eumycetoma is a chronic , relentlessly progressive , granulomatous subcutaneous disease caused by a true fungus . it commonly occurs in the extremities , the foot being the most common site of involvement . cranial involvement has only rarely been reported[24 ] and is often due to direct extension from the paranasal sinuses . recently , characteristic mri findings of the  dot - in - circle  sign and a conglomeration of multiple extremely hypointense  dots  have been reported in pedal eumycetoma.[58 ] we describe these characteristic findings on an mri of the brain in a case of cranial eumycetoma ( ce ) that was caused by direct inoculation of the organism madurella grisea . a 35-year - old man presented with complaints of seizures for 1 year , slowly increasing left parietal swelling for 6 months , and sudden - onset weakness of the right upper and lower limbs and inability to speak for 6 days . he had been diagnosed elsewhere as cranial tuberculosis on the basis of imaging findings and had been on regular antituberculous treatment and steroids for the last 1 year . there was no significant premorbid illness apart from history of trauma to the scalp on the left side . on examination , the patient had a glasgow coma scale ( gcs ) score of 10/15 , papilledema , and right facial palsy . there was a small , tender , focal scalp swelling in the left parietal region . mri of the brain done elsewhere 1 year ago showed a left parasagittal , homogeneously enhancing , dural - based mass with surrounding edema , involving the underlying cerebral cortex . ct scan [ figure 1 ] done in our institution at the time of presentation showed an intensely enhancing mass , with features of osteomyelitis in the adjacent parietal bone . contrast enhanced ct scan of the brain shows an intensely enhancing mass ( arrow ) in the left frontal lobe with adjacent edema the patient underwent biopsy of the lesion via a left parietal flap . it was firm and yellowish , with multiple blackish granules within ; it was also stuck to the calvarium . histology [ figure 2 ] revealed fibrocollagenous connective tissue containing multiple microabscesses , with the central cavitary spaces containing several pigmented grains composed of hyphal mats . the abscess walls displayed granulomatous reaction , with dense infiltrates of histiocytes , foreign body photomicrograph shows a microabscess containing pigmented grains ( arrows ) surrounded by an inflammatory reaction , including foreign body giant cells ( h and e , 90 ) postoperatively , there was some improvement in speech and right upper and lower limb power . repeat mri after 1 year [ figures 3 and 4 ] revealed an iso- to hypointense mass and surrounding edema in the left frontal region on t2w and fluid - attenuated inversion recovery ( flair ) images . dots  representing fungal grains and the  dot - in - circle  sign was present . when compared to the previous imaging findings , there was a slight decrease in the size of the mass and the surrounding edema . currently , he is doing well clinically . his epilepsy is mostly controlled and he has grade 3 - 4 power in the limbs . axial flair ( a ) and t2w ( b ) mri images show a conglomeration of multiple extremely hypointense dots ( arrows ) within an iso- to hypointense mass in the left parasagittal frontal lobe , involving the motor cortex coronal t2w mri image ( a ) shows an iso- to hypointense left parasagittal frontal lobe mass ( black arrow ) , with altered marrow signal ( white arrow ) in the overlying parietal bone . magnified coronal t2w mri images ( b , c ) show a few hypointense dots ( open arrows ) within the hyperintense granulomas ( white stars ) separated by hypointense walls ( white arrows ) , giving the  dot - in - circle  sign . diffusion - weighted mri image ( d ) shows small hyperintense areas ( arrow ) of restricted diffusion , probably representing microabscesses . the recently described characteristic  dot - in - circle  mri sign in pedal eumycetoma represents a t2-hyperintense granuloma , with central hypointense dots  of fungal grains separated by hypointense fibrous walls.[58 ] a conglomeration of multiple hypointense dots of fungal grains against the background of inflammatory granulomas was also seen . the grains were identified as hypointense dots on both t1w and t2w images and their mri signal was attributed to the magnetic - susceptibility effects of the paramagnetic elements of the grains . the present case also showed the typical conglomeration of multiple extremely hypointense dots within the mass , correlating histopathologically with multiple fungal grains . a few of the hypointense dots within the hyperintense granuloma were seen separated by hypointense walls , giving rise to the characteristic  dot - in - circle  sign on t2w images and probably correlating histopathologically with central fungal grains surrounded by dense granulomatous inflammation and fibrocollagenous tissue . we also noted a few small areas of restricted diffusion on dwi , probably reflecting microabscesses [ figure 4d ] . an isointense to hypointense mass on t1w and t2w images , with or without peripheral extremely hypointense areas and central necrosis , has been described in ce . ce may be mistaken for other dural - based masses , such as meningioma or tuberculomas , even in endemic regions . both meningiomas and tuberculomas can present with a similar iso- to hypointense dural - based mass on t1w and t2w images , but the characteristic mri findings of ce would not be present . culture of the organism is considered the gold standard for confirming the diagnosis of eumycetoma . however , this takes a long time and false positive results can occur due to contamination of the sample . the characteristic mri findings can help make an early noninvasive diagnosis of ce and allow differentiation from other dural - based hypointense lesions .