Giant mesencephalothalamic VR spaces and obstructive hydrocephalus

Case contributed by Mohammad A. ElBeialy


History of trauma 10 years ago; the patient was admitted to ICU where CT brain was done and a "brain tumor" was diagnosed. The patient disappeared to follow up and now is presenting with headache and left sided weakness.

Patient Data

Age: 50 years
Gender: Male

Multiple thin-walled cystic spaces are seen; predominantly at the right midbrain and right hypothalamus as well as the right thalamus and basal ganglia. They present isointense signal to the CSF on all pulse sequences with no significant post-contrast enhancement. Similar lesions are seen within the left midbrain and basal ganglia. The lesions are seen surrounding and significantly compressing the cerebral aqueduct with consequent moderate dilatation of the ventricular system.  normal adjacent brain parenchyma. No area of restricted diffusion.   Prominent extra-axial CSF spaces. No extra-axial collections. Partial empty sella with intra-sellar herniation of the supra-sellar cistern with widened sella turcica and the pituitary gland is seen flattened against the sellar floor.

Diagnosis: Expanding and giant Virchow-Robin spaces; predominantly within the right midbrain, hypothalamus, thalamus and basal ganglia (mesencephalothalamic giant VR spaces) with mass effect on the cerebral aqueduct and supratentorial obstructive hydrocephalus.

Case Discussion

The typical CSF signal and normal adjacent brain parenchyma as well as lack of soft tissue component and post-contrast enhancement allow a confident diagnosis of giant  virchow Robin (VR) spaces. It is also helpful that the patient has had this finding for almost a decade without change. 

 The differential diagnosis of dilated VR spaces include lacunar infarctions ( with perilesional gliosis), multiple sclerosis, neurocysticercosis, cystic neoplasms e.g. pilocytic astrocytoma ( with small solid component and post contrast enhancment of the cystic wall and the solid component), mucopolysaccharidoses e.g. Hurler's syndrome as well as neuroepithelial and arachnoid cysts.    

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