/haemangiopericytoma-1">haemangiopericytoma</a>: can look identical. often has prominent flow voids</li>~~
+<a href="/articles/haemangiopericytoma-1">haemangiopericytoma</a>: can look identical; often has prominent T2 flow voids</li>
~~-<a href="/articles/secondary-cns-lymphoma">CNS lymphoma</a> dural involvement: diffusely enhancing dural mass, often multifocal, T2 low signal due to hypercellularity, no calvarial invasion.</li>~~
+<a href="/articles/secondary-cns-lymphoma">CNS lymphoma</a> dural involvement: diffusely enhancing dural mass, often multifocal, T2 low signal due to hypercellularity, no calvarial invasion</li>
~~-<a href="/articles/gliosarcoma">gliosarcoma</a>: rare. often with dural involvement. heterogeneously enhancing parenchymal mass.</li>~~
~~-<li>leukemia/myeloma.</li>~~
+<a href="/articles/gliosarcoma">gliosarcoma</a>: rare; often with dural involvement; heterogeneously enhancing parenchymal mass.</li>
+<li>leukemia/myeloma</li>
-<a href="/articles/tuberculosis-of-the-central-nervous-system-1">CNS tuberculosis</a>: strong meningeal enhancement with basilar predominance, dural thickening. abnormail CXR, lab. endemic areas/immuncompromised</li>
+<a href="/articles/tuberculosis-of-the-central-nervous-system-1">CNS tuberculosis</a>: strong dural thickening and enhancement with basilar predominance; usually abnormal chest x-ray; more common endemic areas / immunocompromised patients</li>
~~-<a href="/articles/neurosarcoidosis">neurosarcoidosis</a>: sometimes: multifocal dural based masses. leptomeningeal enhancement. no skull involvement. abnormal CXR, lab (ACE,ESR, skin test).</li>~~
+<a href="/articles/neurosarcoidosis">neurosarcoidosis</a>: multifocal dural based masses; leptomeningeal enhancement; no skull involvement; abnormal chest x-ray and serum markers</li>
~~-<a href="/articles/subdural-haemorrhage">chronic subdural hemmorhage</a>: trauma history, fluid-fluid levels. varying density.</li>~~
+<a href="/articles/subdural-haemorrhage">chronic subdural haemorrhage</a>: trauma history, fluid-fluid levels; varying density/intensity</li>
-<a href="/articles/extramedullary-haematopoiesis">extramedullary hematopoiesis</a>: chronic anemic patients. smooth homogeneous dural based masses with strong homogeneous enhancement. T1 isointense with brain and T2↓. strong homogeneous enhancement. Tc-99m-sulfur colloid scan positive. ± underlying disease osseous findings </li>
+<a href="/articles/extramedullary-haematopoiesis">extramedullary hematopoiesis</a>: chronically anemic patients; smooth homogeneous dural based masses with strong homogeneous enhancement</li>

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