Sellar meningioma

A young female with visual deficit, previous CT report mentions a sellar supra sellar iso dense enhancing mass. Possibility given was Macro adenoma.

Pt refereed for further evaluation by MRI.

Sagittal T2w images show a sellar supra sellar soft tissue signal intensity well circumscribed mass.Pituitary seen separately in at the floor of hypophyseal fossa. Lesion show homogenous enhancement, a focal dural tailing anteriorly on sagittal post contrast T1 w images.

Radiological diagnosis: Sellar meningioma.

Take home massage is all sellar supra sellar masses are not macro adenoma or Craniopharyngioma. Never play on front foot while reporting CT. Always entertain DDs for sellar supra sellar masses on CT and advise MRI for further evaluation as MRI can demonstrate sellar anatomy better than CT due to its high resolution and multi planner imaging capability compared to CT. MRI can demonstrate pituitary separately in hypophyseal fossa which rules out Macroadenoma as in this case of sellar supra sellar meningioma.

Sphenoid wing Meningioma MRI

MRI Brain Axial T2, T1 and Post contrast T1.

Axial T1 and T2w MRI sections show an extra axial dura based solid signal intensity mass, overlying lateral sphenoid wing, homogenously iso intense to cortical grey matter on T1 and T2w images, intense homogenous enhancement on post contrast T1 with dural tailing.
Marked peri lesional Odema in adjacent compressed left frontal lobe parenchyma.
An associated adjacent meningeal cyst in left sylvian fissure.

Significant mass effect as mid brain is compressed.

On single voxel MR Spectroscopy,
At 1.3ppm Peaks of Alanine which is very typical for meningioma.
Absence of NAA at 2 ppm implies to Non neuronal neoplasm with high choline at 3.2ppm.


Imagingwise diagnosis : Sphenoid wing Meningioma. 




Histopathological report : Meningioma (Transitional – psammomatous variant).
Gross Appearance : Dull – grey tan tissue with friable appearance.
Microscopy : : Benign neoplasm of probable meningothelial cell origin. It comprise moderately cellular, largely patternless or sheet - like growth of intermediate sized, round to oval cells having modestly hyperchromatic nuclei with round to oval configuration and having delicate - peripherally condensed chromatin and many cells having small nucleoli. Overall scattered cells show nucleoli - cytoplasmic invaginations. The cells have faint eosinophilic cytoplasm with indistinct margins. Few foci show vague lobularity and occasional mitotic figure. Many scattered foci show psammomatous calcific spherules. The scanty interstitium shows entrapped congested blood vessels. 

Other similar cases : Meningioma

Dural Tail Sign – Meningioma

Dural tailing is seen on post contrast T1w MRI images, as focal thickening of the enhancing dura adjacent to the mass that resembles a tail extending from the lesion.

The sign first described by Wilms and colleagues in relation to Meningioma.
Goldsher and his associates in 1990, adopted three criteria to define dural tailing radiologically;
1. The tail should be identified on two successive sections,
2. The focal thickening should taper smoothly away from the mass and
3. The intensity of enhancement same or greater than that of the mass.
Based on these criteria dural tail sign was demonstrated in 60% of meningioma cases and it was concluded that its presence was very specific for meningioma.

Many non meningioma cases have now been reported with dural tails, like chloroma, primary central nervous system lymphoma, sarcoidosis, vestibular schwannoma, metastatic tumor, syphilitic gumma, and an aggressive papillary middle ear tumor.
So the Dural tailing is one of the supportive findings for radiological diagnosis of Meningioma and not specific for Meningioma.
It was initially proposed that dural tails resulted from direct tumor invasion but most of studies later failed to demonstrate any direct tumor involvement histopathologically. It is now therefore proposed that dural tails represents reactive change of adjacent dura mater.

Multiple intracranial Meningiomas

A19 yo male with history of mild headache.

MRI study shows:
Three meningiomas, largest is falcine meningioma along inter hemispheric fissure, 2nd in left frontal region near orbit, 3rd smaller one in left parietal region.  Signal iso intense to cortical grey matter. Mild perilesional odema.
No vestibular schwannoma on any side.
Clinically no family history or signs of NF2. No family history of meningiomatosis.

Imaging diagnosis : Multiple intracranial meningiomas.

Multiple intracranial meningiomas is a condition where more than one meningioma in several intracranial locations in the same patient without signs of neurofibromatosis.
Incidence varies from 1 to10%.


Multiple intracranial meningiomas do not imply neurofibromatosis.
Despite of multiplicity, multiple meningiomas does not differ in prognosis from benign solitary meningiomas.

Related post : Meningioma MR Spectroscopy