Dural metastases

Changed by Rohit Sharma, 13 Sep 2018

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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 metastases include (in descending order of frequency) ^1,2:

Radiographic features

MRI

Dural metastases present as a focal mass, although there are typically multiple lesions.

Signal characteristics

include:

T1: typically iso/hypointense to adjacent cortex
T2: iso/hyperintense to adjacent cortex
T1 C+ (Gd): vivid enhancement ⁴
MR spectroscopy:
- increased choline/creatine ratio ⁵
- prominent lipid peak ⁵
- occasional lactate peak ⁵
- absence of NAA peak ⁵

Differential diagnosis

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

meningiomas: can look indistinguishable; dural based mass ~~with~~with "dural tail", hyperostosis and calcification; MRS: increased alanine peak and 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 with dural involvement; heterogeneously enhancing parenchymal mass.
~~leukemia~~leukaemia/myeloma
CNS tuberculosis: strong dural thickening and enhancement with basilar predominance; usually abnormal chest x-ray; more common endemic areas /and in immunocompromised patients
neurosarcoidosis: multifocal dural based masses; leptomeningeal enhancement; no skull involvement; abnormal chest x-ray and serum markers
chronic subdural haemorrhage: trauma history, fluid-fluid levels; varying density/intensity
extramedullary hematopoiesis: chronically anemic patients; smooth homogeneous dural based masses with strong homogeneous enhancement

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.

~~-<a href="/articles/glioblastoma">glioblastoma multiforme</a> (GBM) <sup>8</sup>~~
+<a href="/articles/glioblastoma">glioblastoma</a> <sup>8</sup>
~~-<a title="Renal cell carcinoma" href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a> <sup>10</sup>~~
+<a href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a> <sup>10</sup>
~~-</ul><h4>Radiographic features</h4><h5>MRI</h5><p>Dural metastases present as a focal mass, although there are typically multiple lesions.</p><h6>Signal characteristics</h6><ul>~~
+</ul><h4>Radiographic features</h4><h5>MRI</h5><p>Dural metastases present as a focal mass, although there are typically multiple lesions. Signal characteristics include:</p><ul>
-<a href="/articles/meningioma">meningiomas</a>: can look indistinguishable; dural based mass with "dural tail", hyperostosis and calcification; MRS: increased alanine peak and no lipid/lactate peak</li>
+<a href="/articles/meningioma">meningiomas</a>: can look indistinguishable; dural based mass with "dural tail", hyperostosis and calcification; MRS: increased alanine peak and no lipid/lactate peak</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>leukaemia/myeloma</li>
-<a href="/articles/tuberculosis-intracranial-manifestations">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/tuberculosis-intracranial-manifestations">CNS tuberculosis</a>: strong dural thickening and enhancement with basilar predominance; usually abnormal chest x-ray; more common endemic areas and in immunocompromised patients</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/neurosarcoidosis">neurosarcoidosis</a>: multifocal dural based masses; leptomeningeal enhancement; no skull involvement; abnormal chest x-ray and serum markers</li>

References changed:

4. David Schiff, Santosh Kesari, Patrick Y. Wen. Cancer Neurology in Clinical Practice. (2008) ISBN: 9781588299833 - <a href="http://books.google.com/books?vid=ISBN9781588299833">Google Books</a>
6. Kim H, Yi K, Kim W et al. Sequential Spinal and Intracranial Dural Metastases in Gastric Adenocarcinoma: A Case Report. WJG. 2018;24(5):651-6. <a href="https://doi.org/10.3748/wjg.v24.i5.651">doi:10.3748/wjg.v24.i5.651</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29434454">Pubmed</a>
7. Higuchi M, Fujimoto Y, Miyahara E, Ikeda H. Isolated Dural Metastasis from Colon Cancer. Clin Neurol Neurosurg. 1997;99(2):135-7. <a href="https://doi.org/10.1016/s0303-8467(97)80011-x">doi:10.1016/s0303-8467(97)80011-x</a>
8. Lettau M, Jedrusik P, Laible M. Dural Metastases of a Glioblastoma. Clin Neuroradiol. 2013;23(4):323-5. <a href="https://doi.org/10.1007/s00062-012-0192-8">doi:10.1007/s00062-012-0192-8</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23263292">Pubmed</a>
9. Tonomura S, Kitaichi T, Onishi R et al. A Dural Metastatic Small Cell Carcinoma of the Gallbladder as the First Manifestation: A Case Report. World J Surg Oncol. 2018;16(1):57. <a href="https://doi.org/10.1186/s12957-018-1356-z">doi:10.1186/s12957-018-1356-z</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29548338">Pubmed</a>
4. Cancer Neurology in Clinical Practice: Neurologic Complications of Cancer and Its Treatment. Humana Press. ISBN:158829983X. <a href="http://books.google.com/books?vid=ISBN158829983X">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/158829983X">Find it at Amazon</a><span class="auto"></span>
6. Sequential spinal and intracranial dural metastases in gastric adenocarcinoma: A case report. (2018) World Journal of Gastroenterology. 24 (5): 651. <a href="https://doi.org/10.3748/wjg.v24.i5.651">doi:10.3748/wjg.v24.i5.651</a> <span class="ref_v4"></span>
7. M.Higuchi, Y.Fujimoto, E.Miyahara, H.Ikeda Isolated dural metastasis from colon cancer. (1997) Clinical Neurology and Neurosurgery. 99 (2): 135. <a href="https://doi.org/10.1016/S0303-8467(97)80011-X">doi:10.1016/S0303-8467(97)80011-X</a> <span class="ref_v4"></span>
8. M. Lettau, P. Jedrusik, M. Laible. Dural Metastases of a Glioblastoma. (2013) Clinical Neuroradiology. 23 (4): 323. <a href="https://doi.org/10.1007/s00062-012-0192-8">doi:10.1007/s00062-012-0192-8</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23263292">Pubmed</a> <span class="ref_v4"></span>
9. S Tonomura, T Kitaichi, R Onishi, et al. A dural metastatic small cell carcinoma of the gallbladder as the first manifestation: a case report. (2018) World Journal of Surgical Oncology. 16 (1): 57. <a href="https://doi.org/10.1186/s12957-018-1356-z">doi:10.1186/s12957-018-1356-z</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29548338">Pubmed</a> <span class="ref_v4"></span>

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