Dural metastases

Subdural Hematoma due to Dural Metastasis: A Systematic Review on Frequency, Clinical Characteristics, and Neurosurgical Management

BACKGROUND

 Subdural hematoma (SDH) occasionally accompanies dural metastasis and is associated with high recurrence rate, significantly impacting patient morbidity and mortality. This systematic review aims to evaluate the characteristics, management options, and outcomes of patients with SDH associated with dural metastasis.

METHODS

 A comprehensive search of the PubMed and Cochrane databases was conducted for English-language studies published from inception to March 20, 2023, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors reviewed cases of histopathologically confirmed SDH with non-central nervous system (non-CNS) tumor metastasis, focusing on therapeutic management of SDH. Statistical analysis was performed using SPSS software, with a significance level set at 0.05.

RESULTS

 This review included 32 studies comprising 37 patients with 43 SDH cases associated with dural metastasis. Chronic SDH was the most frequently observed presentation (n = 28, 65.12%). The systemic malignancies most commonly associated with SDH due to dural metastasis were prostate carcinoma (n = 9, 24.32%) and gastric carcinoma (n = 5, 13.51%). A statistically significant association was found between metastatic melanoma and subacute SDH (p = 0.010). The majority of patients were treated with burr holes (n = 15, 40.54%) or craniotomies (n = 14, 37.84%), with no statistically significant difference in mortality rates between the two techniques (p = 0.390). Adjuvant therapy was administered to a limited number of patients (n = 5, 13.51%), including chemotherapy (n = 2, 5.41%), whole brain radiotherapy (n = 1, 2.70%), a combination of chemotherapy and whole brain radiotherapy (n = 1, 2.70%), and transcatheter arterial chemoembolization (n = 1, 2.70%). The overall recurrence rate was 45.95% (n = 17), with burr holes being the most common management approach (n = 4, 10.81%). Within a median of 8 days, 67.57% (n = 25) of patients succumbed, primarily due to rebleeding (n = 3, 8.11%), disseminated intravascular coagulation (n = 3, 8.11%), and pneumonia (n = 3, 8.11%).

CONCLUSION

 This review highlights the need for improving existing neurosurgical options and exploring novel treatment methods. It also emphasizes the importance of dural biopsy in patients with suspected metastasis to rule out a neoplastic etiology.

Dural metastasis of prostate carcinoma mimicking intracranial hematoma: a case report and literature review

Dural metastases of prostate adenocarcinoma are an extremely rare complication and may mimic intracranial hematoma. Preoperatively diagnosis may be difficult due to similarities in symptoms and radiological appearance. We present a 65-year-old man admitted to the ED with a history of headache, nausea, vomiting, vertigo, diplopia, as well as numbness of his left lower extremity. Past medical history confirmed metastatic prostate cancer disease. After computed tomography and contrast computed tomography, the consulting radiologist diagnosed a chronic subdural hematoma. After burr hole trephination and dural opening, tumorous mass was detected. Histopathologic samples were taken. Histopathological examination was consistent with metastatic adenocarcinoma of the prostate. Although rare, dural metastases need to be included in oncological patients presenting in the ED with symptoms and radiological imaging suggesting hematoma. Both neurooncological and neurosurgical consultations are essential in order to apply the best treatment strategy.

Meningeal Metastasis Causing Chronic Subdural Hematoma in a Cancer Patient with Bilateral Papilledema and Suspected Cerebral Venous Thrombosis: A Case Report

Meningeal metastasis has been reported as a very rare cause of chronic subdural hematoma (CSH). Here, we report a female patient who had undergone initial burr hole drainage of a CSH at an outside hospital. Postoperatively, the patient additionally suffered from visual impairment due to bilateral papilledema and the patient was eventually transferred to our neurosurgical department for additional treatment. A craniotomy was performed and due to intraoperative suspicious findings, histopathologic samples were obtained that revealed a metastasis of thus far undiagnosed triple negative breast cancer. Furthermore, the patient was suspected to have a partial cerebral venous thrombosis (CVT). Our case report addresses this extremely rare clinical constellation. We provide a detailed overview on our patient's clinical and radiologic course, and discuss the potential association of CSH with meningeal metastasis and bilateral papilledema.

A rare case of solitary, isolated dural metastasis from hepatocellular carcinoma mimicking a meningioma

Background

Distinguishing an isolated metastatic dural tumor from a meningioma on imaging is challenging and may lead to a delay in treatment. Here, we present the first known case of isolated, solitary dural metastasis from hepatocellular carcinoma (HCC) mimicking a meningioma.

Case Description

A 64-year-old male with a history of liver cirrhosis presented with a 5.8 cm enhancing left parafalcine hemorrhagic dural-based mass extending across the midline. Cerebral angiography revealed a distal left anterior pseudoaneurysm, and tumor contrast blush with feeders from the left ophthalmic and right middle meningeal artery. The pseudoaneurysm was successfully embolized to stop the bleeding, followed by an uneventful bi-coronal frontal craniotomy for falcine tumor resection to relieve brain compression. Histopathological analysis of the dural-based tumor showed poorly differentiated carcinoma with positive albumin in situ hybridization and cytokeratin tumor markers, consistent with dural metastases from HCC.

Conclusion

When encountering a solitary, highly vascular mass bearing resemblance to a meningioma, it may be prudent to consider the possibility of a dural-based metastatic carcinoma.

The Unique Case of Lumbar Dural Metastasis From Cervical Carcinoma on Pembrolizumab

Lumbar metastasis is a rare manifestation of cervical carcinoma which may present as lower extremities symptoms. Immune-checkpoint inhibitors like pembrolizumab, used for the treatment of various metastatic carcinomas, have been linked to Guillain-Barré Syndrome (GBS), which is characterized by ascending weakness and areflexia. A 52-year-old female with metastatic cervical cancer on pembrolizumab for two months presents with lower back pain, progressive bilateral lower extremities ascending weakness, and areflexia of affected limbs. Cerebrospinal fluid analysis showed albuminocytologic disassociation. Spine magnetic resonance imaging showed L4-L5 fracture associated with metastasis and contrast-enhancing adjacent dura and nerve roots. Despite the clinical presentation being consistent with lumbar metastasis, the possibility of masked pembrolizumab-induced GBS presented a therapeutic challenge. Plasmapheresis conferred no clinical improvement and later nerve conduction study was unrevealing for GBS. Subsequently, laminectomy of lumbar vertebrae improved the symptoms. The unique clinical scenario of lumbar dural metastasis from cervical cancer on pembrolizumab, a condition with a similar clinical presentation, is explored in this case.

Dural metastasis from prostate carcinoma mimicking tuberculum sellae meningioma: A case report

Background:

Prostate carcinoma rarely metastasizes to the central nervous system. However, when it does, a dural lesion is a common and possible misdiagnosis of meningioma. Here, we describe a case of a 77-year-old man with dural metastasis from prostate carcinoma of the tuberculum sellae.

Case Description:

The patient was diagnosed with prostate carcinoma 7 years previously and was well-controlled by hormone therapy. He was incidentally found to have a suprasellar tumor and underwent endoscopic endonasal transsphenoidal surgery because of rapid tumor growth and worsening visual impairment. Since his serum prostate-specific antigen (PSA) level was within the normal range, malignant meningioma was suspected based on the magnetic resonance imaging (MRI) and the course. However, the pathological findings revealed dural metastasis from prostate carcinoma. He received radiation therapy, and the tumor disappeared on MRI. His visual impairment improved without recurrence. This case report highlights that dural metastasis of the tuberculum sellae arose despite the patient’s PSA level being within the normal range, and a single metastasis to the dura was found.

Conclusion:

In patients with a history of prostate carcinoma or older men, careful follow-up considering the possibility of metastasis is required when a dural lesion is found.

Full-Thickness Craniodural Metastasis with Leptomeningeal Infiltration of Salivary Origin: A Radiological Lesson and a Technical Remark

Calvarial metastases are a relatively rare entity, with an overall incidence of 3-4%. Among these cases, metastases arising from salivary gland cancers are even rarer; in fact, large studies regarding salivary gland tumors showed that brain metastases are observed in 0.8% of the cases. Generally, bone metastases have been described in proximity to primary tumors, while bloodstream-disseminated lesions are often located inside the brain parenchyma. During every surgical step, traction on lower-lying infiltrated tissues must be avoided in order to successfully remove the lesion. This case report presents the first ever case of a 67-year-old woman affected by submandibular gland undifferentiated adenocarcinoma metastasis with a full-thickness involvement of the calvarium, pachy- and leptomeninges.

Incidence of dural metastases in castrate-resistant prostate cancer

Purpose:

The natural history and clinical manifestations of dural metastases (DM) in castrate-resistant prostate cancer (CRPC) will change with advances in new hormonal therapy. Here, we characterised the incidence, clinical presentation, and outcomes of patients with DM in a contemporary patient cohort with CRPC.

Methods:

We retrospectively reviewed our CRPC database from 2012 to 2020. The primary outcome was the diagnosis of DM, defined as metastasis to the dura mater in the brain or spine. We describe the presenting symptoms, biochemistry, radiologic findings, and therapy sequence for all DM patients. Multivariable logistic regression was performed to identify predictors of DM.

Results:

Six of the 275 patients (2.2%) with CRPC developed DM. The average age of CRPC diagnosis for patients with DM was 65.6 years. Mean patient survival was 4.5 months after the diagnosis of DM. At the time of CRPC diagnosis, patients who developed DM were significantly younger, had lower baseline haemoglobin, higher lactate dehydrogenase (LDH), and elevated alkaline phosphatase (ALP) compared to those without DM. On multivariable analysis, younger age of CRPC diagnosis was found to be a predictor for DM.

Conclusion:

The presence of neurological symptoms in the context of younger age, anaemia, and elevated baseline LDH and ALP are associated with DM in CRPC.

Level of Evidence:

4

Holohemispheric Prostate Carcinoma Dural Metastasis Mimicking Subdural Hematoma: Case Report and Review of the Literature

Prostate carcinomas are the most common malignancy to metastasize to the dura. These metastases can commonly mimic subdural hematomas and may similarly present with brain compression. The optimal management and outcomes after surgical management are not well characterized. We present a case of prostate carcinoma metastatic to the dura that was initially thought to be a large isodense subdural hematoma and was treated with surgical decompression. We also review the literature regarding prostate dural metastases mimicking subdural hematomas and discuss the relevant imaging findings, treatments, and outcomes. Dural metastasis should be considered when a patient with known metastatic prostate cancer presents with imaging evidence of a subdural mass.

Solitary Isolated Dural Metastasis From Lung Adenocarcinoma Mimicking Meningioma

ABSTRACT

Solitary isolated dural metastasis is extremely rare. Distinguishing solitary dural metastasis from meningioma based on radiological findings can be challenging. We describe MRI and FDG PET/CT findings in 2 cases of histologically proved solitary isolated dural metastasis from lung adenocarcinoma. Enhanced brain MRI of the 2 cases showed parafalcine extra-axial, dural-based tumors with hypervascularity mimicking meningioma. Preoperative FDG PET/CT was performed in one case with a known history of lung adenocarcinoma showing intense FDG uptake of the parafalcine tumor. Postoperative FDG PET/CT was performed in the other case showing solitary lung tumor, suggestive of the primary tumor.

Chronic subdural hematoma associated with dural metastasis leads to early recurrence and death: A single-institute, retrospective cohort study

The prevalence of chronic subdural hematoma (CSDH) associated with dural metastasis is uncertain, and appropriate treatment strategies have not been established. This study aimed to investigate the characteristics of and appropriate treatment strategies for CSDH associated with dural metastasis. We retrospectively reviewed the charts of 214 patients who underwent surgery for CSDH. The patients were divided into the dural metastasis group (DMG; n = 5, 2.3%) and no dural metastasis group (No-DMG; n = 209, 97.3%). Patient characteristics, treatment, and outcomes were compared between the two groups. Active cancer was detected in 31 out of 214 patients, 5 of whom (16.1%) had dural metastasis. In-hospital death (80.0% vs. 0%; p < 0.001) and recurrence within 14 days (80.0% vs. 2.9%; p < 0.001) and 60 days (80.0% vs. 13.9%; p = 0.002) were significantly prevalent in the DMG. All patients in the DMG developed subdural hematoma re-accumulation requiring emergent surgery because of brain herniation, and patients in the DMG had significantly worse recurrence-free survival (p < 0.001). This relationship remained significant (p < 0.001) even when the analysis was limited to the active cancer cohort (n = 31). CSDH associated with dural metastasis leads to early recurrence and death because of the difficulty in controlling subdural hematoma re-accumulation by common drainage procedures. Depending on the primary cancer status, withdrawal of active treatment and change to palliative care should be discussed after diagnosing CSDH associated with dural metastasis.

Pitfalls in the diagnosis of subdural hemorrhage - Mimics and uncommon causes

PURPOSE

Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management.

Dural spread from metastatic prostate cancer

A 59-year-old man with a known breast cancer type 1 gene mutation and a 2-year history of metastatic prostate cancer to bone and lymph nodes presented with a sudden onset of thunderclap headache, photophobia and a left sided facial droop. He was being treated at the time with the poly ADP ribose polymerase inhibitor Rucaparib. Of note, 6 weeks prior to this presentation, he had been diagnosed with malignant spinal cord compression at T3-T6, he underwent an emergency decompressive laminectomy and had received palliative postoperative radiotherapy. An urgent CT brain revealed dural metastases from his prostate cancer, with extensive oedema and midline shift. He underwent palliative whole brain radiotherapy but died 2 weeks later.

A clinical approach to hypertrophic pachymeningitis

IMPORTANCE

Hypertrophic pachymeningitis (HP) is a non-usual manifestation of rheumatologic, infectious, and neoplastic diseases. Etiological diagnosis is a challenge, but when made promptly it creates a window of opportunity for treatment, with the possibility of a total reversal of symptoms.

OBSERVATIONS

HP is an inflammatory process of the dura mater that can occur as a manifestation of sarcoidosis, granulomatosis with polyangiitis, and IgG4-related disease. The HP case evaluation is extensive and includes central nervous system imaging, cerebrospinal fluid analysis, serology, rheumatologic tests, and systemic survey for other manifestations sites. After systemic investigation, meningeal biopsy might be necessary. Etiology guides HP treatment, and autoimmune disorders are treated with corticosteroids alone or associated with an immunosuppressor.

CONCLUSION

HP is a manifestation of several diseases, and a precise etiological diagnosis is crucial because of the difference among treatments. An extensive investigation of patients with HP helps early diagnosis and correct treatment.

Intracranial metastasis from prostate adenocarcinoma: a case report and literature review

Intracranial metastasis from prostate adenocarcinoma is rare. A 70-year-old African American male with a history of prostate adenocarcinoma for the last 14 years, presented to our hospital complaining of generalized weakness for the past 2 weeks. He was found to have fever with left ptosis and mild eyelid edema. Brain MRI showed dural metastasis. Two months after the first presentation, he was readmitted with a suspected acute cerebral vascular accident (CVA). CT brain showed vasogenic edema in the right subcortical, likely from intracranial metastasis. His acute neurological symptoms improved with intravenous dexamethasone. This case highlights the possibility of intracranial metastasis from prostate adenocarcinoma. With the advent of novel therapies for prostate cancer, which prolong life expectancy, intracranial metastasis from prostate adenocarcinoma may become an increasingly frequent clinical scenario.

Dural metastasis of prostate carcinoma misdiagnosed as a bilateral subdural hematoma: A case report

Dural metastases originating from prostate cancer are exceedingly uncommon and may clinically imitate a subdural hematoma. Additionally, head computed tomography scan findings can be mistaken for meningioma or subdural hematoma. We present a 75-year-old male patient with dural metastasis as a first presenting sign of prostate cancer, misdiagnosed as a bilateral subdural hematoma on initial non-contrast brain CT scan. Also, a review of literature is presented. We found 12 cases of dural metastasis of prostate cancer mimicking subdural hematoma described in the literature, and unlike in our case, prostate cancer was already diagnosed.

Spontaneous acute epidural hematoma associated with chronic subdural hematoma due to dural metastasis of gastric carcinoma: a case report and literature review

Background: Non-traumatic spontaneous acute epidural hematoma (EDH) happening to chronic subdural hematoma (SDH) caused by dural metastases is a rare entity. Pathogenesis can be derived from infection, coagulopathy, and inflammation. Malignant tumors metastasize to dura mater is one of the most infrequent causes. The exact mechanism remains elusive in spite of several possible speculations. The clinical manifestations, management and outcomes vary among reported cases.Case Description: A 45-year-old woman without history of trauma presented with headache, vomiting and disturbance of consciousness and developed brain hernia rapidly. On arival, she has lost into coma with Glasgow coma scale (GCS) score 5, bilateral pupils were not equal, with disappeared reflectance. Emergency imaging prompted large acute EDH, combined with SDH, arising from dural granular neoplasm confirmed intraoperatively. Four days after surgery, the bilateral pupils were equal in size and sensitive to light reflection.Conclusion: Dural metastases can cause EDH, chronic SDH can also be resulted from metastatic tumors of dura mater. When dealing with spontaneous non-traumatic hematoma around the dura mater, to make the precise diagnosis is sometimes doubtful and confusing. The stream of diagnostic thinking should be opened, including medical diseases such as liver and kidney disease, drug history, history of cancer and other possible clues. Thus, a detailed and purposeful systematic medical history review and physical examination is important in order to make more appropriate strategies for the clinic.

[COMBINING MODALITY THERAPY WITH SURGERY CAN PROVIDE LONG-TERM SURVIVAL WITH IMPROVED QUALITY OF LIFE FOR PATIENTS WHO HAVE PROSTATE CANCER WITH INTRACRANIAL DURAL METASTASIS: A CASE REPORT]

A 61-year-old man visited our hospital with a headache and left visual field defect. A head MRI showed an intracranial dural tumor with cerebral compression, which was suspected to be metastatic. Analysis of the tumor markers revealed an increase in prostate-specific antigen (PSA) levels (172.8 ng/mL), and therefore prostate cancer was suspected as the primary tumor. Histological diagnosis of a prostatic tissue sample using a transrectal needle biopsy gave a prostate carcinoma with Gleason score of 5+4=9. Additional imaging examinations revealed metastatic lesions in the intra-pelvic lymph node and bones. These data indicated to us that curative surgery was unlikely to be successful, but finally we decided to perform a craniotomy for tumor resection for the intracranial dural tumor to remove his neurological symptoms. After surgery, his headache and visual field defect improved. The pathological finding was intracranial dural metastasis from prostate cancer and the clinical stage was diagnosed as T3bN1M1c in the UICC criteria (ver. 8). Endocrine therapy with degarelix and bicalutamide was started for the primary and residual metastatic prostate cancers. After one year of initial treatment, bicalutamide was changed to enzalutamide because of a tendency towards increased plasma PSA levels. The patient has survived for two and a half years after surgery with no new metastatic tumors or intracranial tumors. Our experience indicates that combined modality therapy with surgery can provide long-term survival with no cranial nerve disorders for patients who have prostate cancer with intracranial dural metastasis.

Remote Leptomeningeal Dissemination in Olfactory Neuroblastoma Mimicking Multiple Parasagittal Meningiomas: Diagnostic and Therapeutic Challenge

BACKGROUND

Olfactory neuroblastoma (ON) is a highly aggressive and locally recurrent neoplasm. Distant systemic metastases are not uncommon, but remote leptomeningeal dissemination is extremely rare.

CASE DESCRIPTION

We report 2 cases of ON previously treated with endoscopic endonasal radical surgical resection and radiotherapy. After a relatively long period of disease-free survival, multiple leptomeningeal lesions were seen around the sagittal sinus giving a radiologic appearance of parasagittal meningiomas. Both patients underwent surgery and multimodal treatment with radiotherapy and chemotherapy for the disseminated disease. Pathologic examination confirmed the parasagittal lesions as metastatic ON.

CONCLUSIONS

A high suspicion of secondary disease should be maintained in patients with previous history of ON and parasagittal leptomeningeal enhancing lesion, particularly when multiple lesions are detected around the sagittal sinus. Radical resection and multimodal treatment are warranted to improve long-term outcome. Understanding the venous drainage route as a potential pathway for remote seeding from the primary site of disease has therapeutic implications. We postulate that en-bloc tumor resection and proximal sagittal sinus ligation might reduce potential for leptomeningeal metastasis.

Rapid Progression of Intracranial Dural Metastases in a Patient with Carcinoma of Unknown Primary Site

Dural metastases are uncommon in cancer patients, but can have as much of an effect on the lives of patients as brain metastases. Dural metastases are most commonly associated with primary cancers of the breast, prostate, and lung, and it is rare that the primary site of the tumor is unknown. In this study, we encountered a 51-year-old woman who had developed multiple bone tumors, with no known primary cancer lesion. A tumor biopsy of the sacral bone revealed non-keratinizing squamous cell carcinoma; the patient was therefore diagnosed as having multiple bone metastases of an unknown primary cancer. Magnetic resonance imaging revealed cranial metastases and partial thickening of the dura with suspected dura metastases. Platinum-based chemotherapy reduced the bone metastases and the thickened dura. However, as resistance to chemotherapy developed, invasions progressed rapidly and diffusely throughout the dura. This was accompanied by the development of dysarthria, visual impairments, and delirium. The patient died 10 months after being diagnosed with dural metastases. This report provides information on the clinical course and prognosis of patients with dural metastases of unknown primary cancer. Furthermore, it may help to construct a treatment strategy for dural metastases.

When hoofbeats mean zebras not horses: Tumour mimics of subdural haematoma - Case series and literature review

Chronic subdural haematomas are common neurosurgical conditions, especially in the elderly patients, with straightforward surgical treatments. However, infrequently, tumours are misdiagnosed as subdural haematoma on initial brain CT scans and are only discovered intraoperatively. In this case series, we presented 3 different patients who were initially thought to have subdural haematoma but later found to be tumour mimics of different histological origin. A literature review and discussion of recently published tumour mimics of subdural haematoma was also performed. It is recommended that in patients with suggestive oncological or haematological history, or unusual characteristics on the plain CT brain, a high level of suspicion of tumour mimics needs to be maintained. A full workup with contrast-enhanced magnetic resonance imaging is important to distinguish from subdural haematoma, as the treatment paradigms and prognoses are vastly different.

Acute Subdural Hemorrhage Associated With Both Metastatic Adenocarcinoma of the Dura and Minor Head Trauma: A Case Report and Review of the Literature

While reportedly a relatively common finding at the autopsy of decedents with metastatic neoplasms, dural metastases are infrequently described in the medical literature and only 55 cases of subdural hemorrhage associated with dural metastases have been described, with only one of these cases associated with head trauma. We report a 50-year-old incarcerated male who died as the result of acute and chronic subdural hemorrhage associated with recent minor head trauma and dural metastases, which were most likely of pancreatic origin. He had sustained a fall, possibly due to a seizure in his jail cell, developed an acute subdural hemorrhage, and died, necessitating an autopsy. Metastatic tumor in the dura and other organs was identified upon histologic examination and found to be CK7 and CK20 positive and TTF-1 and CDX2 negative, consistent with a pancreatic adenocarcinoma. In addition, marantic endocarditis was identified, which can occur in individuals with mucinous tumors, such as a pancreatic neoplasm. This case report offers the second description of a subdural hemorrhage occurring in association with both dural metastases and recent head trauma and confirms the importance of histologic examination of the subdural hemorrhage and adjacent dura at autopsy for reasons other than just timing of the event.

Dural and Leptomeningeal Spine Metastases of Breast Cancer

We present a case of a 57-year-old female diagnosed with invasive ductal breast cancer, which was treated and in remission for 12 years. In 2018 she presented a progressive dorsal back pain, which prevented her from performing basic tasks. An MR study was performed and revealed the presence of an extramedullary metastatic sleeve located in the thoracic intradural space. Concomitant multiple small nodular foci were adhering diffusely to the spinal cord, compatible with leptomeningeal metastatic disease. The occurrence of both forms of spread in the spine is uncommon, and its distinction on imaging is of particular importance taking into account the differences in treatment approach and prognosis.

Subdural haematoma mimics

A subdural haematoma (SDH) is a frequently encountered pathology seen on an emergency room computed tomography (CT) head scan. An extra-axial crescentic density along the convexity of the brain or within the interhemispheric fissure is generally thought to represent a SDH; however, SDH mimics are known to occur in nature, and can be broadly classified under the subcategories of normal anatomy, artefacts, tumour, inflammation, infection, ischaemia, trauma, and iatrogenic. Understanding the typical characteristics of a SDH, knowledge of normal anatomy, close inspection of the morphology of the subdural process, changes to the adjacent structures, and rigorous attention to clinical details may reveal subtle clues that distinguish a true SDH from a mimic. This is crucial in appropriately directing clinical management. This review amalgamates most of the rare subdural processes that have been reported to mimic SDH, and discusses the imaging and clinical features that help to differentiate between them. This topic is highly valuable for radiology trainees, general radiologists, and emergency room physicians, and may serve as a refresher for the practising neuroradiologist.

Serum tumor marker levels at the development of intracranial metastasis in patients with lung or breast cancer

Background

Intracranial metastasis (IM) is observed in various cancers, including in lung and breast cancer, and its timely diagnosis is required for successful patient treatment. Various tumor serum markers, such as carcinoembryonic antigen (CEA), pro-gastrin-releasing peptide (ProGRP), neuron-specific enolase (NSE), and cancer antigen 15-3 (CA15-3), serve not only as prognostic indicators in lung and breast cancer but also as risk factors for IM development. This study is the first to assess a subgroup of cancer patients with IM that did not show elevated serum tumor marker levels.

Methods

This retrospective study included 53 patients with lung or breast cancer in which IM was detected by enhanced brain magnetic resonance imaging between January 2013 and December 2018. IM was classified into three types [parenchymal metastasis (PM), leptomeningeal metastasis and dural metastasis]. Serum CEA level was measured using an electrochemiluminescence immunoassay (ECLIA) or chemiluminescent immunoassay. Plasma ProGRP level was measured using a chemiluminescent enzyme immunoassay (CLEIA), and the serum NSE level was measured using ECLIA. The serum CA15-3 level was measured using CLEIA. Univariate and multivariate analyses were performed using Pearson's χ² test and logistic regression analysis, respectively.

Results

Among the total 53 patients, 15 patients (28.3%) did not show elevated serum tumor marker levels. Univariate analysis showed that the patients with PM only significantly correlated with no increasing tumor marker level compared with other IM types (P=0.030), as well as female patients and patients without symptoms (P=0.010 and 0.046, respectively). Multivariate showed that the patients with PM only and female patients significantly correlated with no increasing tumor marker level (P=0.038 and 0.014, respectively).

Conclusions

Our findings describe a subgroup of lung and breast cancer patients with IM that do not show elevated tumor marker levels, indicating the need for the identification of novel indicators for IM or increased monitoring of these patients.

Esthesioneuroblastoma: A Comprehensive Review of Diagnosis, Management, and Current Treatment Options

INTRODUCTION

Many controversies exist in the diagnosis and management of this aggressively malignant condition, mainly because of limited literature and lack of randomized control trials, resulting in nonstandardized treatment methods. We performed a comprehensive review of the literature to identify management approach and treatment options for esthesioneuroblastoma.

METHODS

An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of esthesioneuroblastoma. Terms for search included esthesioneuroblastoma (ENB) and olfactory neuroblastoma (ONB). No date restrictions were used.

RESULTS

The search yielded 3876 related articles. Cross-checking of articles led to exclusion of duplicate articles. The remaining 1170 articles were screened for their full text and English language availability. Of 609 full-text articles available, animal studies, irrelevant articles, and studies with mixed/confusing data were excluded. We finalized 149 articles pertaining to the topic, including 119 original research articles, 3 book chapters, 11 reviews, 9 case reports, and 7 case series.

CONCLUSIONS

Surgical resection followed by radiotherapy is the standard for treatment for higher-grade lesions. The endoscopic endonasal approach is gaining further recognition with more favorable outcomes and better survival than for open surgery. Postoperative radiotherapy is associated with the highest overall survival and shows benefit for patients with higher-stage disease and those who receive chemotherapy. Recurrence rates after treatment vary drastically in the literature and, therefore, prolonged follow-up with repeated imaging is recommended. Lifelong surveillance is recommended because of late recurrences associated with this tumor.

Metastatic Subdural Hematoma with Dural Metastasis Secondary to Poorly Differentiated Adenocarcinoma of Unknown Origin

BACKGROUND

Metastatic subdural hematoma with dural metastasis in the setting of an underlying malignancy is a rare condition that is difficult to diagnose and associated with a poor prognosis. Knowledge of this rare entity is of a paramount importance to neurosurgeons, as its diagnosis may affect the management plan and overall survival. Here, we report a rare case of atraumatic subdural hematoma with dural metastasis in a patient with poorly differentiated adenocarcinoma of unknown origin.

CASE DESCRIPTION

A 34-year-old man presented with an insidious onset of headaches, severe light headedness, progressive low back pain, and generalized weakness for 2 weeks. On imaging, he was found to have left-sided acute on chronic subdural hematoma with midline shift. The patient underwent surgical evacuation of the hematoma and the subdural membrane was biopsied. Histopathologic examination revealed metastatic poorly differentiated adenocarcinoma of unclear origin. A full metastatic workup was unremarkable.

CONCLUSIONS

Metastatic subdural hematoma with dural metastasis should be included in differential diagnosis of subdural hematoma, especially in patients with atypical presentation and in the presence of an underlying malignancy, as it may affect the management plan and overall survival.

Dural masses: meningiomas and their mimics

Meningiomas are the most common dural tumour. They are regularly being seen as an incidental finding on brain imaging and treated conservatively. However, there are many other dural masses which mimic their appearances, including primary neoplastic processes, metastases, granulomatous diseases and infection. While some of these are rare, others such as metastases and tuberculosis arise relatively frequently in practice. Although not pathognomonic, key features which increase the probability of a lesion being a meningioma include intralesional calcifications, skull hyperostosis, local dural enhancement and increased perfusion. It is important to have an awareness of these entities as well as their main imaging findings, as they have a wide range of prognoses and differing management strategies. This review outlines several of the most important mimics along with their imaging findings on both standard and advanced techniques with key features which may be used to help differentiate them from meningiomas.

Patterns of failures after surgical resection in olfactory neuroblastoma

INTRODUCTION

Patterns of failure in patients with olfactory neuroblastoma (ONB) according to two surgical approaches, craniofacial resection (CFR) and endoscopic surgery (ENDO), have yet to be analyzed.

METHODS

We retrospectively reviewed 28 patients with surgically treated ONB between January 1995 and October 2017. Fourteen (50.0%) patients underwent CFR (9 CFR alone, 5 ENDO-assisted CFR) and 14 (50.0%) underwent ENDO. Nineteen (67.9%) patients underwent post-operative radiotherapy (RT).

RESULTS

At a median follow-up of 53.8 months (range 10.4-195.3), the 5-year progression-free survival (PFS) and 10-year overall survival were 37.3% and 57.5%, respectively. Patients with adjuvant RT had a 5-year PFS of 46.7%, whereas those treated with surgery alone had a 5-year PFS of 19.4% (p = 0.01). Locoregional failure (LRF) occurred in ten patients (median 59.6 months after initial diagnosis; range 12.7-59.7). Neck node metastasis occurred in 25.0% (7 of 28). Five patients with ENDO showed LRF and underwent proper subsequent treatments with either surgery or adjuvant RT. Approximately 35.7% patients (five patients) in the CFR group experienced distant metastasis in the intracranial dura region (median 116.4 months after initial diagnosis; range 2.6-142.4). Three of four patients who developed LRF after CFR developed dura-based metastasis.

CONCLUSIONS

Both dura-based and neck node metastasis in the delayed phase were distinct patterns of failure in ONB. Patterns of recurrence differed based on surgical approach; dura-based metastases were common after CFR. LRF was the distinct failure pattern in ENDO, but could be successfully salvaged. Treatment outcome was improved considerably with RT following surgical resection.

Metastatic prostate cancer mimicking a subdural hematoma: A case report and literature review

Occurrences of metastatic prostate cancer imitating a subdural hematoma are limited to a small number of case reports, even though prostate cancer spreads to the dura more than other types of cancer. Here, we present the case of a 64 year-old male whose prostate carcinoma's metastasis mimicked a subdural hematoma, and he suffered a middle cerebral artery stroke. Prostate cancer's high rate of progression to the dura is disproportionate to its relatively low rate of brain metastasis. Furthermore, we explore the potential molecular implications of prostate cancer's propensity to spread to the dura.

Non-contiguous Meningeal Recurrence of Olfactory Neuroblastoma: A Case Report and Literature Review

Olfactory neuroblastoma is an uncommon malignant tumor of neural crest origin arising from the olfactory epithelium of the superior nasal cavity. There are some reports of local recurrence or continuous extension along the olfactory epithelium to the central nervous system, but non-contiguous distant meningeal metastasis without local recurrence at the primary site is rare. We report a case of non-contiguous meningeal recurrence of olfactory neuroblastoma presenting as a giant frontal mass. A 66-year-old woman was admitted with a left nasal intranasal localized tumor without cranial extension and gross total removal was achieved. Pathological examination showed olfactory neuroblastoma and radiation therapy was added in a limited region of the removal cavity. Radiological follow-up continued for 10 years and there was no local recurrence. Sixteen years after radiation therapy, the patient found a slight frontal mass gradually growing. Magnetic resonance imaging revealed an enhanced mass lesion of 7 cm in thickness and 9 cm in diameter associated with marked thickness of the frontal bone, intradural cystic mass compressing the bilateral frontal lobe, and no local recurrence. A second operation was performed followed by radiotherapy and we diagnosed no-contiguous meningeal recurrence of metastatic olfactory neuroblastoma. Olfactory neuroblastoma is a locally aggressive tumor. Although metastasis of this tumor has been reported, non-contiguous spread to the dura is rare. Understanding the route of remote metastasis and careful evaluation after primary treatment are needed to avoid misdiagnosis and treatment delays.

Metastatic Complications of Cancer Involving the Central and Peripheral Nervous Systems

Neurologic complications of cancer may involve both the central nervous system and peripheral nervous system manifesting as brain, leptomeningeal, intramedullary, intradural, epidural, plexus, and skull base metastases. Excluding brain involvement, neurologic complications affecting these other sites are relatively infrequent, but collectively they affect more than 25% of patients with metastatic cancer causing significant morbidity and mortality. Early diagnosis and intervention optimize quality of life and improve survival.

Chronic subdural collection overlying an intra-axial hemorrhagic lesion in chronic myelomonocytic leukemia: special report and review of the literature

Introduction: Chronic myelomonocytic leukaemia (CMML) is a clonal hematopoietic stem cell disorder characterized by the presence of an absolute monocytosis in the peripheral blood (>1 x 10⁹/L) and the presence of myelodysplastic and myeloproliferative features in the bone marrow. Involvement of the central nervous system (CNS) is uncommon in CMML.Areas covered: Herein described is a case report of a CMML patient who presents with symptomatic chronic subdural collection overlying a haemorrhagic brain lesion, along with diffuse dural infiltration, after two cycles of azacytidine. Surgical intervention was performed to alleviate the mass effect on the brain, and obtain a tissue sample for diagnosis. Histopathological report confirmed brain infiltration with myeloid leukemic cells.Expert commentary: Despite its rarity, cerebral dissemination should be considered even in patients with CMML. A multidisciplinary approach, lead by a hematologist, is mandatory in order to correct the underlying haematological disorder, with specific attention to the coagulation profile. Surgical intervention is necessary for symptomatic patients, and should be performed once an improvement of clinical conditions has been achieved. Despite appropriate surgical and medical therapy, the prognosis remains poor with high risk of perioperative complications, such as rebleeding, and progressive systemic involvement.

A dural metastatic small cell carcinoma of the gallbladder as the first manifestation: a case report

Background

A dural metastasis is one of the essential differential diagnoses of meningioma. In general, carcinomas of the breast and lung in females and prostate in males have been the most commonly reported primary lesions of dural metastases. However, dural metastasis of gallbladder carcinoma is extremely rare. Here, we report a unique case of a dural matter metastasis of gallbladder carcinoma as the first manifestation, which was autopsy-defined as small cell carcinoma.

Case presentation

A 78-year-old man came to our hospital complaining of left hemianopia. Brain computed tomography (CT) revealed a sizeable parasagittal dural-based extra-axial tumor. However, the findings for meningioma were atypical by magnetic resonance imaging, suggesting a meningioma mimic. A contrast-enhanced CT scan of the abdomen revealed a large gallbladder carcinoma. The patient opted for the best supportive care and died 2 months later. The post-mortem examination revealed small cell carcinoma in gallbladder carcinoma. Moreover, an immunologically similar carcinoma was detected in the dural metastasis.

Conclusions

To the best of our knowledge, this is the first case of a dural metastasis of gallbladder small cell carcinoma. A systemic examination is essential for clinicians when atypical findings of meningioma are observed, suggesting a meningioma mimic. We present this rare case with a review of the literature.

Sequential spinal and intracranial dural metastases in gastric adenocarcinoma: A case report

Dural metastasis from primary gastric adenocarcinoma has been rarely reported, and its prognosis is very poor because it frequently leads to acute subdural hematoma. Here, we describe a case with sequential spinal and cranial dural metastases from gastric adenocarcinoma without subdural hematoma. A 43-year-old woman with gastric adenocarcinoma and well-controlled peritoneal carcinomatosis presented with back pain, right radiating leg pain, left facial palsy, and hearing loss. Magnetic resonance imaging of the spine and brain revealed dural masses at the lumbosacral junction with invasion to the L5 and S1 nerve roots and at the skull base with invasion to the internal auditory canal. She was treated with local radiotherapy, and her pain and neurologic symptoms improved after palliative radiotherapy. This is the first reported case of dural metastases of gastric adenocarcinoma of the spine and skull base but with a relatively indolent course and without subdural hematoma.

Intracranial dural, calvarial, and skull base metastases

Metastatic disease to the intracranial dura, the calvarium, and the skull base is relatively uncommon but presents unique diagnostic and management challenges in the patient with cancer. Modern imaging techniques have facilitated the detection of intracranial tumor deposits, leading to increased incidence. While dural and calvarial metastases often present with nonspecific symptoms, skull base metastases present with distinct clinical syndromes dependent on the local neurovascular structures affected. Intracranial dural metastases can often be confused with meningioma and pose a diagnostic challenge, as well as significant neurologic morbidity, especially in the setting of hemorrhage. Surgical intervention may be helpful in selected patients for symptomatic relief as well as survival benefit. Management paradigms need to take into account the relative risks, benefits, and likely outcomes for each possible modality of treatment. Surgical excision is useful in many patients and in combination with radiation therapy can provide significant palliation. While medical therapy is rarely an initial therapy in these entities, it may be of added benefit dependent on the underlying tumor histology and prior treatment history. Occasionally treatment with curative intent is justified.

Dural prostate metastasis presenting as a subdural hematoma

The incidence of subdural hematoma is approximately 13.1/100.000 per year. Subdural hematoma due to skull and dura mater metastases is rare. In this study, a 71-year-old patient with prostate adenocarcinoma who presented with chronic subdural hematoma due to skull bone and dura mater metastasis is presented.

Acute on chronic bilateral subdural hematoma presenting with acute complete flaccid paraplegia and urinary retention mimicking an acute spinal cord injury: a case report

Background

A subdural hematoma refers to a collection of blood between the dura and the arachnoid membranes and is classified into acute, sub acute and chronic. Subdural hematoma has been referred to as the “great neurologic imitator” as it can mimic many neurological conditions.

Case presentation

Forty-three year old Sri Lankan female presented 2 weeks following traumatic head injury with bilateral flaccid complete paraplegia and urinary retention. Her non-contrast computer tomography of the brain revealed bilateral acute, chronic subdural hematomas. Both subdural hematomas were aspirated and she recovered completely.

Conclusions

Chronic subdural hematoma can present in many different unusual ways including bilateral complete paraplegia and acute urinary retention mimicking acute spinal cord pathology. The exact mechanism of this clinical presentation is not clear and may be due to direct compression of the motor cortex to the falx or due to compression of the anterior cerebral artery due to subfalcine herniation. This case illustrates the importance of considering subdural hematoma as a rare cause for acute paraplegia and the importance of performing a computer tomography scan in traumatic brain injury when indicated. Failure to consider non-spinal causes of paraplegia results in potential mismanagement. According to our knowledge this is the first case report of acute on chronic subdural hematoma presenting as acute flaccid complete paraplegia with urinary retention.

Isolated pachymeningeal metastasis from breast cancer: Clinical features and prognostic factors

PURPOSE

To evaluate the clinical features and prognoses of patients with isolated pachymeningeal metastasis (IPM) from breast cancer.

METHODS

We reviewed the medical records of all patients with metastatic breast cancer (MBC) treated from January 2009 to August 2016. Eligibility criteria included diagnosis of pachymeningeal metastasis based on brain magnetic resonance imaging and histologic diagnosis of primary breast cancer. We excluded patients with concomitant parenchymal or leptomeningeal metastases.

RESULTS

Thirty-eight patients who matched our inclusion criteria were included in this study. The incidence of IPM in breast cancer was 1.5% of all patients with MBC. The molecular subtype distribution was: triple negative, 29.0%; ER+/HER2-, 44.7%; ER+/HER2+, 18.4%; and ER-/HER2+, 7.9%. All isolated pachymeningeal involvement resulted from the direct extension of skull metastases. The median time to IPM from systemic metastasis was 28.6 (95% CI: 23.6-33.6) months. The median time to IPM from skull metastasis was 5.2 (95% CI: 0-10.9) months. The median overall survival (OS) from IPM was 4.0 (95% CI: 2.5-5.5) months. In patients who received chemotherapy the OS was longer than for those who received radiotherapy or supportive care only [median OS 8.9 (95% CI: 0.0-18.4), 2.8 (95% CI: 0.5-5.0), and 0.8 (95% CI: 0.6-1.1) months, respectively (p = 0.006)]. Multivariate analysis revealed that good performance status and chemotherapy were associated with better survival outcomes.

CONCLUSION

Stratified evaluation is required for patients with skull metastasis from breast cancer, as pachymeningeal involvement can develop and be associated with unsuspected outcomes.

Widespread subdural metastasis from breast cancer progressing rapidly with cerebral herniation: A case report

We herein present the case of a 49-year-old female patient presenting with nausea and headache. The patient's medical history included breast cancer with bone and lymph node metastasis. Computed tomography (CT) examination revealed a high-density lesion in the right subdural space, suggesting hematoma. During surgery planned for subdural hematoma drainage, an en plaque subdural yellowish-white tumor was identified, without hematoma. Histopathological examination revealed metastatic breast cancer. The patient was administered predonisolone and her neurological symptoms gradually recovered. However, 12 days after the first operation, the clinical course was complicated by vomiting and rapid loss of consciousness. Emergency CT revealed that the subdural tumor had enlarged and decompression was performed as life-saving surgery. However, the patient's condition progressively deteriorated and she finally succumbed to the disease 2 months after the second operation. The aim of this study was to present the case of a patient with a large en plaque subdural tumor mimicking subdural hematoma and causing rapid loss of consciousness and cerebral herniation.

Facial Paralysis and Hearing Loss: A Rare Manifestation of Prostate Cancer Metastases

Dural prostate metastases (DPM) are a rare manifestation of metastatic prostate cancer seen in approximately one to six percent of cases. Presenting symptoms may include signs of elevated intracranial pressure, headache, altered mental status, or cranial nerve palsies. Hearing loss, sensory changes, dysarthria, and dysphagia are rare symptoms in DPM that were present in our patient. We present a case of a 58-year-old male with a known diagnosis of adenocarcinoma of the prostate presenting with symptoms of acute exacerbation of chronic obstructive pulmonary disease (COPD), sub-acute right-sided hearing loss, and right-sided facial paralysis. Over the course of hospitalization, his neurological symptoms worsened and he developed dysarthria, dysphagia, facial numbness, and worsening back pain. He also appeared more withdrawn and lethargic. The symptoms prompted a neurological evaluation and a magnetic resonance imaging (MRI) revealed multiple areas of bone marrow signal abnormality compatible with osseous metastatic disease. There was extensive smooth dural thickening as well as focal nodular thickening, both consistent with dural metastases. The patient was treated with corticosteroids and external beam radiation therapy (EBRT) with improvement in his back pain and facial paralysis. He died two weeks after completing EBRT. Although rare, DPM should be suspected in males over 50 years of age presenting with neurological symptoms. An MRI with gadolinium is most helpful in delineating the presence and extent of dural and calvarial involvement. Corticosteroids and EBRT have been shown to improve neurological function in up to 67% of patients. However, median survival post-radiation remains approximately three months.

Recurrent Olfactory Neuroblastoma in Remote Leptomeninges, Mimicking Intracranial Meningioma

BACKGROUND

Olfactory neuroblastoma (ONB) is an uncommon neoplasm that arises from olfactory epithelium in the nasal cavity near the cribriform plate. Although local recurrence or direct extension along olfactory epithelium and metastasis to the central nervous system has been reported, remote leptomeningeal metastasis is quite rare. In our report of a leptomeningeal metastasis of ONB without recurrence of primary site, we discuss the possible pathogenesis of this rare phenomenon with a review of the literature.

CASE DESCRIPTION

A 56-year-old woman was admitted with epistaxis. Magnetic resonance imaging revealed a mass in the right cribriform plate and ethmoid sinus with intracranial extension. She was primarily treated with craniofacial resection followed by radiotherapy. Gross total resection was achieved, but annual follow-up magnetic resonance imaging showed a new enhancing mass in the left parietal meninges mimicking meningioma without local recurrence at 5 years after the first operation. A second operation was performed, and pathologic examination confirmed the lesion as metastatic olfactory neuroblastoma.

CONCLUSIONS

ONB is a locally aggressive tumor, but it also potentially spreads to remote leptomeninges via blood or cerebrospinal fluid. Therefore, careful evaluation is needed not to misdiagnose a meningioma and delay the treatment. Moreover, understanding the route of remote leptomeningeal metastasis and en-bloc resection of tumor at first operation might reduce leptomeningeal metastasis, irrespective of surgical corridors.