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The Journal of Clinical Endocrinology & Metabolism Vol. 92, No. 9 3367-3368
Copyright © 2007 by The Endocrine Society

IMAGE IN ENDOCRINOLOGY

A Dural Tale

Allan F. Moore and Steven K. Grinspoon

Endocrine Division (A.F.M.) and Neuroendocrine Unit (S.K.G.), Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114

Address all correspondence and requests for reprints to: Steven K. Grinspoon, M.D., Program in Nutritional Metabolism and Neuroendocrine Unit, Massachusetts General Hospital, 55 Fruit Street, Longfellow 207, Boston, Massachusetts 02114. E-mail: sgrinspoon{at}partners.org.

A 44-yr-old cushingoid-appearing male was referred to the Massachusetts General Hospital for evaluation of a new sellar mass. He presented with rapid onset of symptoms over 6 months, including weight loss and hypokalemia. The 3-cm T1-enhancing sellar mass tapered posteriorly along the left tentorium, forming a "dural tail" (Fig. 1Go), suggesting a meningioma. Endocrine evaluation revealed ACTH-dependent Cushing’s syndrome, with a urine-free cortisol of 303 µg/24 h (normal 20–70 µg/24 h) 1 and an ACTH level of 83 pg/ml (normal 6–76 pg/ml) 2. An inferior sinus petrosal catheterization, performed due to the unusual radiological characteristics of the sellar mass and symptoms of weight loss and hypokalemia, confirmed a central source of excess ACTH secretion. Tissue obtained during transsphenoidal debulking revealed a corticotroph macroadenoma without evidence of meningioma. The dural tail sign is usually associated with meningiomas (1, 2, 3). The sign was thought initially to be specific for meningioma but has been described in association with other pituitary and intracranial processes. The sensitivity and specificity of the dural tail sign are approximately 60 and 95%, respectively (4). The tail results from a reactive inflammatory process in the dura mater adjacent to the point of tumor attachment rather than direct tumor infiltration. This case demonstrates that the dural tail sign may be seen with pituitary macroadenomas, and such tumors should be included in the differential diagnosis associated with this sign. The tumor in this case is unusual for Cushing’s disease in its size and radiological presentation (5). This case also demonstrates that ACTH-secreting macroadenomas can be associated with severe symptoms of cortisol excess and mimic ectopic ACTH-secreting tumors.


Figure 1
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  		FIG. 1. Coronal (A), axial (B), and sagittal (C) magnetic resonance imaging of a 3-cm T1-enhancing sellar mass tapered posteriorly along the left tentorium, forming a "dural tail." Arrowsmark dural tail.

 


   Footnotes
 
Disclosure Statement: None of the authors has any disclosures to make.

1 To convert to nmol/d, multiply by 2.759. Back

2 To convert to pmol/liter, multiply by 0.2202. Back

Received April 30, 2007.

Accepted May 24, 2007.


   References
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 References
 

  1. Wilms G, Lammens M, Marchal G, Calenbergh FV, Plets C, Fraeyenhoven LV, Baert AL 1989 Thickening of dura surrounding meningiomas: MR features. J Comput Assist Tomogr 13:763–768[Medline]
  2. Tokumaru A, O’uchi T, Eguchi T, Kawamoto S, Kokubo T, Suzuki M, Kameda T 1990 Prominent meningeal enhancement of the dura adjacent to meningioma on Gd-DTPA enhanced MR images: histopathologic correlation. Radiology 175:431–433[Abstract/Free Full Text]
  3. Goldsher D, Litt AW, Pinto RS, Brannon KR, Kricheff II 1990 Dural "tail" associated with meningiomas on Gd-DTPA enhanced MR images: characteristics, differential diagnostic value and possible implications for treatment. Radiology 176:447–450[Abstract/Free Full Text]
  4. Rokni-Yazdi H, Sotoudeh H 2006 Prevalence of "dural tail sign" in patients with different intracranial pathologies. Eur J Radiol 60:42–45[CrossRef][Medline]
  5. Woo YS, Isidori AM, Wat WZ, Kaltsas GA, Afshar F, Sabin I, Jenkins PJ, Monson, JP, Besser GM, Grossman AB 2005 Clinical and biochemical characteristics of adrenocorticotropin-secreting macroadenomas. J Clin Endocrinol Metab 90:4963–4969[Abstract/Free Full Text]



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