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Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 955-957 Letter to Editor Significance of dural tail sign in cerebellar stroke Carmelo Lucio Sturiale Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy Date of Acceptance: 23-Aug-2010 Code Number: ni10269 PMID: 21150071 Sir, A 69-year-old man presented with a 9-day history of disorientation that was acute in onset, dizziness and appendicular ataxia. Neurological examination showed the patient to be alert and oriented to name and place; a minor dysmetria in the upper limbs, prominent on the left side, associated with slightly dysarthric speech was noted. Fundus oculi showed disputable early papilledema. Neither cranial nerve involvement nor pyramidal and meningeal signs were evident. A brain MRI scan revealed an irregularly shaped lesion in the left cerebellar hemisphere, partly involving the homolateral upper cerebellar peduncle. Lesion demonstrated mild hypointensity on T1-weighted and slight hyperintensity on T2-weighted images, showing a relatively intense enhancement and a marked dural tail sign (DTS) along its tentorial implant after gadolinium administration [[Figure - 1]a-d]. On the basis of clinical and neuroradiological findings, first presumptive diagnosis was meningioma, because the presence of the DTS is usually considered specific for this tumor. The patient underwent steroid therapy with progressive clinical improvement. On the second MRI scan, surprisingly, the lesion appeared to be reduced in size, heterogeneously enhanced after gadolinium administration, without DTS, outlining a cerebellar infarct [[Figure - 2]a-d]. DTS usually appears on MRI as a narrowing rim, smooth or slightly nodular, ranging from 0.5 to 3 cm in length. This comes out from a reactive thickening of the dura mater, adjacent to a dural-based lesion. [1] When this sign was first described by Wilms et al. in 1989, it was thought to be specific for meningiomas. [1] Goldsher et al. in 1990 confirmed this sign was present in about 60% of meningiomas, representing tissue containing tumoral nodules; it was not significantly associated with other intracranial tumors in their series. [2] Successively, many authors demonstrated that DTS was highly suggestive but not specific for meningiomas. Indeed, up to now, it has been reported in a growing number of brain tumors other than meningiomas; as well as in infectious, autoimmune and vascular diseases. [3] The presence of DTS in cerebral or cerebellar infarct can pose difficulties in differential diagnosis. Specifically, an ischemic lesion with mass effect is able to mimic a tumor mass, especially when it undergoes hemorrhagic transformation, demonstrating contrast enhancement [4] or MRI "fogging" on T2-weighted images in subacute phase. [5] In the case we reported, the initial diagnosis was re-discussed, considering the clinical acute onset not clearly matching with a slow-growing benign lesion and the clinical improvement after steroid therapy. Thus, patient underwent further brain MRI investigation 1 month later, revealing likely evolutive morphologic changes: lesion appeared reduced in size, heterogeneously enhanced on T1-weighted+c images, with disappearance of the DTS previously documented, thus outlining a case of cerebellar infarct, probably concerning left superior cerebellar artery territory [[Figure - 2]a-d]. Hence even if DTS remains a highly sensitive sign for meningiomas, it is not specific. At the same time, it strengthens the hypothesis that DTS is not only related to properly dural lesions, but it can also depict a reactive state of the dura mater due to a contiguous parenchymal lesion, even not neoplastic in origin. References
Copyright 2010 - Neurology India The following images related to this document are available:Photo images[ni10269f1.jpg] [ni10269f2.jpg] |
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