Beyond the Usual Suspects: Atypical Dural-Based Tumors With Rare Histology and Intracranial Extension

Dural-based lesions are commonly presumed to be meningiomas due to characteristic imaging features. However, rare neoplastic entities may mimic their radiologic appearance, leading to potential diagnostic pitfalls. This report highlights two unusual cases of dural-based tumors with features mimicking meningiomas: metastatic hepatocellular carcinoma (HCC) and Ewing sarcoma (ES). The first case involved a 52-year-old man presenting with a painless parietal scalp swelling. Imaging revealed a dural-based mass with bone erosion and extracranial extension, initially suspected to be a meningioma. Histopathological evaluation confirmed metastatic HCC. The second case described a 22-year-old man with a large frontoparietal mass exhibiting both intra- and extracranial components. Imaging suggested a meningioma; however, histology and immunohistochemistry confirmed the diagnosis of Ewing sarcoma. Both cases underscore the importance of considering differential diagnoses beyond meningioma for dural-based lesions, particularly when clinical or radiologic findings are atypical. While metastatic HCC to the dura is rare and typically managed with palliative intent, ES requires aggressive multimodal therapy including surgery, chemotherapy, and radiotherapy. These cases emphasize that dural-based lesions with meningioma-like features may harbor unexpected pathology. A high index of suspicion, coupled with thorough histopathological evaluation, is essential for accurate diagnosis and appropriate management.