Dural metastases

Changed by Rohit Sharma, 15 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:

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 "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
  • 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. 

  • -<li> <a href="/articles/gallbladder-carcinoma-1">carcinoma of the gallbladder</a> <sup>9</sup>
  • +<li>
  • +<a href="/articles/gallbladder-carcinoma-1">carcinoma of the gallbladder</a> <sup>9</sup>
  • -<a title="Ewing's sarcoma" href="/articles/ewing-sarcoma">Ewing's sarcoma</a> <sup>11</sup>
  • +<a href="/articles/ewing-sarcoma">Ewing sarcoma</a> <sup>11</sup>

References changed:

  • 2. Jeffrey Raizer, Lauren E. Abrey. Brain Metastases. (2007) ISBN: 9780387692210 - <a href="http://books.google.com/books?vid=ISBN9780387692210">Google Books</a>
  • 11. Ben Nsir A, Boughamoura M, Maatouk M, Kilani M, Hattab N. Dural Metastasis of Ewing's Sarcoma. Surg Neurol Int. 2013;4(1):96. <a href="https://doi.org/10.4103/2152-7806.115487">doi:10.4103/2152-7806.115487</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23956939">Pubmed</a>
  • 2. Brain metastases. Springer. ISBN:0387692215. <a href="http://books.google.com/books?vid=ISBN0387692215">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0387692215">Find it at Amazon</a><span class="auto"></span>
  • 11. A Ben Nsir, M Boughamoura, M Maatouk, et al. Dural metastasis of Ewing's sarcoma. (2013) Surgical neurology international. 4: 96. <a href="https://doi.org/10.4103/2152-7806.115487">doi:10.4103/2152-7806.115487</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23956939">Pubmed</a> <span class="ref_v4"></span>

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