|Year : 2018 | Volume
| Issue : 6 | Page : 234-237
Hemorrhage glioblastoma mimicks a dural-based meningioma
Tse-Fu Wen, Lin-Hsue Yang, Che-Kuang Lin
Department of Surgery, Division of Neurosurgery, Far Eastern Memorial Hospital, Banqiao, New Taipei City, Taiwan
|Date of Submission||26-Feb-2018|
|Date of Decision||20-Mar-2018|
|Date of Acceptance||24-May-2018|
|Date of Web Publication||11-Dec-2018|
Dr. Che-Kuang Lin
Department of Surgery, Division of Neurosurgery, Far Eastern Memorial Hospital, Banqiao, New Taipei City
Source of Support: None, Conflict of Interest: None
The so-called “dural tail sign” (DTS) is a thickening of the dura that is most often seen adjacent to a meningioma. Although the DTS is highly specific for meningioma, it has been observed in numerous other intracranial lesions. The origin of the DTS is an issue of debate. Some authors have described it as a tumor extension, while others have considered it as a proliferation of connective tissue, hypervascularity, and vascular dilatation within the dura and adjacent to cranial masses. Here, we reported a rare case of glioblastoma multiforme (GBM) with image findings of a DTS. A 74-year-old female was taken to our hospital due to the sudden onset of mental status change and right-side hemiparesis. Brain magnetic resonance imaging (MRI) with contrast enhancement showed an intracranial mass with heterogeneous enhancement in the left temporal lobe which was consistent with the DTS. A left frontotemporal craniotomy was performed, and grossly total tumor removal was achieved. The final pathology reported was GBM. Although it is rare, GBM may also on occasion be associated with a DTS. The histopathological examination for DTS in GBM is limited. Currently, excision of the dural tail in GBM is suggested.
Keywords: Dural tail sign, glioblastoma, intracerebral hemorrhage
|How to cite this article:|
Wen TF, Yang LH, Lin CK. Hemorrhage glioblastoma mimicks a dural-based meningioma. Formos J Surg 2018;51:234-7
| Introduction|| |
The so-called “dural tail sign” (DTS) is a linear thickening and contrast enhancement of the meninges adjacent to peripherally located cranial masses. The DTS was first described in association with meningioma by Wilms et al. in 1989, who identified it using T1-weighted enhanced magnetic resonance imaging (MRI). In 1990, Goldsher et al. used the following features to define the DTS: (1) the presence of at least two consecutive sections through the tumor at the same site in more than one imaging planes, (2) greatest thickness adjacent to the tumor and tapering away from it, and (3) an enhancement more intense than that of the tumor itself. The authors also suggested that the presence of the DTS is a highly specific sign of meningioma. Since then, numerous studies concerning this topic have been reported. Although meningioma is the most likely diagnosis when the DTS is found, other intracranial lesions may also be associated with this phenomenon. Indeed, the DTS has been reported in cases of hemangioblastoma, cavernoma, sarcoma, lymphoma, schwannoma, tuberculoma, ependymoma, and metastasis.,,,,,,,,
Glioblastoma multiforme (GBM) is one of the most frequent intraparenchymal tumors. GBM can extend to the dura and rarely shows dural thickening or the DTS., Interestingly, these studies found no involvement of the DTS with tumoral cells. This may suggest that the DTS associated with GBM has a different pathophysiology to the DTS associated with other conditions.
Here, we report a case of GBM with hemorrhage in which the initial MRI showed characteristic findings of the DTS. A tentative diagnosis of atypical meningioma, hemangiopericytoma, angiosarcoma, or other hypervascular metastases was made. During surgery, an infiltrating tumor was encountered and removed. The final pathological diagnosis was GBM. The clinical and pathological findings are described along with a review of the associated literature.
| Case Report|| |
A 74-year-old female was admitted to our hospital due to sudden onset of mental status change and right-side hemiparesis. She had a history of hypertension that was controlled by regular medication. On arrival, the patient was alert but confused. Right-side hemiparesis was noted. A brain computed tomography scan revealed an intracranial mass with hemorrhage in the left temporal region [Figure 1]. The presence of an intracranial mass with hemorrhage was confirmed by a brain MRI with contrast enhancement compatible with computed tomography images, which also revealed heterogeneous enhancement in the left temporal lobe. A DTS was noted, and we made a tentative diagnosis of atypical meningioma, hemangiopericytoma, angiosarcoma, or other hypervascular metastases [Figure 2]a and [Figure 2]b. A left frontotemporal craniotomy was performed. During surgery, an infiltrative mass with recent hemorrhage was encountered. There was no clear margin between the tumor and its surrounding parenchyma. Adhesion of the tumor to the meningeal layer of the dura was strong and dural invasion could not be excluded. The dural invasion was removed until grossly normal dura was encountered. The pathology report described a hypervascular tumor composed of highly atypical cells with enlarged/rounded nuclei, a coarse chromatin pattern, and fibrillary cytoplasm. Increased mitotic activity of up to five mitotic figures per 10 HPFs was observed. High tumor vascularity and focal hemorrhage necrosis were also apparent. The immunohistochemical analysis demonstrated that the tumor cells were diffusely positive for glial fibrillary acidic protein stain but negative for cytokeratin stain. Leukocyte common antigen CD34-positive findings highlighted proliferative endothelial cells in vascular channels. The overall picture confirmed the diagnosis of GBM. Microscopically, it showed some meningeal tissues involved by glioblastoma cells [Figure 3]. The patient recovered quickly after surgery; both her mental condition and motor functioning returned to normal. The patient underwent adjuvant chemotherapy with temozolomide and whole-brain radiotherapy for 42 days. Three months later, a brain MRI showed total removal of the tumor without recurrence.
|Figure 1: Noncontrast computed tomography brain scan revealed a 4.5-cm intracerebral hemorrhage in the left temporal lobe with regional subarachnoid hemorrhage of the left frontotemporal region|
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|Figure 2: (a and b) T1-weighted magnetic resonance image scan with gadolinium enhancement (arrowhead) demonstrated an ill-defined irregular mass with hemorrhage (arrow) around 5 cm in diameter, which was attached to the dura at the left temporal region. The dural tail sign was noted (white arrow)|
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|Figure 3: Section of the thickened dura. Histopathological staining revealed a variable degree of thickness of the dura layer, which was infiltrated by tumor cells (H and E, ×40)|
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| Discussion|| |
The prevalence of the DTS in meningioma cases has been reported as 60%, 72%, 78%, and 52%.,,, In a study conducted by Rokni-Yazdi and Sotoudeh in 2006, the DTS was found to have a sensitivity of 58.6% and specificity of 94.02% in the diagnosis of meningioma. Thus, the DTS, when present, is not always “pathognomonic of meningiomas.”
Although the DTS is highly specific for meningiomas, it is also present in other conditions., Indeed, many other brain lesions, including various kinds of tumors and infection-mediated lesions, also share the typical appearance of the DTS. Among these, GBM has been seldom reported.,
The origin of the dural tail has yet to be defined. Some authors have described dural tail it as a tumor extension within or at the surface of the dura,,, while others have considered it as a proliferation of connective tissue, hypervascularity, and vascular dilatation within dura adjacent to cranial masses.,, Since its description in 1989, only about 80 DTSs have been pathologically evaluated. Of these, over 50% have reported the involvement of the DTS with tumoral cells (primarily in meningiomas) and the rest have described DTSs associated with vascular congestion and inflammation.,,,,,,,,,
Of the two studies that have reported the appearance of the DTS in patients with GBM, involvement of the DTS with tumoral cells was not observed., The proliferation of connective tissues and vessels within the dura adjacent to cranial masses may be considered as the pathophysiology of DTS in patients with GBM. However, the case presented here showed the involvement of the DTS with tumoral cells.
Extent of tumor resection is one factor that influences survival in newly diagnosed adult patients with GBM. Indeed, Lacroix et al. found that an extent of resection of 98% or more for GBM was associated with a good chance of survival. Surgical resection of GBMs relieves the mass effect, pathologically confirms the diagnosis, and sets the stage for multimodal adjuvant therapy.,,, Poor prognostic factors for survival include a higher age (particularly >75 years), chronic obstructive pulmonary disease, preoperative motor, language, and cognitive deficits, as well as a Karnofsky Performance Scale score of <80 and a tumor diameter larger than 4 cm.
| Conclusion|| |
We performed wide excision for malignant glioma, including the adjacent dural thickening, in a patient with GBM. The final pathology showed some meningeal tissues involved by glioblastoma cells. Involvement of the DTS with tumoral cells has not previously been reported in patients with GBM with DTS. Wide excision including the thickening dura is suggested for dura-based tumors, especially tumors with DTS.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The auther thanks Dr. Yue-hong Zhou at the Department of Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan for his assistance in histopathological findings of this case.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]