Giant Tumefactive Perivascular Spaces.

HomeRadiologyVol. 307, No. 4 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyGiant Tumefactive Perivascular SpacesDhairya A. Lakhani , Joe JosephDhairya A. Lakhani , Joe JosephAuthor AffiliationsFrom the Department of Radiology, West Virginia University, 1 Medical Center Dr, Morgantown, WV 26506 (D.A.L.); and Department of Neuroradiology, Rockefeller Neuroscience Institute, West Virginia University, Morgantown, W.Va. (J.J.).Address correspondence to D.A.L. (email: [email protected]).Dhairya A. Lakhani Joe JosephPublished Online:Apr 4 2023https://doi.org/10.1148/radiol.222559MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In Supplemental material is available for this article.A 55-year-old woman with no prior medical history presented to the emergency department with suspected head injury following a ground-level fall. Examination revealed no neurologic or cognitive impairments. CT head scan showed no evidence of intracranial hemorrhage (Fig 1). Greater than expected white matter (WM) hypoattenuation was present throughout the brain parenchyma. MRI scan revealed multilocular cystic lesions with extensive hemispheric and subcortical WM involvement, most pronounced in the right frontal lobe. Mildly increased perilesional signal intensity in fluid-attenuated inversion recovery (FLAIR) sequences was noted. In the right frontal lobe, gray matter was stretched and displaced over the multiloculated cysts. No abnormal enhancement, increased perfusion, or diffusion abnormalities were present, and the cysts followed cerebrospinal fluid signal characteristics. Hence, the findings were consistent with giant tumefactive perivascular spaces (PVS) (Fig 2, Movie).Figure 1: (A–C) Axial unenhanced CT brain images obtained in a 55-year-old woman with no prior medical history who presented with suspected head injury following ground-level fall show no evidence of intracranial hemorrhage. Greater than expected white matter hypoattenuation was present throughout the brain parenchyma, most pronounced in the right frontal lobe (A).Figure 1:Download as PowerPointOpen in Image Viewer Figure 2: (A–C) Axial T2-weighted, (D) axial fluid-attenuated inversion recovery (FLAIR), (E) axial T1-weighted postcontrast, and (F) axial diffusion-weighted MRI scans obtained in a 55-year-old woman with no prior medical history who presented with suspected head injury following ground-level fall show multilocular cystic lesions with extensive hemispheric and subcortical white matter involvement, most pronounced in the right frontal lobe (A–C). (D) Mild increased perilesional T2-weighted FLAIR signal intensity was present. (A, D) In the right frontal lobe, gray matter was stretched and displaced over the multiloculated cysts. (E) No abnormal enhancement or (F) diffusion abnormalities were present, and the cysts followed (D) cerebrospinal fluid signal characteristics, findings consistent with giant tumefactive perivascular spaces.Figure 2:Download as PowerPointOpen in Image Viewer Get the Flash Player to see this video.Movie: Movie file of axial T2-weighted (left panel), axial fluid-attenuated inversion recovery (middle panel) and postcontrast axial T1-weighted (right panel) MR examination in a 55-year-old woman with no prior medical history who presented with suspected head injury following ground level fall show giant tumefactive perivascular spaces with extensive hemispheric and subcortical WM involvement.Download Original Video (20.0 MB)PVS, also referred to as Virchow–Robin spaces, are fluid-filled cavities around small cerebral penetrating vessels. Recently, they have been discovered to be an important component of the glymphatic system, which is responsible for clearing waste and interstitial fluid from the brain. PVS are normally microscopic and not visible with MRI. When visible with MRI, these are considered dilated (1). Typical dilated PVS are round or oval cysts with a well-defined and smooth margin, along the path of penetrating arteries. They are typically found around the lenticulostriate arteries but can occur in any location. The cysts follow cerebrospinal fluid signal characteristics on all sequences (2). When these cysts are expanded and cause focal mass effect, they are referred to as giant PVS, cavernous dilation, or Poirier Type IIIb “expanding lacunae” (2). Giant PVS have shown associated perilesional T2-weighted FLAIR white matter signal intensity changes (2). Both typical and giant PVS would typically present with more focal and/or regional manifestations (1,2); in rare occasions, PVS can present with more diffuse manifestation (3). Dilated PVS have varied clinical presentation, ranging from being asymptomatic to presenting with headache, seizure, and dementia. There has been increasing interest in understanding the risk factors, pathophysiologic conditions, and implications of dilated PVS, due to their established association with aging, hypertension, small vessel disease, multiple sclerosis, and Alzheimer disease (2).Disclosures of conflicts of interest: D.A.L. 2022 RSNA William W. Olmsted Editorial Fellow. J.J. No relevant relationships.References1. Choi Y, Nam Y, Choi Y, et al. MRI-visible dilated perivascular spaces in healthy young adults: A twin heritability study. Hum Brain Mapp 2020;41(18):5313–5324. Crossref, Medline, Google Scholar2. Salzman KL, Osborn AG, House P, et al. Giant tumefactive perivascular spaces. AJNR Am J Neuroradiol 2005;26(2):298–305. Medline, Google Scholar3. Eichhorn GR, Ammache Z, Bell W, Yuh WT. Unusually prominent perivascular spaces. Neurology 2001;56(9):1242. Crossref, Medline, Google ScholarArticle HistoryReceived: Oct 6 2022Revision requested: Nov 29 2022Revision received: Nov 30 2022Accepted: Dec 20 2022Published online: Apr 04 2023 FiguresReferencesRelatedDetailsRecommended Articles Congenital Brain Abnormalities and Zika Virus: What the Radiologist Can Expect to See Prenatally and PostnatallyRadiology2016Volume: 281Issue: 1pp. 203-218Current Concepts in Intracranial Interstitial Fluid Transport and the Glymphatic System: Part II—Imaging Techniques and Clinical ApplicationsRadiology2021Volume: 301Issue: 3pp. 516-532White Matter Diseases with Radiologic-Pathologic CorrelationRadioGraphics2016Volume: 36Issue: 5pp. 1426-1447Case 252: Acute Hyperammonemic Encephalopathy Resulting from Late-Onset Ornithine Transcarbamylase DeficiencyRadiology2018Volume: 287Issue: 1pp. 353-359Imaging of Creutzfeldt-Jakob Disease: Imaging Patterns and Their Differential DiagnosisRadioGraphics2017Volume: 37Issue: 1pp. 234-257See More RSNA Education Exhibits Progressive Multifocal Leukoencephalopathy: Classic and New MRI FindingsDigital Posters2020Brain Perivascular Spaces: Anatomy, Differential Diagnosis and Associated PathologiesDigital Posters2020Case Based Review of Meningeal DisordersDigital Posters2022 RSNA Case Collection Focal cortical dysplasiaRSNA Case Collection2021Subcortical HeterotopiaRSNA Case Collection2021Tuberous sclerosisRSNA Case Collection2020 Vol. 307, No. 4 Metrics Altmetric Score PDF download