Dilated Virchow-Robin spaces

Clinical History

Patient female 76 years old, with no significant clinical background, for episodes of inexplicable falls , with recent amnesia.

Imaging Findings

MR images show marked dilatation of perivascular spaces (Virchow-Robin) that involved basal ganglia (thalami and lenticular nucleus) without associated mass effect.
It behaves similarly to CSF on all sequences, so it's hypointense on T1 (Fig 1) and hyperintense on T2 (Fig 2), without restricted diffusion or enhancement after contrast administration.(Fig 4)
The sequence FLAIR is the most important because it allows us to differentiate it from other entities by appearing as hypointense lesions unlike other of the differential diagnosis. (Fig 3)

Discussion

Virchow-Robin spaces (VR spaces) also known as perivascular spaces, are spaces surrounding the walls of arteries, arterioles, veins, and venules as their course from the subarachnoid space through the brain parenchyma.
This spaces don't communicate directly with the subarachnoid space but they are filled with interstitial fluid which behaves similarly to CSF in MR.[1]

Dilated perivascular spaces consist of regular cavities containing an artery. The mechanism that occurs is not well known but there are many hypotheses in study.
It is considered to be dilated when the size exceeds 2 mm visualized better in T2 weighted images. Rarely the size of the space is so large that produces mass effect on the adjacent brain parenchyma and it can cause hydrocephalus. The prevalence increased with aging, and in some cases this perivascular atrophy of cerebral tissue, generates lacunae and is called "état criblé".[2]

In image are mostly seen as well-defined oval, rounded, or tubular structures, depending on the plane in which they are intersected. They have smooth margins, commonly appear bilaterally, and usually measure 5 mm or less. In CT appear as small rounded hypodense lesions (< 1cm). In MRI they behave similar to CSF in all sequences but when the signal strengths are measured these have a lower intensity than the CSF and closer to the interstitial fluid.
There are no flow restriction in diffusion-weighted images and they don't enhance after the administration of contrast material. The key to differentiate it from other pathologies is that VR spaces are hypointense in sequence FLAIR unlike other entities in the differential diagnosis.

According to the location of Virchow-Robin spaces can be classified into three types:[1]
Type I: Appear along lenticulostriate arteries through the basal ganglia. The example shown is classified into this group.
Type II: They are in the path of the medullary perforating arteries when they enter the gray matter and heading toward the white matter.
Type III: Appears in the midbrain mainly in the cerebral peduncles.

The VR spaces may show atypical dilatations, making it difficult to differentiate with others cysts by image alone.[3]

In summary, widened VR spaces are a common aging phenomenon which it should not be confused with other diseases. The FLAIR image showing its hypointense appearence is the most useful for us in the differential diagnosis.

Differential Diagnosis List

Final Diagnosis

Dilated Virchow-Robin spaces

URL:	https://www.eurorad.org/case/11131
DOI:	10.1594/EURORAD/CASE.11131
ISSN:	1563-4086