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Enlarged Perivascular Spaces

Summary

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  • Enlarged perivascular spaces (EPVS) are fluid-filled cavities surrounding small blood vessels in the brain
  • They are commonly seen on neuroimaging, particularly in older individuals
  • EPVS are generally considered a benign finding but may be associated with various neurological conditions

Pathophysiology

  • EPVS, also known as Virchow-Robin spaces, are extensions of the subarachnoid space
  • They contain interstitial fluid and follow the course of penetrating arteries and veins
  • Enlargement occurs due to:
    • Increased fluid accumulation
    • Impaired drainage of interstitial fluid
    • Alterations in blood-brain barrier permeability
  • Associated with:
    • Normal ageing
    • Cerebral small vessel disease
    • Inflammation
    • Hypertension

Demographics

  • Prevalence increases with age
  • More common in:
    • Elderly individuals
    • Patients with hypertension
    • Those with cerebral small vessel disease
  • No significant gender predilection reported

Diagnosis

  • Often an incidental finding on neuroimaging
  • Clinical presentation:
    • Usually asymptomatic
    • Rarely, may cause mass effect leading to focal neurological deficits
  • Differential diagnosis:
    • Lacunar infarcts
    • Cystic periventricular leukomalacia
    • Multiple sclerosis lesions

Imaging

  • MRI is the modality of choice for detecting EPVS
  • Characteristics on MRI:
    • T2-weighted and FLAIR sequences: Hyperintense signal
    • T1-weighted sequences: Hypointense signal
    • Follow the course of penetrating vessels
    • No enhancement with contrast
  • Common locations:
    • Basal ganglia
    • Centrum semiovale
    • Midbrain
  • Grading systems:
    • Based on number and size of EPVS
    • E.g., Wardlaw scale: 0 (none) to 4 (severe)

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  • A cluster of T2-hyperintense lesions centred on the right cingulum fully suppressed on FLAIR and had no surrounding parenchymal signal change.

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  • There is an enlarged perivascular space (T2-hyperintense and fully suppressing on FLAIR) in a typical location; in the subganglionic region.
  • Both T2-weighted, time-of-flight angiography and post-gadolinium T1-weighted imaging showed the vessel traversing the perivascular space.

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  • Incidental finding of a clustered subcortical CSF signal without mass effect was consistent with enlarged perivascular spaces.
  • With no FLAIR hyperintensity, an MVNT was not likely.

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  • An incidental enlarged perivascular space in the left subganglionic region.
  • The transiting artery is seens as a flow void on T2-weighted imaging.

Treatment

  • No specific treatment required for asymptomatic EPVS
  • Management focuses on underlying conditions:
    • Blood pressure control
    • Management of cerebrovascular risk factors
  • In rare cases of symptomatic EPVS:
    • Surgical decompression may be considered
    • Cerebrospinal fluid diversion procedures

Differential diagnosis

Differential Diagnosis Differentiating Feature
Lacunar infarcts Irregular shape, surrounding gliosis on FLAIR
Multiple sclerosis lesions Ovoid shape, periventricular predilection, enhancement
Small vessel ischaemic changes Irregular margins, hyperintense on FLAIR
Cystic neoplasms Mass effect, enhancement, irregular borders
Neurocysticercosis Eccentric scolex, surrounding oedema, enhancement
Cryptococcosis Gelatinous pseudocysts, meningeal enhancement
Mucopolysaccharidosis White matter abnormalities, skeletal dysplasia
Arachnoid cysts Larger size, displacement of adjacent structures
Adrenoleukodystrophy White matter involvement, contrast enhancement