Question:

Which of the following is not a classic angiographic imaging finding for a meningioma?
1. "Mother-in-law" sign
2. External carotid artery branch vessel can be the vascular source
3. Accumulation of contrast agent in the capillary phase
4. Star-burst vascular pattern
5. Middle meningeal artery typically is the vascular source





Answer:

The correct answer for the question "Which of the following is not a classic angiographic imaging finding for a meningioma?" is:

3. Accumulation of contrast agent in the capillary phase



Explanation

1, 2, 4, and 5. The classic CT scan findings for meningiomas are listed in Table 1 (1, 11, 12), (Table 1). The classic MRI findings for meningiomas, irrespective of histological subtype, are included in Table 2 (3, 11, 12), (Table 2). In particular for MRI, post-contrast T1-weighted images using intravenous gadolinium-DTPA demonstrate intense homogeneous or heterogeneous enhancement with a well-defined margin for meningiomas approximately 95% of the time (3, 11). Additionally, the dural tail sign (noted on CT and MRI) appears as an area of enhancement in the dura mater adjacent to the tumor. Finally, the classic selective angiography findings for meningiomas are included in Table 3 (4, 12), (Table 3). Concerning the "mother-in-law" sign noted in cerebral angiography, this refers to a persistent homogenous tumor blush that appears early and persists until later after contrast injection during angiography (12). All 3 of the angiographic findings were evident in this case report. 3. Dural metastatic lesions generally present as either a subdural hematoma or a tumor mass, the latter contributing to the diagnostic dilemma in differentiating a dural metastatic lesion versus a meningioma (11). Metastatic brain lesions have common CT findings. First, there are areas of necrosis inside the tumor with associated large areas of surrounding edema. Second, on non-contrast imaging there is a hypodense to mild hyperdense appearance; with strong and homogeneous enhancement of the lesion after contrast administration (5). Additionally, brain metastatic lesions typically demonstrate hypervascularity, intraaxial location, and necrosis associated with hemorrhage (13). Concerning specifically adenocarcinoma lesions and moreso those of a colonic nature, multiple case reports state that they present as hyperdense masses on CT and this finding is related to multiple mechanisms (14). First, the hyperdensity may be a result of hemorrhage within the tumor; second, the tight and densely packed cell structure of the tumor; third, the occurrence of calcium microdeposits within the metastasis; or fourth, mucoid degeneration may have occurred (5, 14). MR imaging of brain metastases of colon adenocarcinoma demonstrates hypointense areas on T1-weighted images and hyperintense areas on T2-weighted images (14). For further delineation, contrast-enhanced T1-weighted images will show a distinctly hyperintense lesion and are considered the best modality for radiologic diagnosis; however, speculation ensues when enhancement of the dural tail occurs because this was once specific for meningiomas, but is now nonspecific (11, 14). Concerning angiography, when an accumulation of contrast agent in the capillary phase is evident, this may be typical of metastatic disease (12). This additional diagnostic clue is a significant reason why a cerebral angiogram should be performed in all patients with a history of primary malignancy and a dural-based lesion in order to guide therapeutic intervention. (Tables 1, 2, and 3)

 



From the manuscript:
Dural Based Mass: Malignant or Benign
Radiology Case. 2009 Nov; 3(11):1-12


This article belongs to the Neuro section.




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From the manuscript

Dural Based Mass: Malignant or Benign

Free full text article: Dural Based Mass: Malignant or Benign

Abstract
In March 2007, a 68 year old female was diagnosed with colonic adenocarcinoma metastatic to the lungs and a frontoparietal parafalcine lesion suspected to be a meningioma was also noted. She denied neurologic symptoms and resection of the parafalcine lesion did not occur. For 14 months, she received chemotherapy with poor response. In June 2008, she developed multiple focal neurologic deficits. Enlargement of the parafalcine brain lesion was noted on head computerized tomography and magnetic resonance imaging. Cerebral angiogram demonstrated a parafalcine mass supplied by the middle meningeal artery. All 3 modality findings confirmed a meningioma. Embolization of the middle meningeal artery with craniotomy for excision of the suspected meningioma was performed. Pathology indicated metastatic adenocarcinoma with colonic primary without evidence of meningioma. Meningiomas are the most common dural based lesions; however, a variety of dural lesions mimic meningiomas. Dural metastatic tumors mimicking meningiomas is an uncommon phenomenon, particularly when the primary location is the colon. This paper additionally discusses the differentiation of benign dural based tumors like meningiomas from malignant findings. Multiple adjunct studies can differentiate meningiomas from metastatic tumor. The definitive diagnosis is based on histopathology.






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