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Giant Perivascular Spaces

Open Table of Contents: Giant Perivascular Spaces

Figure 1: Large oval structure within the right putamen that follows CSF signal intensity on T1-weighted (top left), T2-weighted (top right), FLAIR (middle left), and DWI (middle right) imaging. Notice that there are a few additional smaller similar-appearing cystic structures medially, also representing dilated perivascular spaces. There is no significant adjacent FLAIR signal abnormality (middle left) or enhancement (bottom) to suggest an alternative diagnosis.

Figure 1: Large oval structure within the right putamen that follows CSF signal intensity on T1-weighted (top left), T2-weighted (top right), FLAIR (middle left), and DWI (middle right) imaging. Notice that there are a few additional smaller similar-appearing cystic structures medially, also representing dilated perivascular spaces. There is no significant adjacent FLAIR signal abnormality (middle left) or enhancement (bottom) to suggest an alternative diagnosis.

Description

  • Pia-lined interstitial fluid-filled spaces
  • Do not communicate with subarachnoid space
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Pathology

  • Fluid accumulation causing cystic-appearing spaces

Clinical Features

  • Symptoms
    • Almost always normal, although patients may have headache
    • Can have an association with small-vessel disease and hemorrhage
  • Age
    • No age predilection
  • Gender
    • Male > female

Imaging

  • General
    • Variably sized fluid-filled spaces with the signal of cerebrospinal fluid (CSF)
  • Modality specific
    • CT
      • Round or even linear hypodense lesions with characteristics similar to those of CSF
      • Nonenhancing
  • MRI
    • T1WI
      • Multiple well-delineated small cysts isointense to CSF
      • Can have cumulative focal mass effect, particularly if involving the basal ganglia
    • T2WI/FLAIR
      • Isointense to CSF without surrounding edema
    • DWI
      • Normal diffusivity
    • Contrast
      • No enhancement
  • Imaging recommendations
    • MRI with contrast
    • DWI can be helpful
  • Mimic
    • Can mimic infection, lacunar infarct, or even cystic tumor; location is often a key to the correct diagnosis, but MRI might help by demonstrating identical signal intensity to normal CSF and a lack of surrounding gliosis or enhancement

For more information, please see the corresponding chapter in Radiopaedia.

Contributor: Sean Dodson, MD

DOI: https://doi.org/10.18791/nsatlas.v1.03.02.15

References

Eluvathingal Muttikkal TJ,  Raghavan P. Spontaneous regression and recurrence of a tumefactive perivascular space. Neuroradiol J 2014;27:195–202. doi.org/10.15274/NRJ-2014-10034

John S, Samuel S, Lakhan SE. Tumefactive perivascular spaces mimicking cerebral edema in a patient with diabetic hyperglycemic hyperosmolar syndrome: a case report. J Med Case Rep 2013;7:51. doi.org/10.1186/1752-1947-7-51

Salzman KL, Osborn AG, House P, et al. Giant tumefactive perivascular spaces.  AJNR Am J Neuroradiol 2005;26:298–305.

Stephens T, Parmar H, Cornblath W. Giant tumefactive perivascular spaces. J Neurol Sci 2008;266:171–173. doi.org/10.1016/j.jns.2007.08.032

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