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Glioblastoma Mimicking : Report of 2 Cases Mohit Patel, Ha Son Nguyen, Ninh Doan, Michael Gelsomino, Saman Shabani, Wade Mueller

Key words - BACKGROUND: can mimic various pathologies, including - CSF cleft sign arteriovenous malformation, hemorrhage from ischemic , cerebral contu- - Dural tail sign - Glioblastoma multiforme sion, metastatic disease, , and infection. The literature is limited - Meningioma regarding diagnostic confusion with meningioma. Herein, we present 2 patients - Middle meningeal artery that exhibited imaging, including cerebral angiography during preoperative - Occipital artery , which was consistent with meningioma, but where final surgical - Preoperative embolization - Spoke wheel sign diagnosis revealed glioblastoma. - Sunburst sign - CASE DESCRIPTION: Case 1 was a 57-year-old woman presenting with Abbreviations and Acronyms , ataxia, and memory lapses for the past month. magnetic AV: Arteriovenous resonance imaging (MRI) demonstrated a heterogeneous-enhancing right tem- CSF: poroparietal mass with broad contact along the right tentorium, cerebrospinal MMA: Middle meningeal artery fluid (CSF) cleft sign, and dural tail sign—consistent with meningioma. Patient Department of , Medical College of Wisconsin, underwent angiography with successful polyvinyl alcohol foam (PVA) particle Milwaukee, Wisconsin, USA embolization of the petrosquamosal branch of the right middle meningeal artery To whom correspondence should be addressed: (MMA) and meningeal branch of the right occipital artery, resulting in significant Ha Son Nguyen, M.D. [E-mail: [email protected]] devascularization of the tumor blush. Subsequently, the patient underwent tumor Citation: World Neurosurg. (2016) 95:624.e9-624.e13. resection, where pathology revealed glioblastoma. Case 2 was a 60-year-old http://dx.doi.org/10.1016/j.wneu.2016.08.048 man presenting with right . Brain MRI demonstrated a left para- Journal homepage: www.WORLDNEUROSURGERY.org sagittal, heterogeneous-enhancing mass abutting the falx with a dural tail Available online: www.sciencedirect.com sign—consistent with meningioma. Patient underwent angiography with suc- 1878-8750/ª 2016 The Author(s). Published by Elsevier Inc. cessful PVA particle embolization of the left MMA, resulting in significant This is an open access article under the CC BY-NC-ND devascularization of the tumor blush. Patient underwent a tumor resection license (http://creativecommons.org/licenses/by-nc-nd/4.0/). where pathology revealed glioblastoma.

INTRODUCTION - CONCLUSIONS: Glioblastoma can mimic meningioma on MRI with dural tail Glioblastoma is the most common ma- sign, CSF cleft sign, and broad dural contact. Moreover, cerebral angiography lignant primary tumor of the central ner- can reveal tumor feeders commonly associated with meningioma. These fea- vous system.1,2 The tumor can mimic tures can contribute to diagnostic confusion. Based on these 2 cases, preop- various pathologies, including arteriove- erative embolization of tumor feeders is possible with glioblastoma. nous (AV) malformation, hemorrhage from ischemic stroke, cerebral contusion, metastatic disease, lymphoma, and infec- with broad contact along the right tento- noted. Estimated blood loss was 450 mL. tion. The literature is limited regarding rium (Figure 1). Along with minimal The final pathology revealed a diagnosis of diagnostic confusion with meningioma. vasogenic edema, cerebrospinal fluid glioblastoma. Currently, the patient is on Herein, we present 2 patients that exhibi- (CSF) cleft sign, and dural tail sign, final concurrent whole brain radiation and ted imaging, including cerebral angiog- radiology interpretation noted findings . raphy during preoperative embolization, most suggestive for a meningioma. which was consistent with meningioma, Subsequently, the patient underwent but where final surgical diagnosis revealed angiography with successful polyvinyl CASE 2 glioblastoma. alcohol particle embolization of the A 60-year-old man presented with right petrosquamosal branch of the right middle hemiparesis. Brain magnetic resonance meningeal artery (MMA) and meningeal imaging demonstrated a left parasagittal, CASE 1 branch of the right occipital artery, heterogeneous-enhancing mass abutting A 57-year-old woman presented with head- resulting in significant devascularization of the falx with a dural tail sign (Figure 4). ache, ataxia, and memory lapses for the past the tumor blush (Figures 2 and 3). The Final radiology interpretation noted month. Brain magnetic resonance imaging following day, the patient underwent a findings most suggestive for a demonstrated a large, heterogeneous- right frontotemporal for tumor meningioma. Subsequently, the patient enhancing right temporoparietal mass resection, where necrotic tumor was underwent angiography with successful

624.E9 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.08.048 CASE REPORT MOHIT PATEL ET AL. GLIOBLASTOMA MIMICKING MENINGIOMA: REPORT OF 2 CASES

Figure 1. Case 1: (A) axial magnetic resonance (MR) T2 image (C) Coronal MR T1 image with contrast demonstrates broad dural contact demonstrates minimal vasogenic edema and CSF cleft sign (arrowheads). along the tentorium (red arrowheads) with small dural tail sign (yellow (B) Axial MR T1 image with contrast demonstrates well-defined margins. arrowhead).

polyvinyl alcohol particle embolization of underwent infusion and present. Common differential diagnoses the left MMA, resulting in significant pulsed low-dose . His include cerebral , metastases, devascularization of the tumor blush condition progressed and he passed away lymphoma, and tumefactive demyelin- (Figure 5). The following day, the patient 6 months after recurrence. ation. On the other hand, meningioma underwent a left parasagittal craniotomy presents as a lobular, extra-axial mass for mass resection, where necrotic tumor with well-defined boundaries and intense was noted. Estimated blood loss was 200 DISCUSSION enhancement.3 The pathology frequently mL. The final pathology revealed a On magnetic resonance imaging, glio- exhibits broad-based dural contact.3 With diagnosis of glioblastoma. The patient appears as a sizeable, intra-axial a large mass, there is inward underwent concurrent whole brain mass with ill-defined margins. The pa- displacement of the cortical gray matter.3 radiation and temozolomide, followed by thology can exhibit irregular, peripheral, Common locations include the cerebral 12 months of adjuvant temozolomide. At and/or nodular enhancement with a cen- convexity, parasagittal, and sphenoid 22 months after the initial diagnosis, the tral heterogeneous signal (caused by ne- wing regions.3 Classic magnetic patient exhibited recurrent disease with crosis or intratumoral hemorrhage). resonance imaging features include the right hemiparesis and aphasia. He Profound vasogenic edema is typically CSF cleft sign (a perimeter of CSF

Figure 2. Case 1: right external carotid artery injection before (A) anterior (C) lateral projection). Notice decrease in tumor blush (arrows). posterior projection and (B) lateral projection) and after embolization

WORLD NEUROSURGERY 95: 624.e9-624.e13, NOVEMBER 2016 www.WORLDNEUROSURGERY.org 624.E10 CASE REPORT MOHIT PATEL ET AL. GLIOBLASTOMA MIMICKING MENINGIOMA: REPORT OF 2 CASES

Figure 3. Case 1: right occipital artery injection before (A) and after (B) embolization. Notice decrease in tumor blush (arrows).

between the tumor and brain meningioma: the first patient exhibited prior cases stress the potential confusion parenchyma), sunburst or spoke wheel well-defined margins, displacement of between meningioma and glioblastoma on pattern (radial divergence of feeder cortical gray matter, CSF cleft sign, dural magnetic resonance imaging: the dural tail arterial branches), and dural tail sign tail sign, relatively profound enhancement, sign has been reported in 9 prior cases4-8 (thickening and enhancement of the and mild vasogenic edema given the size of and the CSF cleft sign in 1 case.7 adjacent dura).3 the mass; the second patient exhibited On cerebral angiography, Yoshikawa Both of the patients exhibited magnetic well-defined margins, a superficial para- et al.9 demonstrated that AV shunting was resonance imaging features consistent with sagittal location, and dural tail sign. Several present in 72% of patients with perisylvian and 13% of patients with nonperisylvian glioblastomas. Glioblastomas are often hypervascular tumors associated with oversecretion of growth factors, such as vascular endothelial growth factors, that may induce angiogenesis and alter flow dynamics. With AV shunting, low- resistance vessels may develop, leading to more regional blood flow and hemo- dynamic stress to vessel walls that could promote formation of aneurysms.10-14 Moreover, of tumor cells into blood vessel walls may lead to formation of aneurysms as well.10,11,15 Instances of AV malformation within glioblastoma have also been described.16,17 Preoperative embolization is not commonplace. Imai et al.1 described a case that involved embolization of AV shunting in a glioblastoma where the neurosurgical team deemed it beneficial to decrease intraoperative bleeding. For intratumoral aneurysms, Nguyen et al.13 and Ene Figure 4. Case 2: coronal magnetic resonance T1 image with contrast et al.18 used coil embolization of the demonstrates left parasagittal mass with dural tail sign (arrow). aneurysm prior to tumor resection, given

624.E11 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2016.08.048 CASE REPORT MOHIT PATEL ET AL. GLIOBLASTOMA MIMICKING MENINGIOMA: REPORT OF 2 CASES

Figure 5. Case 2: anterior-posterior images before embolization (A) and after embolization (B) demonstrate decrease tumor blush (arrows).

concerns for potential subarachnoid meningioma can exist for glioblastoma. can contribute to diagnostic confusion. hemorrhage13 and goals to reduce the This feature has been reported in 4 prior Based on these 2 cases, preoperative risk for intraoperative hemorrhage.13,18 cases of glioma4,22-24; preoperative embo- embolization of tumor feeders is possible Endovascular embolization has steadily lization was not an option as the cases with glioblastoma. Further research on gained prominence for the management of predated this technique. preoperative embolization of glioblastoma meningioma.19 Up to 44% of intracranial These 2 cases reveal that preoperative needs to be conducted to evaluate poten- undergo embolization prior embolization of tumor feeders can be done tial benefits in treatment of glioblastoma to resection.20 For cranial vault locations, for glioblastoma. Retrospectively, given the and the embolization effects on intra- primary blood feeders may stem from the final pathology and that preoperative operative bleeding, resection site, and superficial temporal, occipital, middle embolization is not standard treatment for overall prognosis. meningeal, and/or posterior meningeal glioblastoma, the patients may have un- arteries; for skull base locations, feeders derwent unnecessary risks associated with may emanate from the internal carotid embolization. The complication rate for REFERENCES artery or vertebrobasilar system.21 Feeders embolization is 4.6%e6.8%,21 including appear as a tumor blush; the finding is risks for stroke and blood vessel rupture.25 1. Imai T, Ohshima T, Nishizawa T, Shimato S, Kato K. Successful preoperative endovascular generally associated with meningioma but Moreover, with only 2 cases, we cannot embolization of an extreme hypervascular glio- is present in other pathologies, such as say with certainty that preoperative blastoma mimicking an arteriovenous malforma- , , embolization effectively reduced blood tion. World Neurosurg. 2016;86:512.e1-512.e4. and .19 Large series have loss or facilitated tumor resection with reported salient advantages, including increased tumor or tumor 2. Ostrom QT, Gittleman H, Liao P, Rouse C, reduced operative blood loss, shortened softening. Operative findings regarding Chen Y, Dowling J, et al. CBTRUS statistical report: primary brain and operative duration, and increased tumor tumor necrosis may be related to tumors diagnosed in the United States in 2007- necrosis and softening.1,20,21 glioblastoma pathology, rather than 2011. Neuro Oncol. 2014;16(suppl 4):iv1-iv63. With magnetic resonance imaging effects from preoperative embolization. consistent for meningioma, both of the 3. Watts J, Box G, Galvin A, Brotchie P, Trost N, patients underwent preoperative emboli- Sutherland T. Magnetic resonance imaging of CONCLUSIONS meningiomas: a pictorial review. Insights Imaging. zation. Angiography demonstrated a 2014;5:113-122. characteristic tumor blush for both pa- Glioblastoma can mimic meningioma on tients. Moreover, the feeders were typical magnetic resonance imaging with dural 4. Wilms G, Lammens M, Marchal G, Demaerel P, vessels associated with meningioma, such tail sign, CSF cleft sign, and broad dural Verplancke J, Van Calenbergh F, et al. Prominent as branches from the MMA and occipital contact. Moreover, cerebral angiography dural enhancement adjacent to nonmening- iomatous malignant lesions on contrast-enhanced artery. Chance enabled the realization that can reveal tumor feeders commonly asso- MR images. AJNR Am J Neuroradiol. 1991;12: tumor feeders commonly associated with ciated with meningioma. These features 761-764.

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5. Gupta S, Gupta RK, Banerjee D, Gujral RB. cerebral artery aneurysm and a glioblastoma: case 21. Shah AH, Patel N, Raper DM, Bregy A, Ashour R, Problems with the “dural tail” sign. Neuroradiology. report and review of literature. Int Med Case Rep J. Elhammady MS, et al. The role of preoperative 1993;35:541-542. 2015;8:295-299. embolization for intracranial meningiomas. J Neurosurg. 2013;119:364-372. fi 6. Guermazi A, La tte F, Miaux Y, Adem C, 14. Yoon WS, Lee KS, Jeun SS, Hong YK. De novo e Bonneville JF, Chiras J. The dural tail sign aneurysm after treatment of glioblastoma. J Korean 22. Ide M, Jimbo M, Yamamoto M, Tanaka N, beyond meningioma. Clin Radiol. 2005;60:171-188. Neurosurg Soc. 2011;50:457-459. Kubo O. [Gliosarcomaea case report]. No Shinkei 7. Hsieh CT, Liu MY, Tang CT, Sun JM, Tsai WC, Geka. 1987;15:49-54 [in Japanese]. 15. Cowen RL, Siqueira EB, George E. Angiographic Hsia CC. Problem of dural tail sign in glioblas- demonstration of a involving the wall of toma multiforme? Acta Neurol Belg. 2009;109: the anterior cerebral artery. Report of a case. 23. Hasuo K, Fukui M, Tamura S, Numaguchi Y, 310-313. Radiology. 1970;97:577-578. Kishikawa T, Uchino A, et al. with dural 8. Wu B, Liu W, Zhu H, Feng H, Liu J. Primary invasion: computed tomography and angiography. J Comput Tomogr. 1988;12:100-107. glioblastoma of the in 16. Boikov AS, Schweitzer AD, Young RJ, Lavi E, adults. J Neurosurg. 2011;114:1288-1293. Tsiouris AJ, Gupta A. Glioblastoma-arteriovenous fi stula complex: imaging characteristics and 24. Silverberg GD, Hanbery JW. Meningeal invasion 9. Yoshikawa A, Nakada M, Kita D, Watanabe T, treatment considerations. Clin Imaging. 2014;38: by gliomas. J Neurosurg. 1971;34:549-554. Kinoshita M, Miyashita K, et al. Visualization of 187-190. angiographical arteriovenous shunting in peri- sylvian glioblastomas. Acta Neurochir (Wien). 2013; 17. Cemil B, Tun K, Polat O, Ozen O, Kaptanoglu E. 25. Su YS, Ali R, Feroze AH, Li G, Lawton MT, 155:715-719. Glioblastoma multiforme mimicking arteriove- Choudhri O. Endovascular therapies for malignant nous malformation. Turk Neurosurg. 2009;19: gliomas: challenges and the future. J Clin Neurosci. 10. Andrews BT, Raffel C, Rosegay H. Subarachnoid 433-436. 2016;26:26-32. hemorrhage from a peripheral intracranial aneu- rysm associated with malignant glioma: report of 18. Ene CI, Nerva JD, McGrath L, Flanagan ME, a case. Neurosurgery. 1985;17:645-649. Chamberlain MC, Silbergeld DL. Flow-related Conflict of interest statement: The authors declare that the aneurysm within glioblastoma: a case report and article content was composed in the absence of any 11. Aoki N, Sakai T, Oikawa A, Takizawa T, Koike M. review of literature. World Neurosurg. 2016;89: commercial or financial relationships that could be construed Dissection of the middle cerebral artery caused by 729.e1-729.e6. as a potential conflict of interest. invasion of malignant glioma presenting as acute onset of hemiplegia. Acta Neurochir (Wien). 1999; Received 28 May 2016; accepted 12 August 2016 141:1005-1008. 19. Ashour R, Aziz-Sultan A. Preoperative tumor embolization. Neurosurg Clin N Am. 2014;25: Citation: World Neurosurg. (2016) 95:624.e9-624.e13. http://dx.doi.org/10.1016/j.wneu.2016.08.048 12. Hashiguchi A, Morioka M, Ichimura H, Mimata C, 607-617. Kuratsu J. Glioblastoma with an intratumoral Journal homepage: www.WORLDNEUROSURGERY.org 20. Raper DM, Starke RM, Henderson F Jr, Ding D, feeding-artery aneurysm. Clin Neurol Neurosurg. Available online: www.sciencedirect.com 2007;109:302-304. Simon S, Evans AJ, et al. Preoperative emboliza- tion of intracranial meningiomas: efficacy, tech- 1878-8750/ª 2016 The Author(s). Published by Elsevier Inc. 13. Nguyen HS, Doan N, Gelsomino M, Shabani S, nical considerations, and complications. AJNR Am This is an open access article under the CC BY-NC-ND Mueller W, Zaidat OO. Coincidence of an anterior J Neuroradiol. 2014;35:1798-1804. license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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