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Virchow-Robin Spaces at MR Imaging¹

¹ From the Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. Received July 25, 2006; revision requested October 24 and received November 30; accepted December 4. All authors have no financial relationships to disclose.

View larger version (179K): [in this window] [in a new window] [Download PPT slide]   Figure 1.  Photomicrograph (original magnification, x20; hematoxylin-eosin stain) of a coronal section through the anterior perforated substance shows two arteries (straight arrows) with surrounding VR spaces (curved arrows).

 

View larger version (20K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Drawing shows a cortical artery with a surrounding VR space crossing from the subarachnoid and subpial spaces through the brain parenchyma. The magnified view on the right shows the anatomic relationship between the artery, VR space, subpial space, and brain parenchyma.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Bilateral type I VR spaces in a 6-year-old boy. (a) Axial proton-density–weighted image (repetition time msec/echo time msec = 2375/100) shows hyperintense areas (arrows) in the anterior perforated substance on both sides. (b) Axial fluid-attenuated inversion-recovery (FLAIR) image (6606/100) obtained at the same level shows that these areas have CSF-like content (arrows). The signal intensity of the surrounding brain parenchyma is normal. (c, d) Diffusion-weighted image (2574/81; b factor = 1000 sec/mm2) (c) and corresponding apparent diffusion coefficient map (d) show no restricted diffusion in these areas (arrows).

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Bilateral type I VR spaces in a 6-year-old boy. (a) Axial proton-density–weighted image (repetition time msec/echo time msec = 2375/100) shows hyperintense areas (arrows) in the anterior perforated substance on both sides. (b) Axial fluid-attenuated inversion-recovery (FLAIR) image (6606/100) obtained at the same level shows that these areas have CSF-like content (arrows). The signal intensity of the surrounding brain parenchyma is normal. (c, d) Diffusion-weighted image (2574/81; b factor = 1000 sec/mm2) (c) and corresponding apparent diffusion coefficient map (d) show no restricted diffusion in these areas (arrows).

 

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  Bilateral type I VR spaces in a 6-year-old boy. (a) Axial proton-density–weighted image (repetition time msec/echo time msec = 2375/100) shows hyperintense areas (arrows) in the anterior perforated substance on both sides. (b) Axial fluid-attenuated inversion-recovery (FLAIR) image (6606/100) obtained at the same level shows that these areas have CSF-like content (arrows). The signal intensity of the surrounding brain parenchyma is normal. (c, d) Diffusion-weighted image (2574/81; b factor = 1000 sec/mm2) (c) and corresponding apparent diffusion coefficient map (d) show no restricted diffusion in these areas (arrows).

 

View larger version (114K): [in this window] [in a new window] [Download PPT slide]   Figure 3d.  Bilateral type I VR spaces in a 6-year-old boy. (a) Axial proton-density–weighted image (repetition time msec/echo time msec = 2375/100) shows hyperintense areas (arrows) in the anterior perforated substance on both sides. (b) Axial fluid-attenuated inversion-recovery (FLAIR) image (6606/100) obtained at the same level shows that these areas have CSF-like content (arrows). The signal intensity of the surrounding brain parenchyma is normal. (c, d) Diffusion-weighted image (2574/81; b factor = 1000 sec/mm2) (c) and corresponding apparent diffusion coefficient map (d) show no restricted diffusion in these areas (arrows).

 

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 4.  Bilateral type I VR spaces in a 53-year-old woman. Coronal T1-weighted image (500/30) shows symmetrical hypointense areas (arrows) in the anterior perforated substance.

 

View larger version (146K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Type II VR spaces in a 73-year-old woman. (a) Axial proton-density–weighted image (2376/100) shows multiple hyperintense foci in the centrum semiovale in both hemispheres. (b) On an axial FLAIR image (6614/100) obtained at the same level, the VR spaces are seen as hypointense dots without any surrounding high signal intensity. Note the two small lesions with a hypointense center and a hyperintense rim (arrows) in the left hemisphere; these lesions are not VR spaces but old lacunar infarctions.

 

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Type II VR spaces in a 73-year-old woman. (a) Axial proton-density–weighted image (2376/100) shows multiple hyperintense foci in the centrum semiovale in both hemispheres. (b) On an axial FLAIR image (6614/100) obtained at the same level, the VR spaces are seen as hypointense dots without any surrounding high signal intensity. Note the two small lesions with a hypointense center and a hyperintense rim (arrows) in the left hemisphere; these lesions are not VR spaces but old lacunar infarctions.

 

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Type II dilated VR spaces in a 6-year-old boy. (a) Axial T2-weighted image (2620/100) shows linear to punctate hyperintense areas around the occipital horns, especially on the left side (arrow). (b) FLAIR image (7572/100) obtained at the same level shows no abnormal signal intensity (arrow), in accordance with the fact that these areas are true VR spaces.

 

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Type II dilated VR spaces in a 6-year-old boy. (a) Axial T2-weighted image (2620/100) shows linear to punctate hyperintense areas around the occipital horns, especially on the left side (arrow). (b) FLAIR image (7572/100) obtained at the same level shows no abnormal signal intensity (arrow), in accordance with the fact that these areas are true VR spaces.

 

View larger version (157K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Type III VR space in a 25-year-old man. (a) Axial proton-density–weighted image (2620/100) shows a hyperintense spot in the brainstem (arrow). (b) Axial FLAIR image (7292/120) obtained at the same level shows that the spot has CSF-like content without abnormal surrounding signal intensity (arrow). These findings confirm that the spot is a VR space.

 

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Type III VR space in a 25-year-old man. (a) Axial proton-density–weighted image (2620/100) shows a hyperintense spot in the brainstem (arrow). (b) Axial FLAIR image (7292/120) obtained at the same level shows that the spot has CSF-like content without abnormal surrounding signal intensity (arrow). These findings confirm that the spot is a VR space.

 

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Type III VR spaces in a 68-year-old man. (a) Axial proton-density–weighted image (2382/100) shows multiple punctate hyperintense areas in the brainstem (arrow). (b) Close-up T2-weighted image (4615/120) clearly shows the fine punctate pattern. (c) Axial FLAIR image (6609/100) shows the CSF-like content of the dots (arrow). No surrounding high signal intensity is seen. The typical configuration and the fact that no high signal intensity is seen on the FLAIR image confirm that the dots are VR spaces.

 

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Type III VR spaces in a 68-year-old man. (a) Axial proton-density–weighted image (2382/100) shows multiple punctate hyperintense areas in the brainstem (arrow). (b) Close-up T2-weighted image (4615/120) clearly shows the fine punctate pattern. (c) Axial FLAIR image (6609/100) shows the CSF-like content of the dots (arrow). No surrounding high signal intensity is seen. The typical configuration and the fact that no high signal intensity is seen on the FLAIR image confirm that the dots are VR spaces.

 

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Type III VR spaces in a 68-year-old man. (a) Axial proton-density–weighted image (2382/100) shows multiple punctate hyperintense areas in the brainstem (arrow). (b) Close-up T2-weighted image (4615/120) clearly shows the fine punctate pattern. (c) Axial FLAIR image (6609/100) shows the CSF-like content of the dots (arrow). No surrounding high signal intensity is seen. The typical configuration and the fact that no high signal intensity is seen on the FLAIR image confirm that the dots are VR spaces.

 

View larger version (154K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Giant VR spaces in the mesencephalothalamic region in a 19-year-old man. (a, b) Axial (a) and sagittal (b) T2-weighted images (5970/120) show a multicystic lesion in the mesencephalothalamic region. The lesion extends from the left cerebral peduncle to the left thalamus. The content of the cysts is CSF-like. The adjacent brain parenchyma has normal signal intensity. No solid components are identified. (c) Axial gadolinium-enhanced T1-weighted image (478/18) shows no enhancement. The process has caused obstruction of the sylvian aqueduct, resulting in hydrocephalus. The size of the lesion and the degree of hydrocephalus were unchanged compared with the appearance on MR images obtained 2 years earlier.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Giant VR spaces in the mesencephalothalamic region in a 19-year-old man. (a, b) Axial (a) and sagittal (b) T2-weighted images (5970/120) show a multicystic lesion in the mesencephalothalamic region. The lesion extends from the left cerebral peduncle to the left thalamus. The content of the cysts is CSF-like. The adjacent brain parenchyma has normal signal intensity. No solid components are identified. (c) Axial gadolinium-enhanced T1-weighted image (478/18) shows no enhancement. The process has caused obstruction of the sylvian aqueduct, resulting in hydrocephalus. The size of the lesion and the degree of hydrocephalus were unchanged compared with the appearance on MR images obtained 2 years earlier.

 

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Giant VR spaces in the mesencephalothalamic region in a 19-year-old man. (a, b) Axial (a) and sagittal (b) T2-weighted images (5970/120) show a multicystic lesion in the mesencephalothalamic region. The lesion extends from the left cerebral peduncle to the left thalamus. The content of the cysts is CSF-like. The adjacent brain parenchyma has normal signal intensity. No solid components are identified. (c) Axial gadolinium-enhanced T1-weighted image (478/18) shows no enhancement. The process has caused obstruction of the sylvian aqueduct, resulting in hydrocephalus. The size of the lesion and the degree of hydrocephalus were unchanged compared with the appearance on MR images obtained 2 years earlier.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Chronic lacunar infarction of the pons in a 59-year-old man. (a) Axial proton-density–weighted image (2200/100) shows a hyperintense lesion in the pons (arrow). (b) Axial FLAIR image (6614/100) shows that the lesion has a hypointense center with a hyperintense rim (arrow), an appearance that reflects gliosis.

 

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Chronic lacunar infarction of the pons in a 59-year-old man. (a) Axial proton-density–weighted image (2200/100) shows a hyperintense lesion in the pons (arrow). (b) Axial FLAIR image (6614/100) shows that the lesion has a hypointense center with a hyperintense rim (arrow), an appearance that reflects gliosis.

 

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 11a.  Acute and chronic lacunar infarctions in a 66-year-old man. (a) Axial proton-density–weighted image (2385/100) shows multiple high-signal-intensity lesions bilaterally in the basal ganglia, internal capsule, and thalamus (arrows). The signal intensity of the periventricular white matter is abnormally increased. (b) Axial FLAIR image (6608/100) shows multiple small high-signal-intensity lesions and hypointense lesions surrounded by hyperintense rims in the same region (arrows). (c) Apparent diffusion coefficient map shows a recent infarction in the posterior limb of the right internal capsule (arrow).

 

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 11b.  Acute and chronic lacunar infarctions in a 66-year-old man. (a) Axial proton-density–weighted image (2385/100) shows multiple high-signal-intensity lesions bilaterally in the basal ganglia, internal capsule, and thalamus (arrows). The signal intensity of the periventricular white matter is abnormally increased. (b) Axial FLAIR image (6608/100) shows multiple small high-signal-intensity lesions and hypointense lesions surrounded by hyperintense rims in the same region (arrows). (c) Apparent diffusion coefficient map shows a recent infarction in the posterior limb of the right internal capsule (arrow).

 

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 11c.  Acute and chronic lacunar infarctions in a 66-year-old man. (a) Axial proton-density–weighted image (2385/100) shows multiple high-signal-intensity lesions bilaterally in the basal ganglia, internal capsule, and thalamus (arrows). The signal intensity of the periventricular white matter is abnormally increased. (b) Axial FLAIR image (6608/100) shows multiple small high-signal-intensity lesions and hypointense lesions surrounded by hyperintense rims in the same region (arrows). (c) Apparent diffusion coefficient map shows a recent infarction in the posterior limb of the right internal capsule (arrow).

 

View larger version (113K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Cystic periventricular leukomalacia in a 3-year-old boy with a history of perinatal asphyxia who had delayed motor and mental development and epilepsy. (a) Axial proton-density–weighted image (2611/100) shows hyperintense lesions predominantly in the right peritrigonal area (straight arrow) but also in the left peritrigonal area (curved arrow). These lesions could be mistaken for type II VR spaces. (b) Coronal FLAIR image (11,000/140) shows gliosis around the cystic lesions (arrows), a characteristic finding in end-stage cystic periventricular leukomalacia.

 

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Cystic periventricular leukomalacia in a 3-year-old boy with a history of perinatal asphyxia who had delayed motor and mental development and epilepsy. (a) Axial proton-density–weighted image (2611/100) shows hyperintense lesions predominantly in the right peritrigonal area (straight arrow) but also in the left peritrigonal area (curved arrow). These lesions could be mistaken for type II VR spaces. (b) Coronal FLAIR image (11,000/140) shows gliosis around the cystic lesions (arrows), a characteristic finding in end-stage cystic periventricular leukomalacia.

 

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Ovoid MS lesion of the centrum semiovale in a 49-year-old man. Axial proton-density–weighted (2624/100) (a) and FLAIR (7291/120) (b) images show a hyperintense lesion (arrow) in the right centrum semiovale. Other MS lesions were located behind the left occipital horn and in the basal ganglia and brainstem.

 

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Ovoid MS lesion of the centrum semiovale in a 49-year-old man. Axial proton-density–weighted (2624/100) (a) and FLAIR (7291/120) (b) images show a hyperintense lesion (arrow) in the right centrum semiovale. Other MS lesions were located behind the left occipital horn and in the basal ganglia and brainstem.

 

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 14.  Cryptococcosis in a 58-year-old woman with headaches and fever who was seropositive for human immunodeficiency virus. Parasagittal T2-weighted image (5963/120) shows multiple dilated VR spaces in the region of the basal ganglia (arrowheads). C neoformans was cultured from the CSF.

 

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 15a.  Hurler syndrome (mucopolysaccharidosis type I) in a 2-year-old boy with typical external features of this syndrome. A classic Hurler mutation with severe -L-iduronidase deficiency was demonstrated. (a) Axial proton-density–weighted image (3835/150) shows dilated VR spaces in both hemispheres (arrowheads). (b) Coronal FLAIR image (6381/100) shows increased signal intensity in the surrounding brain parenchyma (arrows); this finding indicates that the spaces are not normally dilated VR spaces. There is also increased CSF space frontally.

 

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 15b.  Hurler syndrome (mucopolysaccharidosis type I) in a 2-year-old boy with typical external features of this syndrome. A classic Hurler mutation with severe -L-iduronidase deficiency was demonstrated. (a) Axial proton-density–weighted image (3835/150) shows dilated VR spaces in both hemispheres (arrowheads). (b) Coronal FLAIR image (6381/100) shows increased signal intensity in the surrounding brain parenchyma (arrows); this finding indicates that the spaces are not normally dilated VR spaces. There is also increased CSF space frontally.

 

View larger version (119K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Desmoplastic pilocytic astrocytoma of the right thalamus, cerebral peduncle, and brainstem in a 15-year-old girl. (a, b) Axial proton-density–weighted (2374/100) (a) and FLAIR (6614/100) (b) images show a large mass with solid (arrow) and cystic (arrowheads) components. (c) Axial gadolinium-enhanced T1-weighted image (598/18) shows inhomogeneous enhancement of the solid component (arrow) and rim enhancement of the cystic components (arrowheads). Obstruction of the third ventricle has caused hydrocephalus.

 

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Desmoplastic pilocytic astrocytoma of the right thalamus, cerebral peduncle, and brainstem in a 15-year-old girl. (a, b) Axial proton-density–weighted (2374/100) (a) and FLAIR (6614/100) (b) images show a large mass with solid (arrow) and cystic (arrowheads) components. (c) Axial gadolinium-enhanced T1-weighted image (598/18) shows inhomogeneous enhancement of the solid component (arrow) and rim enhancement of the cystic components (arrowheads). Obstruction of the third ventricle has caused hydrocephalus.

 

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 16c.  Desmoplastic pilocytic astrocytoma of the right thalamus, cerebral peduncle, and brainstem in a 15-year-old girl. (a, b) Axial proton-density–weighted (2374/100) (a) and FLAIR (6614/100) (b) images show a large mass with solid (arrow) and cystic (arrowheads) components. (c) Axial gadolinium-enhanced T1-weighted image (598/18) shows inhomogeneous enhancement of the solid component (arrow) and rim enhancement of the cystic components (arrowheads). Obstruction of the third ventricle has caused hydrocephalus.

 

View larger version (120K): [in this window] [in a new window] [Download PPT slide]   Figure 17.  Parenchymal neurocysticercosis in the vesicular stage in a 17-year-old boy. Axial T1-weighted image (605/18) shows a cystic lesion with an eccentrically located scolex (arrow), a finding pathognomonic of neurocysticercosis.

 

View larger version (149K): [in this window] [in a new window] [Download PPT slide]   Figure 18.  Arachnoid cyst in the perisellar cistern area in a 16-year-old girl. Axial FLAIR image (7292/120) shows a well-defined, round cyst with CSF-like content in the suprasellar cistern (arrow).

 

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 19.  Neuroepithelial cyst of the thalamus in a 53-year-old woman with migraine headaches. Axial FLAIR image (7291/120) shows a multiloculated cyst with CSF-like signal intensity in the right thalamus (arrow). The adjacent brain parenchyma has normal signal intensity. Note that this lesion could also be an enlarged VR space. A final diagnosis can be made with certainty only after pathologic study.

 

View larger version (162K): [in this window] [in a new window] [Download PPT slide]   Figure 20a.  Neuroepithelial cyst of the cerebral peduncle and pons in a 60-year-old woman with epilepsy. Axial T1-weighted (30/13) (a) and coronal FLAIR (11,000/140) (b) images show a cyst with CSF-like content in the left cerebral peduncle (arrow). The adjacent tissue has normal signal intensity. The cyst has a diameter of 15.7 mm as measured on the coronal FLAIR image (b). This benign lesion probably represents a neuroepithelial cyst, although it could also be a huge VR space.

 

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 20b.  Neuroepithelial cyst of the cerebral peduncle and pons in a 60-year-old woman with epilepsy. Axial T1-weighted (30/13) (a) and coronal FLAIR (11,000/140) (b) images show a cyst with CSF-like content in the left cerebral peduncle (arrow). The adjacent tissue has normal signal intensity. The cyst has a diameter of 15.7 mm as measured on the coronal FLAIR image (b). This benign lesion probably represents a neuroepithelial cyst, although it could also be a huge VR space.

 

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 21.  Choroidal fissure cyst in a 1-week-old boy. Axial T1-weighted spectral presaturation inversion-recovery image (5094/30) shows a medial temporal lobe cyst with CSF-like content arising in the choroidal fissure (arrow).

 

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