The nodule-pleura relationship affects pneumothorax in CT-guided percutaneous transthoracic needle biopsy: avoiding to cross pleural tail sign may reduce the incidence of pneumothorax.

OBJECTIVES: To explore the role of nodule-pleural relationship, including nodule with pleural tail sign (PTS), nodule with pleural contact and nodule with pleural unrelated in CT-guided percutaneous transthoracic needle biopsy (PTNB)-induced pneumothorax, and whether employing different puncture routes has an impact on the incidence of pneumothorax in PTNB of nodules with PTS. METHODS: Between April 1, 2019, to June 30, 2021, 775 consecutive PTNB procedures of pulmonary nodules in the Peking University Cancer Hospital were retrospectively reviewed. The univariate and multivariate regression analysis were used to identify the risk factors for pneumothorax in PTNB. RESULTS: The nodule with pleural contact group has a lower incidence of pneumothorax than the nodule with PTS group (p = 0.001) and the nodule with pleural unrelated group (p = 0.002). It was observed that a higher incidence of pneumothorax caused by crossing PTS compared with no crossing PTS (p < 0.001). Independent risk factors for pneumothorax included crossing PTS (p < 0.001), perifocal emphysema (p < 0.001), biopsy side up (p < 0.001), longer puncture time (p < 0.001), deeper needle insertion depth (intrapulmonary) (p < 0.001) and nodules in the middle or lower lobe (p = 0.007). CONCLUSION: Patients with crossing PTS, a nodule in the middle or lower lobe, longer puncture time, biopsy side up, deeper needle insertion depth (intrapulmonary), and perifocal emphysema were more likely to experience pneumothorax in PTNB. When performing the biopsy on a nodule with PTS, selecting a route that avoids crossing through the PTS may be advisable to reduce the risk of pneumothorax.

Comparisons of magnetic resonance imaging, histopathological and Ki-67 labeling index findings in a single myxofibrosarcoma: a case report.

BACKGROUND: Myxofibrosarcoma is a myxoid soft tissue sarcoma showing T2 high intensity on magnetic resonance imaging. However, myxofibrosarcoma is a heterogeneous sarcoma with both myxoid and cellular portions. Magnetic resonance imaging findings were obtained MRI findings for comparison with histological and Ki-67 immunohistochemical features, in different portions of one myxofibrosarcoma. CASE PRESENTATION: Magnetic resonance imaging observations were compared with gross pathological and microscopic findings of a myxofibrosarcoma from a 50-year-old Japanese female. The Ki-67 labeling indices of different portions of the tumor, that is, the myxoid, cellular, and histologically confirmed infiltrative margin portions (pathological tail sign), were compared. The T2 low intensity area was more cellular than the T2 high intensity area, while the cellular portion had a significantly higher Ki-67 index than the myxoid portion (p = 0.0313). The portions with the pathological tail sign had a significantly higher Ki-67 labeling index than those without this sign (p = 0.0313). CONCLUSIONS: More cellular portions of a myxofibrosarcoma correspond to more areas of the tumor showing aggressive features. Furthermore, our data also support the hypothesis of high aggressiveness being associated with the pathological tail sign in myxofibrosarcoma. To our knowledge, this is the first case report to describe comparisons among the imaging findings, histological features, and Ki-67 immunohistochemistry results for different portions of one myxofibrosarcoma.

A huge left buttock mass in an old female.

Introduction: Myxofibrosarcoma also known as myxoid malignant fibrous histiocytoma is a rare soft tissue sarcoma that has a predilection for the elderly (beyond the 6th decade). Clinical observation: We report a case of a 64 years old patient that presented gradual appearance of huge tumor on her left buttock. Radiologic examination (MRI) concluded to MFS. There was no evidence of systemic involvement. The patient was directed in an oncology center, where the diagnostis of MFS was confirmed through surgical biopsy. Discussion: MFS is one of the most frequent sarcoma of soft tissue that occurs in elderly patients. This is an infiltrant tumor that is extending through muscular fascia. MRI is the gold standard in characterisation; it makes the positive diagnosis of MFS thanks to the myxoid signal, triple signal and the tail sign that is corresponding to the extension of the tumor into the muscular fascia and peri nervous spaces. Conclusion: Cross-sectionnal imaging in particular MRI plays a key role in the positive diagnosis of soft tissue tumors. It makes possible to approach with great precision the exact nature of the tumor thanks to specific radiological semiology without however claiming to replace histology.

Intraventricular Meningioma: A Case Report of a Common Tumor in an Uncommon Location.

Intraventricular meningiomas are uncommon neoplasms originating within the ventricular system of the brain, constituting a rare subset of central nervous system tumors. Their unique location poses diagnostic challenges, and understanding their clinical manifestations is imperative for effective management. We present the case of a 56-year-old female who sought medical attention due to persistent, severe headaches localized in the occipital region. Laboratory investigations demonstrated normal values for a complete blood count, electrolytes, and liver function tests. Magnetic resonance imaging revealed a well-defined mass in the left occipital horn of the lateral ventricle, indicative of an intraventricular meningioma. Surgical resection of the intraventricular meningioma resulted in the resolution of the patient's headaches. This case contributes valuable insights into the diagnostic challenges posed by intraventricular meningiomas.

Recurrent Plunging Ranula Due to a Sublingual Ectopic Gland: A Rare Clinical Entity.

Ranula is a benign cystic lesion caused by the escape and collection of salivary mucus. Classically, it is divided into simple ranulas, a cystic mass in the floor of the mouth, and diving/plunging/cervical ranulas, a submandibular mass without apparent intraoral involvement. Although plunging ranula is a well-documented cause of neck swelling, its association with the presence of ectopic sublingual glands is extremely rare, with less than five cases reported. Other cervical cystic lesions may have the same clinical aspect; therefore, advanced diagnostic techniques like a CT scan or MRI play a critical role in early diagnosis. Different approaches have been used to treat ranulas, including non-invasive, minimally invasive, and surgical techniques. The purpose of this paper is to highlight a case report of a giant plunging ranula due to an anatomical aberration of the right sublingual gland, along with a significant literature review.

Dural tail sign positive tumors: Points to make a differential diagnosis.

Representative patients were treated with total surgical mass resection, and each tumor was histopathologically confirmed to have a secretory meningioma, intradural metastasis of gynecologic origin, and dural metastasis of lung origin. The imaging findings of these patients were inconclusive in differentiating meningioma from metastasis; hence, advanced magnetic resonance imaging (MRI) techniques were considered. Based on these reports, we studied how to differentiate typical meningiomas from atypical and malignant meningiomas and other dura-based malignant tumors using conventional computed tomography and MRI.

Deep-learning model for diagnostic clue: detecting the dural tail sign for meningiomas on contrast-enhanced T1 weighted images.

Background: Meningiomas are the most common primary central nervous system tumors, and magnetic resonance imaging (MRI), especially contrast-enhanced T1 weighted image (CE T1WI), is used as a fundamental imaging modality for the detection and analysis of the tumors. In this study, we propose an automated deep-learning model for meningioma detection using the dural tail sign. Methods: The dataset included 123 patients with 3,824 dural tail signs on sagittal CE T1WI. The dataset was divided into training and test datasets based on specific time point, and 78 and 45 patients were comprised for the training and test dataset, respectively. To compensate for the small sample size of the training dataset, 39 additional patients with 69 dural tail signs from the open dataset were appended to the training dataset. A You Only Look Once (YOLO) v4 network was trained with sagittal CE T1WI to detect dural tail signs. The normal group dataset, comprised of 51 patients with no abnormal finding on MRI, was employed to evaluate the specificity of the trained model. Results: The sensitivity and false positive average were 82.22% and 29.73, respectively, in the test dataset. The specificity and false positive average were 17.65% and 3.16, respectively, in the normal dataset. Most of the false-positive cases in the test dataset were enhancing vessels, misinterpreted as dural thickening. Conclusions: The proposed model demonstrates an automated detection system for the dural tail sign to identify meningioma in general screening MRI. Our model can facilitate and alleviate radiologists' reading process by notifying the possibility of incidental dural mass based on dural tail sign detection.

Free water and iron content in the substantia nigra at different stages of Parkinson's disease.

PURPOSE: Abnormalities in free water (FW) and susceptibility values exist in the substantia nigra (SN) of patients with Parkinson's disease (PD), but their role in characterizing the disease processes remains uncertain. This study investigated these values at various SN locations and stages of PD, and their relationship with clinical symptoms. METHOD: FW and quantitative susceptibility mapping (QSM) values were evaluated in the anterior and posterior SN, along with swallow-tail-sign (STS) ratings, in patients with PD (early-stage: n = 39; middle-to-advanced-stage: n = 97) and healthy controls (n = 82). The correlation between these indices and motor and non-motor symptoms, and their capability to distinguish PD from healthy controls, were also examined. RESULTS: Increased FW in the anterior and posterior SN and increased QSM values in the posterior SN were observed in both early-stage and middle-to-advanced-stage PD patients (p < 0.05). However, there was no significant difference in FW, QSM values, or STS ratings among patients at different stages. FW and QSM values correlated with motor symptoms in middle-to-advanced-stage patients (p < 0.05), while STS ratings were associated with non-motor symptoms (p < 0.05). Additionally, combining FW and QSM values in the posterior SN with STS ratings in logistic regression showed better performance in distinguishing PD (area under curve = 0.931) compared to using STS ratings alone (area under curve = 0.880). CONCLUSIONS: Findings suggest elevated FW and iron content in PD at different stages, with dissociation in SN location between the two indices. Elevated signals are related to the motor symptom severity in middle-to-advanced-stage patients, and may have the potential for PD diagnosis and symptom assessment.

The Prognostic Relevance of MRI Characteristics in Myxofibrosarcoma Patients Treated with Neoadjuvant Radiotherapy.

To improve local control, neoadjuvant radiotherapy (nRT) followed by surgery is the standard of care in myxofibrosarcoma (MFS) because of its infiltrative growth pattern. Nevertheless, local recurrence rates are high. Data on prognostic factors for poor clinical outcomes are lacking. This retrospective study thus investigates the prognostic relevance of magnetic resonance imaging (MRI) characteristics before and after nRT in 40 MFS patients, as well as their association with disease-free survival (DFS) and overall survival (OS). A vascular pedicle, defined as extra-tumoral vessels at the tumor periphery, was observed in 12 patients (30.0%) pre-nRT and remained present post-nRT in all cases. Patients with a vascular pedicle had worse DFS (HR 5.85; 95% CI 1.56-21.90; p = 0.009) and OS (HR 9.58; 95% CI 1.91-48.00; p = 0.006). An infiltrative growth pattern, referred to as a tail sign, was observed in 22 patients (55.0%) pre-nRT and in 19 patients (47.5%) post-nRT, and was associated with worse DFS post-nRT (HR 6.99; 95% CI 1.39-35.35; p = 0.019). The percentage of tumor necrosis estimated by MRI was increased post-nRT, but was not associated with survival outcomes. The presence of a tail sign or vascular pedicle on MRI could support the identification of patients at risk for poor clinical outcomes after nRT.

Radiation of meningioma dural tail may not improve tumor control rates.

Introduction: Dural tails are thickened contrast-enhancing portions of dura associated with some meningiomas. Prior studies have demonstrated the presence of tumor cells within the dural tail, however their inclusion in radiation treatment fields remains controversial. We evaluated the role of including the dural tail when treating a meningioma with stereotactic radiation and the impact on tumor recurrence. Methods: This is a retrospective, single-institution, cohort study of patients with intracranial World Health Organization (WHO) grade 1 meningioma and identified dural tail who were treated with stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) from January 2012 to December 2018. SRS and FSRT subgroups were categorized based on coverage or non-coverage of the dural tail by the radiation fields, as determined independently by a radiation oncologist and a neurosurgeon. Demographics, tumor characteristics, radiation plans, and outcomes were evaluated. High grade tumors were analyzed separately. Results: A total of 187 WHO grade 1 tumors from 177 patients were included in the study (median age: 62 years, median follow-up: 40 months, 78.1% female) with 104 receiving SRS and 83 receiving FSRT. The dural tail was covered in 141 (75.4%) of treatment plans. There was no difference in recurrence rates (RR) or time to recurrence (TTR) between non-coverage or coverage of dural tails (RR: 2.2% vs 3.5%, P = 1.0; TTR: 34 vs 36 months, P = 1.00). There was no difference in the rate of radiation side effects between dural tail coverage or non-coverage groups. These associations remained stable when SRS and FSRT subgroups were considered separately, as well as in a high grade cohort of 16 tumors. Conclusion: Inclusion of the dural tail in the SRS or FSRT volumes for meningioma treatment does not seem to reduce recurrence rate. Improved understanding of dural tail pathophysiology, tumor grade, tumor spread, and radiation response is needed to better predict the response of meningiomas to radiotherapy.

Assessing the Utility of 18F-Fluorodeoxyglucose Positron Emission Tomography in the Differential Diagnosis Between Spinal Schwannomas and Meningiomas.

Objective The advantage of 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) for the differential diagnosis of schwannoma and meningioma remains unclear. The purpose of this study was to compare the maximum standardized uptake value (SUVmax) with computed tomography (CT) and magnetic resonance imaging (MRI) findings and assess its utility in the differential diagnosis of schwannomas and meningiomas. Methods This study included 42 patients who underwent surgery and had pathological diagnoses of schwannomas (S group) or meningiomas (M group). Multivariate logistic regression analyses were conducted using meningioma prevalence as the dependent variable, and confounders were selected from those with p-values <0.05, including calcification, dural tail sign, tumor volume, and SUVmax at each spinal level as independent variables. Results The SUVmax of the spinal canal type at the level of the cervical vertebrae was significantly higher in the M group (4.6 ± 0.8) than in the S group (2.7 ± 1.4; P = 0.017). Multivariate logistic regression analysis showed that the dural tail sign was significantly associated with differential diagnosis between the S and M groups (odds ratio [OR], 0.851; 95% confidence interval [CI], 0.704-1.031, p<0.001). Conclusions The dural tail sign on MRI, but not the SUVmax of FDG-PET, was the most useful for the differential diagnosis between schwannomas and meningiomas.

Contrast-enhanced CT longitudinal tail sign as a marker of positive resection margins in adenoid cystic carcinoma of the central airway.

BACKGROUND: Due to submucosal infiltration's biological nature along the airway, adenoid cystic carcinoma (ACC) frequently leaves positive surgical margins. This study evaluated the clinicopathologic, and computed tomography (CT) features for predicting surgical margin status in central airway ACC. METHODS: We retrospectively analyzed the files of 71 patients with ACC of the central airway proven by histopathology and surgery who had presented between January 2010 and December 2018. All patients were classified into positive and negative surgical margin groups according to margin status. Univariate analysis and multivariable logistic regression models were then performed to compare demography, histopathology, and CT characteristics between ACC patients with positive and negative margins. RESULTS: After surgical resection, 59 (83.1%) patients had positive margins, and 12 (16.9%) had negative margins. The contrast-enhanced CT (CECT) longitudinal tail sign (LTS) was identified in 55 of 59 (93.2%) patients with positive margins and was the only feature that had a significant association with positive margins (odds ratio 41.250, 95% CI: 7.886-215.767; P<0.001). Moreover, positive margins in upper or/and lower directions were associated with the LTS in corresponding directions (P<0.001). CONCLUSIONS: Most central airway ACC patients exhibited positive margins following surgery. The appearance of the LTS on CECT was significantly associated with positive margins and could help preoperatively predict the submucosal invasion of ACC.

Tumor volume and the dural tail sign enable the differentiation of intracranial solitary fibrous tumor/hemangiopericytoma from high-grade meningioma.

OBJECTIVES: Intracranial solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare mesenchymal neoplasm with imaging features mimicking high-grade meningioma (HGM) and can easily be misdiagnosed. We sought to determine the value of routine preoperative data in differentiating these tumors. PATIENTS AND METHODS: Patients with confirmed SFT/HPC or HGM between January 2012 and June 2020 were identified. A total of 28 preoperative variables (including age, sex, tumor location, tumor volume, 10 traditional MRI features, and 14 peripheral blood indices) were collected for each patient. The top features were selected sequentially based on the least absolute shrinkage and selection operator (LASSO) and support vector machines-recursive feature elimination (SVM-RFE) methods. Differentiation and calibration of the classifiers were assessed by receiver operating characteristic (ROC) curves and calibration curves, respectively. Nomograms were constructed based on multivariate analysis. RESULTS: A total of 127 patients, including 29 with SFT/HPC and 98 with HGM, were analyzed. Three features were first selected using the LASSO and SVM-RFE methods, and corresponding models were developed. Although the area under the curve (AUC) of model 1 was the highest, a comprehensive analysis suggested the superiority of model 2, which consisted only of the features tumor volume (TV) and dural tail sign (DTS) (AUC: 0.942, sensitivity: 93.10%, p-value of H-L test: 0.734, Brier score: 0.07). A risk score formula and a nomogram were constructed. CONCLUSIONS: TV can be used to effectively identify SFT/HPC and HGM, whereas adding DTS can improve the overall prediction accuracy. As these two variables are routinely available and are easy for clinicians to master, they can provide a powerful reference for clinical decision-making.

Prognostic Assessment in High-Grade Soft-Tissue Sarcoma Patients: A Comparison of Semantic Image Analysis and Radiomics.

BACKGROUND: In patients with soft-tissue sarcomas of the extremities, the treatment decision is currently regularly based on tumor grading and size. The imaging-based analysis may pose an alternative way to stratify patients' risk. In this work, we compared the value of MRI-based radiomics with expert-derived semantic imaging features for the prediction of overall survival (OS). METHODS: Fat-saturated T2-weighted sequences (T2FS) and contrast-enhanced T1-weighted fat-saturated (T1FSGd) sequences were collected from two independent retrospective cohorts (training: 108 patients; testing: 71 patients). After preprocessing, 105 radiomic features were extracted. Semantic imaging features were determined by three independent radiologists. Three machine learning techniques (elastic net regression (ENR), least absolute shrinkage and selection operator, and random survival forest) were compared to predict OS. RESULTS: ENR models achieved the best predictive performance. Histologies and clinical staging differed significantly between both cohorts. The semantic prognostic model achieved a predictive performance with a C-index of 0.58 within the test set. This was worse compared to a clinical staging system (C-index: 0.61) and the radiomic models (C-indices: T1FSGd: 0.64, T2FS: 0.63). Both radiomic models achieved significant patient stratification. CONCLUSIONS: T2FS and T1FSGd-based radiomic models outperformed semantic imaging features for prognostic assessment.

A big encapsulated adrenal mass with well-circumscribed margin.

We present a case on adrenal schwannomas. The CT shows enhancement of distal adrenal gland lesion. We named it rabbit tail sign. Adrenal schwannomas are rare and presents a very small proportion of retroperitoneal schwannomas. It tends to be misdiagnosed because of lacking characteristics clinical presentations and CT features. And there is debate about its origination. The rabbit tail sign of distal adrenal gland is one typical radiographic feature of adrenal schwannomas. It also suggests the tumor may originate from dominate nerve of adrenal medulla.

Temporal bone meningiomas: emphasizing radiologic signs to improve preoperative diagnosis.

PURPOSE: Temporal bone meningioma is an extremely rare disease. Lack of clinical attention due to its rarity might lead to delayed diagnosis. This short communication aims to emphasize radiologic signs of temporal bone meningiomas to improve preoperative diagnosis. METHODS: Radiological characteristics of temporal bone meningiomas are discussed. RESULTS: Temporal bone meningioma is characterized by diffuse "hairy" trabecular hyperostosis without the destruction of trabecular structures, bone thickening, and irregular surface margins of the temporal bone on computed tomography. The dural tail sign is a unique feature of temporal bone meningioma on magnetic resonance imaging. CONCLUSION: Otolaryngologists certainly should be aware of characteristic radiologic signs of temporal bone meningiomas. Using modern computed tomography and magnetic resonance imaging protocols enables with a high degree of accuracy to distinguish temporal bone meningiomas from other more common entities in this location.

Plunging Ranulas and Prevalence of the "Tail Sign" in 126 Consecutive Cases.

OBJECTIVES: Plunging (or diving) ranulas are extravasation pseudocysts arising from the sublingual gland that present as soft submandibular swelling. The "tail sign" has been widely reported as pathognomonic for their diagnosis. It is described as a smooth tapering comet-shaped unilocular fluid mass with its "tail" in the collapsed sublingual space (SLS) and its "head" in the posterior submandibular space. This sign is based on the premise that extravasated saliva from the sublingual gland in the SLS escapes and plunges, over the posterior edge of the mylohyoid muscle into the submandibular space. Therefore, some fluid must be present in the posterior SLS in almost all patients with plunging ranulas. This study aimed to determine the frequency of fluid seen with ultrasound (US) in the posterior SLS to corroborate the tail sign. METHODS: A total of 126 consecutive cases of surgically proven plunging ranulas were investigated with US over 13 years. The findings were reviewed retrospectively for the prevalence of fluid in the posterior SLS. RESULTS: Thirteen patients (10.3%) showed SLS fluid on US images. Most showed fluid extension through a mylohyoid dehiscence. Only 2 patients (1.6%) showed fluid within the posterior SLS, and 1 patient alone in this entire study showed all of the components of the classically described tail sign. CONCLUSIONS: This largest ever radiologic study showed low prevalence of the tail sign in 2 of 126 patients. A mylohyoid dehiscence was the more common route for extravasation. Absence of the tail sign does not exclude the diagnosis of a plunging ranula.

Imaging findings of radiologically misdiagnosed nodular fasciitis.

BACKGROUND: Nodular fasciitis rarely occurs in young adults and children; it usually resembles other tumors, even malignancy. PURPOSE: To review the imaging findings of six cases of nodular fasciitis misdiagnosed radiologically. MATERIAL AND METHODS: The clinical and radiologic features of six cases of histologically proven but radiologically misdiagnosed nodular fasciitis were reviewed retrospectively. Two cases underwent both plain and enhanced computed tomography (CT) scans and the other four had both regular and enhanced magnetic resonance (MR) scans. RESULTS: All six patients were young (five children and one young adult). A rapid growing mass, pain or painless, was the most frequent presentation. Most masses were oval, well-defined, and homogeneous, with an average diameter of 2.2 cm. Five were found in superficial fascia with a broad base. Two cyst-like masses showed hypodensity relative to muscle on plain CT and without enhancement. Compared to muscle, these masses showed isointensity (n = 3) or slight hyperintensity (n = 1) on T1-weighted imaging, hyperintensity on T2-weighted imaging (n = 4), with homogeneous notable enhancement (n = 3) or mild enhancement (n = 1). Five (83.3%) were found with a "fascial tail" sign characterized as thickening of adjacent fascial layer with notable enhancement. One mass showed an "inverted target" sign. CONCLUSION: Nodular fasciitis in young adults and children is usually superficial, rapid growing, well-defined, and homogeneous, frequently with a "fascial tail" sign. Radiologically, it can resemble a benign cyst and might be easily misdiagnosed. Therefore, nodular fasciitis should be remembered in the differential diagnosis for superficial soft tissue tumor found in young adult and children.

A Rare Extra-Axial Midline Tentorial Adult Medulloblastoma with Dural-Tail Sign Mimicking a Meningioma.

Medulloblastomas are categorized as the World Health Organization Grade IV neoplasms. Only 33 cases have been reported of extra-axial, mostly in the cerebellar pontine angle and lateral cerebellar hemisphere, medulloblastomas in the current literature. Our study showcases the first case of an extremely rare presentation of an extra-axial midline tentorial adult medulloblastoma with the dural-tail sign mimicking a meningioma. To achieve the best possible outcome, a high index of suspicion for medulloblastoma is critical especially in young patient with an atypical posterior fossa mass as treatment regimens drastically different between a medulloblastoma and a meningioma.

Ambiguity in the Dural Tail Sign on MRI.

BACKGROUND: Meningiomas give rise to the dural tail sign (DTS) on contrast-enhanced magnetic resonance imaging (CEMRI). The presence of DTS does not always qualify for a meningioma, as it is seen in only 60-72% of cases. This sign has been described in various other lesions like lymphomas, metastasis, hemangiopericytomas, schwannomas and very rarely glioblastoma multiforme (GBM). The characteristics of dural-based GBMs are discussed here, as only eleven such cases are reported in the literature till date. Here we discuss the unique features of this rare presentation. CASE DESCRIPTION: A 17-year-old male presented to the emergency department (ED) with, complaints of headache, recurrent vomiting, vision loss in right eye and altered sensorium. On examination patient was drowsy with right hemiparesis, secondary optic atrophy in the right eye and papilledema in the left eye. MRI brain showed, heterogeneous predominantly solid cystic lesion with central hypo-intense core suggestive of necrosis with heterogeneous enhancement and a positive DTS. Patient underwent emergency left parasagittal parieto-occipital craniotomy and gross total tumor excision including the involved dura and the falx. On opening the dura, tumor was surfacing, invading the superior sagittal sinus and the falx, greyish, soft to firm in consistency with central necrosis and highly vascular suggesting a high-grade lesion. Postoperative computed tomography (CT) of the brain showed evidence of gross total tumor (GTR) excision. The postoperative course of the patient was uneventful. Histopathological analysis revealed GBM with PNET like components. The dura as well as the falx were involved by the tumor. CONCLUSION: GBMs can arise in typical locations along with DTS mimicking meningiomas. Excision of the involved dura and the falx becomes important in this scenario, so as to achieve GTR. Hence high index of suspicion preoperatively aided by Magnetic Resonance Imaging (MRS) can help distinguish GBMs from meningioma, thereby impacting upon the prognosis.