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LETTER TO EDITOR
Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 955-957

Significance of dural tail sign in cerebellar stroke


Institute of Neurosurgery, Catholic University School of Medicine, Rome, Italy

Date of Acceptance23-Aug-2010
Date of Web Publication10-Dec-2010

Correspondence Address:
Carmelo Lucio Sturiale
Institute of Neurosurgery, Catholic University School of Medicine, Rome
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.73762

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How to cite this article:
Sturiale CL. Significance of dural tail sign in cerebellar stroke. Neurol India 2010;58:955-7

How to cite this URL:
Sturiale CL. Significance of dural tail sign in cerebellar stroke. Neurol India [serial online] 2010 [cited 2019 Dec 11];58:955-7. Available from: http://www.neurologyindia.com/text.asp?2010/58/6/955/73762


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].
Figure 1: Coronal T1-weighted+c brain MRI showing an irregularly shaped lesion involving the left cerebellar hemisphere exhibiting a marked dural tail sign along its tentorial implant after gadolinium administration (a-b). Coronal T2-weighted images showing a mild hyperintense lesion suggestive of perilesional edema (c-d)

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Figure 2: Coronal T1-weighted+c (a-b) and T2-weighted (c-d) MRI performed 1 month after having seen the cerebellar lesion reduced in size, slightly enhanced after gadolinium administration, related to blood-brain barrier disruption, without any DTS. Coronal T2-weighted images showing a residual mild hyperintense signal (c-d)

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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.

 
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1.Wilms G, Lammens M, Marchal G, Van Calenbergh F, Plets C, Van Fraeyenhoven L, et al. Thickening of dura surrounding meningiomas: MR features. J Comput Assist Tomogr 1989;13:763-8.  Back to cited text no. 1
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2.Goldsher D, Litt AW, Pinto RS, Bannon KR, Kricheff II. Dural "tail" associated with meningiomas on Gd-DTPA-enhanced MR images: characteristics, differential diagnostic value, and possible implications for treatment. Radiology 1990;176:447-50.  Back to cited text no. 2
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3.Rokni-Yazdi H, Sotoudeh H. Prevalence of "dural tail sign" in patients with different intracranial pathologies. European Journal of Radiology 2006;60:42-5.  Back to cited text no. 3
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4.Schwartz A, Gass A, Hennerici M. Stroke vignette. Epidural hematoma and hemorrhagic infarction mimicking a left temporal meningioma. Cerebrovascular Diseases 1999;9:251-2.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Danchaivijitr N, Wakeham NR, Patel MC, McEvoy AW, Van dellen J, Waldman AD. Subacute cerebellar infarct mimicking meningioma. Clinical Radiology 2004;59:531-3.  Back to cited text no. 5
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