Perivascular spaces
Updates to Article Attributes
Perivascular spaces, also known as Virchow-Robin spaces, are pial-lined interstitial fluid-filled spaces in the brain that surround perforating vessels. They do not have a direct connection with the subarachnoid space and in fact, the fluid within them is a slightly different composition as compared to CSF.
On axial imaging, they appear as smoothly demarcated fluid-filled cysts, typically less than 5 mm in diameter, showing the same attenuation or intensity as CSF and often found in the basal ganglia or midbrain.
Terminology
When perivascular spaces are very numerous the brain can have a colander-like appearance, referred to as état criblé (as opposed to numerous lacunes, sometimes referred to as état lacunaire).
When perivascular spaces are very large then they are referred to as tumefactive perivascular spaces.
When located in the anterior temporal lobe and related to a vascular loop they are known as an anterior temporal lobe perivascular spaces, but are almost certainly a different entity to typical scattered perivascular spaces.
Epidemiology
Overall perivascular spaces are very common, and increasingly seen with better MRI image quality. Depending on the definition, they are seen in 50-100% of patients 2,3 and their relevance is mainly in not mistaking them for pathology.
Clinical features
They are almost invariably asymptomatic, even when quite large. Rarely, they can cause mass effect and even result in obstructive hydrocephalus.
Pathology
Perivascular spaces consist of a single or double layer of invaginated pia 8. They are typically less than 5 mm in diameter but can reach much larger sizes, a so-called giant perivascular space or tumefactive perivascular space, and can exert enough mass effect to be symptomatic 1. They tend to enlarge with age and with hypertension. When very numerous the brain can have a colander-like
Historically they were believed to be entirely incidental and asymptomatic, and that their relevance was mainly in not mistaking them for other more sinister pathology (especially true when tumefactive or unusual in appearance referred to as (e.g. anterior temporal lobe perivascular spaces often mistaken for tumours).
More recent work has shown an association between extensive basal ganglia perivascular spaces (état criblé (as opposed to numerous lacunes, sometimes referred to as état lacunaire)
Location
Most commonly, perivascular spaces are located in the lower half of the basal ganglia, especially in the anterior perforated substance along the line of the anterior commissure 3. They are also found in 1:
- substantia nigra
- dentate nucleus
- subinsular region: "subinsular bright spots"
- corpus callosum and cingulate gyrus
The cortical regions are spared. In contrast to lacunar infarcts encountered more frequently in the upper half of the putamen, perivascular spaces are seen more often in the lower half.
A special type of perivascular space occurs in the anterior temporal lobe and can mimic a cystic tumour. These are discussed separately: anterior temporal lobe perivascular spaces 9,10.
Types
Perivascular spaces are divided into three main types 4:
- type 1: located in the area supplied by the lenticulostriate arteries entering the basal ganglia
- type 2: located in the area supplied by the perforating medullary arteries as they enter the cortical grey matter
- type 3: located in the midbrain
Associations
They are usually idiopathic, although they are seen in greater frequency in 1,4,11:
- mucopolysaccharidoses, e.g. Hunter disease, Hurler disease
- some muscular dystrophies
- traumatic brain injury
- cerebral amyloid angiopathy
Radiographic features
As they are filled with a fluid similar to CSF, perivascular spaces have appearances akin to water on all imaging modalities and sequences. Differentiating them from foci of encephalomalacia that result from chronic lacunar infarcts can be challenging but is important as imaging findings of ischaemia can lead to patients being put on medication such as antiplatelet therapy.
Perivascular spaces should be considered if:
- patient is young
- absence of vascular risk factors
- no other changes of chronic small vessel ischaemia.
CT
- well-circumscribed fluid-density spaces
- no enhancement
- no calcification
- CT angiography occasionally demonstrates a traversing vessel
MRI
They follow CSF signal on all pulse sequences 7. When small, the adjacent white matter is normal, thus helping to distinguish perivascular spaces from lacunar infarcts, which have surrounding gliosis (best seen on T2 FLAIR sequence).
Although generally cyst-like on axial sequences, on sagittal and coronal sequences a linear radiating morphology may be seen consistent with their role in surrounding vessels.
In a minority of cases, especially when they are large, a thin increased T2-signal halo may be seen. Usually, they will have a positive mass effect. On T2 sequences, a traversing vessel is sometimes seen.
The exception to the 'no surrounding high T2 signal' rule is are anterior temporal lobe perivascular spaces 9,10.
History and etymology
Virchow-Robin spaces are named after German pathologist Rudolf Virchow (1821–1902) and French anatomist Charles Philippe Robin (1821–1885).
Differential diagnosis
For small perivascular spaces, consider:
- choroid fissure cyst
-
lacunar infarcts and striatocapsular infarcts
- a rim of gliosis seen best on FLAIR 8
- neutral or negative mass effect
- typically upper two-thirds of basal ganglia (due to infarcts of perforating end arteries)
-
chronic small vessel ischaemic disease
- typically periventricular and subcortical
-
neurocysticercosis
- cyst with a dot sign
- enhancement
- calcification
- CNS cryptococcosis: if multiple
For giant perivascular spaces consider:
- cystic neoplasms 1,8
- they rarely exhibit similar CSF intensity on all MRI sequences
- ventricular diverticula
- cystic encephalomalacia
- non-neoplastic neuroepithelial cyst(s)
-<p><strong>Perivascular spaces</strong>, also known as <strong>Virchow-Robin spaces</strong>, are pial-lined interstitial fluid-filled spaces in the brain that surround perforating vessels. They do not have a direct connection with the subarachnoid space and in fact, the fluid within them is a slightly different composition as compared to <a href="/articles/cerebrospinal-fluid-1">CSF</a>.</p><p>On axial imaging, they appear as smoothly demarcated fluid-filled cysts, typically less than 5 mm in diameter, showing the same attenuation or intensity as CSF and often found in the basal ganglia or midbrain.</p><h4>Terminology</h4><p>When perivascular spaces are very numerous the brain can have a colander-like appearance, referred to as <a href="/articles/tat-crible">état criblé</a> (as opposed to numerous lacunes, sometimes referred to as <a href="/articles/tat-lacunaire">état lacunaire</a>).</p><h4>Epidemiology</h4><p>Overall perivascular spaces are very common, and increasingly seen with better MRI image quality. Depending on the definition, they are seen in 50-100% of patients <sup>2,3</sup> and their relevance is mainly in not mistaking them for pathology.</p><h4>Clinical features</h4><p>They are almost invariably asymptomatic, even when quite large. Rarely, they can cause mass effect and even result in <a href="/articles/obstructive-hydrocephalus">obstructive hydrocephalus</a>.</p><h4>Pathology</h4><p>Perivascular spaces consist of a single or double layer of invaginated pia <sup>8</sup>. They are typically less than 5 mm in diameter but can reach much larger sizes, a so-called giant perivascular space or <a href="/articles/tumefactive-perivascular-spaces-1">tumefactive perivascular space</a>, and can exert enough mass effect to be symptomatic <sup>1</sup>. They tend to enlarge with age and with hypertension. When very numerous the brain can have a colander-like appearance referred to as <a href="/articles/tat-crible">état criblé</a> (as opposed to numerous lacunes, sometimes referred to as <a href="/articles/tat-lacunaire">état lacunaire</a>).</p><h5>Location</h5><p>Most commonly, perivascular spaces are located in the lower half of the <a href="/articles/basal-ganglia">basal ganglia</a>, especially in the anterior perforated substance along the line of the anterior commissure <sup>3</sup>. They are also found in <sup>1</sup>:</p><ul>- +<p><strong>Perivascular spaces</strong>, also known as <strong>Virchow-Robin spaces</strong>, are pial-lined interstitial fluid-filled spaces in the brain that surround perforating vessels. They do not have a direct connection with the subarachnoid space and in fact, the fluid within them is a slightly different composition as compared to <a href="/articles/cerebrospinal-fluid-1">CSF</a>.</p><p>On axial imaging, they appear as smoothly demarcated fluid-filled cysts, typically less than 5 mm in diameter, showing the same attenuation or intensity as CSF and often found in the basal ganglia or midbrain.</p><h4>Terminology</h4><p>When perivascular spaces are very numerous the brain can have a colander-like appearance, referred to as <a href="/articles/tat-crible">état criblé</a> (as opposed to numerous lacunes, sometimes referred to as <a href="/articles/tat-lacunaire">état lacunaire</a>).</p><p>When perivascular spaces are very large then they are referred to as <a href="/articles/tumefactive-perivascular-spaces-1">tumefactive perivascular spaces</a>. </p><p>When located in the anterior temporal lobe and related to a vascular loop they are known as an <a title="Anterior temporal lobe perivascular spaces" href="/articles/anterior-temporal-lobe-perivascular-spaces">anterior temporal lobe perivascular spaces</a>, but are almost certainly a different entity to typical scattered perivascular spaces. </p><h4>Epidemiology</h4><p>Overall perivascular spaces are very common, and increasingly seen with better MRI image quality. Depending on the definition, they are seen in 50-100% of patients <sup>2,3</sup>.</p><h4>Clinical features</h4><p>They are almost invariably asymptomatic, even when quite large. Rarely, they can cause mass effect and even result in <a href="/articles/obstructive-hydrocephalus">obstructive hydrocephalus</a>.</p><h4>Pathology</h4><p>Perivascular spaces consist of a single or double layer of invaginated pia <sup>8</sup>. They are typically less than 5 mm in diameter but can reach much larger sizes, a so-called giant perivascular space or <a href="/articles/tumefactive-perivascular-spaces-1">tumefactive perivascular space</a>, and can exert enough mass effect to be symptomatic <sup>1</sup>. They tend to enlarge with age and with hypertension.</p><p>Historically they were believed to be entirely incidental and asymptomatic, and that their relevance was mainly in not mistaking them for other more sinister pathology (especially true when tumefactive or unusual in appearance (e.g. <a href="/articles/anterior-temporal-lobe-perivascular-spaces">anterior </a><a href="/articles/anterior-temporal-lobe-perivascular-spaces">temporal</a><a href="/articles/anterior-temporal-lobe-perivascular-spaces"> lobe perivascular spaces</a> often mistaken for tumours). </p><p>More recent work has shown an association between extensive basal ganglia perivascular spaces (<a href="/articles/tat-crible">état criblé</a>) and the development of progressive white matter lesions <sup>12</sup>. They are now considered a marker for early chronic small vessel ischaemia and can be considered a form of localized atrophy <sup>12</sup>. </p><h5>Location</h5><p>Most commonly, perivascular spaces are located in the lower half of the <a href="/articles/basal-ganglia">basal ganglia</a>, especially in the anterior perforated substance along the line of the anterior commissure <sup>3</sup>. They are also found in <sup>1</sup>:</p><ul>
-<li><a href="/articles/traumatic-brain-injury">traumatic brain injury</a></li>- +<li><a href="/articles/traumatic-brain-injury">traumatic brain injury </a></li>
-<a title="Leukoaraiosis" href="/articles/leukoaraiosis">chronic small vessel ischaemic disease</a><ul><li>typically periventricular and subcortical</li></ul>- +<a href="/articles/leukoaraiosis">chronic small vessel ischaemic disease</a><ul><li>typically periventricular and subcortical</li></ul>
References changed:
- 12. Loos CM, Klarenbeek P, van Oostenbrugge RJ, Staals J. Association between Perivascular Spaces and Progression of White Matter Hyperintensities in Lacunar Stroke Patients. (2015) PloS one. 10 (9): e0137323. <a href="https://doi.org/10.1371/journal.pone.0137323">doi:10.1371/journal.pone.0137323</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26352265">Pubmed</a> <span class="ref_v4"></span>
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