When It Looks Like a Duck and Walks Like a Duck - Importance of DOTATATE PET Imaging in Assessing Putative Sphenoid Wing Meningioma for Stereotactic Radiosurgery

Sep 29, 2026

MRI is central to evaluating skull-base lesions, yet morphologic features alone can misclassify vascular anomalies as neoplasms. A 27-year-old man with left monocular diplopia had an enhancing dural-based cavernous-sinus lesion interpreted as a sphenoid-wing meningioma and referred for stereotactic radiosurgery. Incorporation of 68Ga-DOTATATE PET showed no somatostatin receptor avidity, leading to re-review of angiography and orbital CT support for a cavernous-sinus venous varix. SRS was withheld and two subsequent DOTATATE PET scans confirmed persistent non-avidity during observation.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages5

Reading Time13 min

AccessFree to download

Introduction

Case Presentation

Imaging workup and differential diagnosis

Decision-making for stereotactic radiosurgery

Discussion

Conclusion

Received 10/22/2025 Review began 10/28/2025 Review ended 11/19/2025 Published 12/06/2025 © Copyright 2025 Ofori-Darko et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98574 Open Access Case Report Published via Contemporary Updates: Radiotherapy Innovation & Evidence (CURiE) When It Looks Like a Duck and Walks Like a Duck: Importance of DOTATATE PET Imaging in Assessing Putative Sphenoid Wing Meningioma for Stereotactic Radiosurgery Afua Ofori-Darko 1, 2, Shearwood McClelland III 1, 3 1. Department of Radiation Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, USA 2. School of Medicine, Case Western Reserve University School of Medicine, Cleveland, USA 3. Department of Neurological Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA Corresponding author: Shearwood McClelland III, [drwood@post.harvard.edu](drwood@post.harvard.edu) Abstract MRI is central to evaluating skull-base lesions, but morphologic features alone can misclassify vascular anomalies as neoplasms. A 27-year-old man presented with left monocular diplopia and an enhancing dural-based lesion along the lateral-superior wall of the left cavernous sinus, read as a sphenoid-wing meningioma. He was evaluated for stereotactic radiosurgery. Incorporation of 68Ga-DOTATATE PET demonstrated no somatostatin receptor avidity, prompting neuroradiology re-review of prior angiography and subsequent orbital CT that supported a cavernous-sinus venous varix. Stereotactic radiosurgery was withheld, and the patient remained clinically stable on observation with a second DOTATATE PET confirming non-avidity. This case highlights the value of DOTATATE PET as a complementary study for indeterminate skull-base lesions, particularly when tissue diagnosis is unavailable, to prevent inappropriate intervention. Categories: Radiology, Radiation Oncology, Neurosurgery Keywords: dotatate, ga-68 dotatate scan, meningioma diagnosis, neuro mri, neuro-ophthalmology, neurosurgery, photon stereotactic radiosurgery, radiation oncology education, sphenoid ridge meningioma, venous varix Introduction Meningiomas are responsible for approximately one-third of all primary intracranial neoplasms and, if diagnosed on a radiographic basis, are frequently encountered when there is a homogeneously enhancing dural-based lesion with a dural tail present in the vicinity of the skull base [1] . Vascular abnormalities of the cavernous sinus may enhance and simulate these features, creating a risk of misdiagnosis if decisions rely on MRI alone. 68Ga-DOTATATE binds somatostatin receptor subtype 2, which is strongly expressed by most meningiomas, and has proven useful for diagnosis, radiotherapy planning, and follow-up in this disease [2] . We present a case in which DOTATATE PET averted stereotactic radiosurgery (SRS) by rediagnosing a presumed meningioma as a venous varix. Case Presentation A 27-year-old man presented with a seven-month history of left monocular diplopia that resolved when viewing with the right eye. He remained able to drive and function at work. Neuro-ophthalmologic examination found left hypertropia without trochlear nerve palsy. Contrast-enhanced brain MRI showed a homogeneously enhancing dural-based lesion along the lateral-superior wall of the left cavernous sinus with mild sphenoid-wing extension, consistent with a putative sphenoid-wing meningioma (Figure 1), and the patient was referred to neurosurgery and radiation oncology for further evaluation. Neurosurgery suggested resection, observation, or SRS. The patient wished to avoid open surgery while restoring normal vision. How to cite this article Ofori-Darko A, McClelland III S (December 06 , 2025) When It Looks Like

FAQs

Why can MRI misclassify cavernous-sinus vascular anomalies as meningiomas?

Vascular abnormalities of the cavernous sinus may enhance and simulate the homogeneously enhancing dural-based appearance with a dural tail, creating a risk of misdiagnosis if decisions rely on MRI alone.

How did 68Ga-DOTATATE PET change the patient’s management?

DOTATATE PET demonstrated no somatostatin receptor avidity in the lesion, prompting re-review of prior imaging and additional CT evaluation that supported a venous varix rather than a meningioma. Stereotactic radiosurgery was withheld as a result.

What confirmed the final diagnosis over follow-up?

Subsequent review and orbital CT corroborated absence of a soft-tissue mass and presence of a venous varix, while follow-up DOTATATE PET scans again showed no avidity, supporting persistent non-tumor behavior during observation.

Sep 29, 2026

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