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Dural metastases

Changed by Martin Bundi Rugendo, 2 Feb 2024
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Disclosures - updated 25 Jan 2024: Nothing to disclose

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Dural metastases, also known as pachymeningeal metastases, are a relatively common cause of dural masses, although they are less common than brain metastases and and meningiomas. They can occur both within the spine and intracranially - this article is focused 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 of dural metastases (~20%) may be clinically occult.

Pathology

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

The primary malignancies that may 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 particularly:

  • meningiomas: can can look indistinguishable; dural dural based mass with "dural tail", hyperostosis hyperostosis and calcification; MRS MRS: increased alanine peak and no lipid/lactate peak

  • haemangiopericytoma: can can look identical; often often has prominent T2 flow voids

  • CNS lymphoma dural dural involvement: diffusely enhancing dural mass, often multifocal, T2 T2 low signal due to hypercellularity, no calvarial invasion

  • gliosarcoma: rare; often often with dural involvement; heterogeneously heterogeneously enhancing parenchymal mass

  • leukaemia/myeloma

  • CNS tuberculosis: strong strong dural thickening and enhancement with basilar predominance; usually abnormal chest x-ray; more common endemic areas and in immunocompromised patients

  • neurosarcoidosis: multifocal multifocal dural based masses; leptomeningeal leptomeningeal enhancement; no no skull involvement; abnormal abnormal chest x-ray and serum markers

  • chronic subdural haemorrhage: trauma history, fluid-fluid levels; varying varying density/intensity

  • extramedullary haematopoiesis: chronically anaemic patients; smooth 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 or other leptomeningeal processes.

  • -<p><strong>Dural</strong> <strong>metastases</strong>, also known as <strong>pachymeningeal metastases</strong>, are a relatively common cause of <a href="/articles/dural-masses">dural masses</a>, although they are less common than <a href="/articles/brain-metastases">brain metastases</a> and <a href="/articles/meningioma">meningiomas</a>. They can occur both within the spine and intracranially - this article is focused on intracranial dural masses. </p><h4>Clinical presentation</h4><p>Patients may present with headache, fatigue, confusion and focal neurology such as contralateral motor and sensory changes or cranial nerve involvement <sup>4</sup>. A significant number of dural metastases (~20%) may be clinically occult. </p><h4>Pathology</h4><p>There are four mechanisms by which intracranial dural metastases are thought to occur <sup>2</sup>:</p><ul>
  • -<li><p>direct extension from <a href="/articles/skull-metastases">skull metastases</a></p></li>
  • -<li><p>retrograde seeding through the <a href="/articles/vertebral-venous-plexus-1">vertebral venous plexus</a></p></li>
  • -<li><p>haematogenous seeding</p></li>
  • -<li><p>lymphatic seeding</p></li>
  • -</ul><p>The primary malignancies that may cause dural metastases include (in descending order of frequency) <sup>1,2</sup>:</p><ul>
  • -<li><p><a href="/articles/breast-cancer">breast cancer</a></p></li>
  • -<li><p><a href="/articles/prostate-cancer-3">prostate cancer</a></p></li>
  • -<li><p><a href="/articles/lung-cancer-3">lung cancer</a></p></li>
  • -<li><p>head and neck cancers</p></li>
  • -<li><p>haematological cancers</p></li>
  • -<li><p><a href="/articles/neuroblastoma">neuroblastoma</a></p></li>
  • -<li><p><a href="/articles/gastric-adenocarcinoma">gastric adenocarcinoma </a><sup>6</sup></p></li>
  • -<li><p><a href="/articles/colorectal-cancer-1">colon cancer</a> <sup>7</sup></p></li>
  • -<li><p><a href="/articles/glioblastoma-idh-wildtype">glioblastoma</a> <sup>8</sup></p></li>
  • -<li><p><a href="/articles/gallbladder-carcinoma-1">carcinoma of the gallbladder</a> <sup>9</sup></p></li>
  • -<li><p><a href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a> <sup>10</sup></p></li>
  • -<li><p><a href="/articles/ewing-sarcoma">Ewing sarcoma</a> <sup>11</sup></p></li>
  • -<li><p><a href="/articles/uterine-leiomyosarcoma">uterine leiomyosarcoma </a>(very rare) <sup>13</sup></p></li>
  • -<li><p><a href="/articles/squamous-cell-carcinoma-of-the-cervix">squamous cell carcinoma of the uterine cervix</a> <sup>14</sup></p></li>
  • -<li><p><a href="/articles/pancreatic-neoplasms">pancreatic cancer</a> <sup>15</sup></p></li>
  • -<li><p><a href="/articles/esophageal-squamous-cell-carcinoma">oesophageal squamous cell carcinoma</a> (very rare) <sup>12</sup></p></li>
  • -<li><p><a href="/articles/carcinoid-tumour-2">malignant carcinoid tumour</a> (rare) <sup>16</sup></p></li>
  • -</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>
  • -<li><p><strong>T1:</strong> typically iso/hypointense to adjacent cortex</p></li>
  • -<li><p><strong>T2:</strong> iso/hyperintense to adjacent cortex</p></li>
  • -<li><p><strong>T1 C+ (Gd):</strong> vivid enhancement <sup>4</sup></p></li>
  • -<li>
  • -<p><strong>MR spectroscopy:</strong></p>
  • -<ul>
  • -<li><p>increased choline/creatine ratio <sup>5</sup></p></li>
  • -<li><p>prominent lipid peak <sup>5</sup></p></li>
  • -<li><p>occasional lactate peak <sup>5</sup></p></li>
  • -<li><p>absence of NAA peak <sup>5</sup></p></li>
  • -</ul>
  • -</li>
  • -</ul><h4>Differential diagnosis</h4><p>When mass like the differential diagnosis is essentially that of other <a href="/articles/dural-masses">dural masses</a> particularly:</p><ul>
  • -<li><p><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</p></li>
  • -<li><p><a href="/articles/haemangiopericytoma-historical">haemangiopericytoma</a>: can look identical; often has prominent T2 flow voids</p></li>
  • -<li><p><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</p></li>
  • -<li><p><a href="/articles/gliosarcoma">gliosarcoma</a>: rare; often with dural involvement; heterogeneously enhancing parenchymal mass</p></li>
  • -<li><p><a href="/articles/leukaemia" title="Leukaemia">leukaemia</a>/<a href="/articles/multiple-myeloma-1" title="Multiple myeloma">myeloma</a></p></li>
  • -<li><p><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</p></li>
  • -<li><p><a href="/articles/neurosarcoidosis">neurosarcoidosis</a>: multifocal dural based masses; leptomeningeal enhancement; no skull involvement; abnormal chest x-ray and serum markers</p></li>
  • -<li><p><a href="/articles/subdural-haemorrhage">chronic subdural haemorrhage</a>: trauma history, fluid-fluid levels; varying density/intensity</p></li>
  • -<li><p><a href="/articles/extramedullary-haematopoiesis">extramedullary haematopoiesis</a>: chronically anaemic patients; smooth homogeneous dural based masses with strong homogeneous enhancement</p></li>
  • -</ul><p>When more diffuse the differential also includes other causes of <a href="/articles/pachymeningeal-enhancement-1">dural enhancement</a>, and sometimes if thin or irregular, it may be difficult to distinguish pachymeningeal metastases from <a href="/articles/leptomeningeal-metastases">leptomeningeal metastases</a> or other leptomeningeal processes. </p>
  • +<p><strong>Dural</strong> <strong>metastases</strong>, also known as <strong>pachymeningeal metastases</strong>, are a relatively common cause of <a href="/articles/dural-masses">dural masses</a>, although they are less common than <a href="/articles/brain-metastases">brain metastases</a>&nbsp;and <a href="/articles/meningioma">meningiomas</a>. They can occur both within the spine and intracranially - this article is focused on intracranial dural masses.&nbsp;</p><h4>Clinical presentation</h4><p>Patients may present with headache, fatigue, confusion and focal neurology such as contralateral motor and sensory changes or cranial nerve involvement <sup>4</sup>. A significant number of dural metastases (~20%) may be clinically occult.&nbsp;</p><h4>Pathology</h4><p>There are four mechanisms by which intracranial dural metastases are thought to occur <sup>2</sup>:</p><ul>
  • +<li><p>direct extension from <a href="/articles/skull-metastases">skull metastases</a></p></li>
  • +<li><p>retrograde seeding through the <a href="/articles/vertebral-venous-plexus-1">vertebral venous plexus</a></p></li>
  • +<li><p>haematogenous seeding</p></li>
  • +<li><p>lymphatic seeding</p></li>
  • +</ul><p>The primary malignancies that may cause dural metastases include (in descending order of frequency)&nbsp;<sup>1,2</sup>:</p><ul>
  • +<li><p><a href="/articles/breast-cancer">breast cancer</a></p></li>
  • +<li><p><a href="/articles/prostate-cancer-3">prostate cancer</a></p></li>
  • +<li><p><a href="/articles/lung-cancer-3">lung cancer</a></p></li>
  • +<li><p>head and neck cancers</p></li>
  • +<li><p>haematological cancers</p></li>
  • +<li><p><a href="/articles/neuroblastoma">neuroblastoma</a></p></li>
  • +<li><p><a href="/articles/gastric-adenocarcinoma">gastric adenocarcinoma </a><sup>6</sup></p></li>
  • +<li><p><a href="/articles/colorectal-cancer-1">colon cancer</a> <sup>7</sup></p></li>
  • +<li><p><a href="/articles/glioblastoma-idh-wildtype">glioblastoma</a>&nbsp;<sup>8</sup></p></li>
  • +<li><p><a href="/articles/gallbladder-carcinoma-1">carcinoma of the gallbladder</a> <sup>9</sup></p></li>
  • +<li><p><a href="/articles/renal-cell-carcinoma-1">renal cell carcinoma</a> <sup>10</sup></p></li>
  • +<li><p><a href="/articles/ewing-sarcoma">Ewing sarcoma</a> <sup>11</sup></p></li>
  • +<li><p><a href="/articles/uterine-leiomyosarcoma">uterine leiomyosarcoma </a>(very rare) <sup>13</sup></p></li>
  • +<li><p><a href="/articles/squamous-cell-carcinoma-of-the-cervix">squamous cell carcinoma of the uterine cervix</a> <sup>14</sup></p></li>
  • +<li><p><a href="/articles/pancreatic-neoplasms">pancreatic cancer</a> <sup>15</sup></p></li>
  • +<li><p><a href="/articles/esophageal-squamous-cell-carcinoma">oesophageal squamous cell carcinoma</a>&nbsp;(very rare)&nbsp;<sup>12</sup></p></li>
  • +<li><p><a href="/articles/carcinoid-tumour-2">malignant carcinoid tumour</a>&nbsp;(rare)&nbsp;<sup>16</sup></p></li>
  • +</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>
  • +<li><p><strong>T1:</strong> typically iso/hypointense to adjacent cortex</p></li>
  • +<li><p><strong>T2:</strong> iso/hyperintense to adjacent cortex</p></li>
  • +<li><p><strong>T1 C+ (Gd):</strong> vivid enhancement <sup>4</sup></p></li>
  • +<li>
  • +<p><strong>MR spectroscopy:</strong></p>
  • +<ul>
  • +<li><p>increased choline/creatine ratio <sup>5</sup></p></li>
  • +<li><p>prominent lipid peak <sup>5</sup></p></li>
  • +<li><p>occasional lactate peak <sup>5</sup></p></li>
  • +<li><p>absence of NAA peak <sup>5</sup></p></li>
  • +</ul>
  • +</li>
  • +</ul><h4>Differential diagnosis</h4><p>When mass like the differential diagnosis is essentially that of other <a href="/articles/dural-masses">dural masses</a>&nbsp;particularly:</p><ul>
  • +<li><p><a href="/articles/meningioma">meningiomas</a>:&nbsp;can look indistinguishable;&nbsp;dural based mass with "dural tail",&nbsp;hyperostosis and calcification;&nbsp;MRS: increased alanine peak and no lipid/lactate peak</p></li>
  • +<li><p><a href="/articles/haemangiopericytoma-historical">haemangiopericytoma</a>:&nbsp;can look identical;&nbsp;often has prominent T2 flow voids</p></li>
  • +<li><p><a href="/articles/secondary-cns-lymphoma">CNS lymphoma</a>&nbsp;dural involvement: diffusely enhancing dural mass, often multifocal,&nbsp;T2 low signal due to hypercellularity, no calvarial invasion</p></li>
  • +<li><p><a href="/articles/gliosarcoma">gliosarcoma</a>: rare;&nbsp;often with dural involvement;&nbsp;heterogeneously enhancing parenchymal mass</p></li>
  • +<li><p><a href="/articles/leukaemia" title="Leukaemia">leukaemia</a>/<a href="/articles/multiple-myeloma-1" title="Multiple myeloma">myeloma</a></p></li>
  • +<li><p><a href="/articles/tuberculosis-intracranial-manifestations">CNS tuberculosis</a>:&nbsp;strong dural thickening and enhancement with basilar predominance; usually abnormal chest x-ray; more common endemic areas and in immunocompromised patients</p></li>
  • +<li><p><a href="/articles/neurosarcoidosis">neurosarcoidosis</a>:&nbsp;multifocal dural based masses;&nbsp;leptomeningeal enhancement;&nbsp;no skull involvement;&nbsp;abnormal chest x-ray and serum markers</p></li>
  • +<li><p><a href="/articles/subdural-haemorrhage">chronic subdural haemorrhage</a>: trauma history, fluid-fluid levels;&nbsp;varying density/intensity</p></li>
  • +<li><p><a href="/articles/extramedullary-haematopoiesis">extramedullary haematopoiesis</a>: chronically anaemic patients;&nbsp;smooth homogeneous dural based masses with strong homogeneous enhancement</p></li>
  • +</ul><p>When more diffuse the differential also includes other causes of <a href="/articles/pachymeningeal-enhancement-1">dural enhancement</a>, and sometimes if thin or irregular, it may be difficult to distinguish pachymeningeal metastases from <a href="/articles/leptomeningeal-metastases">leptomeningeal metastases</a>&nbsp;or other leptomeningeal processes.&nbsp;</p>
Images Changes:

Image 9 MRI (T1 C+) ( create )

Caption was added:
Case 7: Dural metastases from prostatic carcinoma
Position was set to 9.

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