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Atypical Virchow-Robin Spaces Mimicking Cystic Primary Brain Tumor

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Atypical Virchow-Robin Spaces Mimicking Cystic Primary Brain Tumor Published online: 2020-09-30 THIEME Case Report | Relato de Caso 311 Atypical Virchow-Robin Spaces Mimicking Cystic Primary Brain Tumor – Clinical Report and Literature Review EspaçosperivascularesatípicosdeVirchow-Robin simulando neoplasia primária do sistema nervoso central – Sériedecasoserevisãodeliteratura Helder Picarelli1 Thales Bhering Nepomuceno2 Yuri Casal3 Vitor Nagai Yamaki2 Manoel Jacobsen Teixeira2 Eberval Gadelha Figueiredo2 1 Division of Neurosurgery, Instituto do Câncer do Estado de São Address for correspondence Helder Picarelli, MD, Divisão de Paulo, São Paulo, SP, Brazil Neurocirugia, Instituto do Câncer do Estado de São Paulo (ICESP), 2 Division of Neurosurgery, Hospital das Clínicas, Faculdade de Rua Itacolomi, 538, apartamento 121, Higienópolis, São Paulo, SP, Medicina,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil 01239-020, Brazil 3 Division of Anatomical Pathology, Hospital das Clínicas, Faculdade (e-mail: [email protected]; [email protected]). de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil Arq Bras Neurocir 2020;39(4):311–316. Abstract The Virchow-Robin spaces (VRSs), which are often incidentally observed in modern structural neuroimaging examinations, are small cystic cavities that usually surround the small arteries and arterioles at the level of basal ganglia, the anterior perforated substance and the thalamic-mesencephalic junction. Typically, they have similar physicochemical characteristics to cerebral spinal fluid (CSF) and there is no contrast enhancement on brain CT and MRI images. Its real meaning is unknown, although some contemporary studies have suggested that it might be related to certain traumatic brain injury or several other central nervous system (CNS) disorders, as degenerative Keywords diseases. Occasionally, some wide and atypical VRS may be mistaken for primary cystic ► virchow-robin space brain tumors, especially in the context of large and symptomatic lesions, multiple ► enlarged perivascular clustered cysts, cortical lesions and if there is adjacent reactive gliosis. The present space paper reports four patients who were affected by atypical VRS mimicking brain tumors ► atypical virchow- that required imaging follow-up or even a biopsy to confirm the diagnosis or to indicate robin space the correct approach. Although it is not so unusual, one of them occurred concomi- ► cystic brain tumor tantly and adjacent to a diffuse glioma (co-deleted 1p19q, WHO-GII). Resumo Os espaços perivasculares alargados de Virchow-Robin (EVRs), que são frequentemente observados incidentalmente nos modernos exames estruturais de neuroimagem como pequenas cavidades císticas, geralmente circundam as pequenas artérias e arteríolas ao nível dos gânglios da base, da substância perfurada anterior e da junção tálamo-mesence- fálica. Normalmente, eles têm características físico-químicas semelhantes às do líquido received DOI https://doi.org/ Copyright © 2020 by Thieme Revinter February 19, 2020 10.1055/s-0040-1716562. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 0103-5355. July 7, 2020 312 Atypical Virchow-Robin Spaces Mimicking Cystic Primary Brain Tumor Picarelli et al. cefalorraquidiano e não apresentam realce após a injeção de contraste iodado ou paramagnético nas imagens obtidas por tomografia ou ressonância magnética de crânio. O significado real desse achado é desconhecido, embora alguns estudos contemporâneos tenham sugerido que eles possam estar relacionados a certas lesões cerebrais traumáticas Palavras-chave ou a vários outros distúrbios do sistema nervoso central (CNS), como algumas doenças ► espaço de Virchow- degenerativas. Ocasionalmente, alguns EVRs volumosos e atípicos podem ser confundidos Robin com tumores cerebrais primários císticos, especialmente no contexto de lesões grandes e ► espaço perivascular sintomáticas, cistos agrupados múltiplos, lesões corticais e se houver gliose reativa aumentado adjacente. O presente artigo relata quatro pacientes portadores de EVR atípicos, mime- ► espaço de Virchow- tizando tumores cerebrais, que necessitaram de acompanhamento com imagens seriadas Robin atípico ou até uma biópsia para confirmar o diagnóstico ou indicar o tratamento adequado. ► tumor cerebral Embora não seja tão incomum, um deles ocorreu concomitantemente e adjacente a um cístico glioma difuso (co-deletado 1p19q, OMS-GII). Introduction nation was unremarkable. The brain MRI images showed The Virchow-Robin spaces (VRSs), or perivascular spaces, are multiple small cystic lesions, in the cortex and in the white small cystic cavities that usually surround the walls of arteries, matter of the superior and middle frontal gyri, with intensities arterioles, veins and venules at the level of the basal ganglia, similar to the CSF (►Fig. 1). Faced with diagnostic hypotheses the anterior perforated substance and the thalamic-mesence- of symptomatic epilepsy, triggered by atypical enlarged VRS or phalic junction, as they course from the subarachnoid space multinodulatedvacuolar neuronaltumor orothercystic glioma – through the brain parenchyma.1 4 These spaces, which are tumor, the patient underwent surgical treatment. We have better visualized in magnetic resonance imaging (MRI) T2- performed an awake craniotomy - with brain mapping - which weighted images, are considered to be enlarged when the size was successful and got subtotal resection without any func- exceeds 2 mm. Typically, its physicochemical characteristics tional impairment. The histopathological workup showed a are similar to the cerebral spinal fluid (CSF), there is no contrast wide VRS around capillary vessels with normal surrounding enhancement and the tissues surrounding it are totally normal tissue. On the immunohistochemical analysis, the tissue was on brain computed tomography (CT) and MRI images. Com- positively marked for Neu-N and CD34 delineating the vascular monly, they are asymptomatic and are found in all age groups, contour (►Fig. 2). although the frequency with which they are observed increases with age. Although some contemporary studies Case 2 have suggested that it might be related to certain traumatic A 38-year-old male patient was submitted to brain CT and brain injury and several other central nervous system (CNS) MRI after mild accidental traumatic brain injury. The MRI – disorders, its real meaning is unknown.5 24 revealed small cystic lesions on T2-weighted in the cingulate Occasionally, some enlarged VRSs can reach a very large gyrus of the right frontal lobe without diffusion restriction volume, assume bizarre settings and have reactional gliosis (►Fig. 3). There was no perilesional edema on fluid attenua- surrounding them. In these particular conditions they are so- tion inversion recovery (FLAIR) and no contrast enhance- called atypical and tumefactive VRSs and may present them- ment. The patient has been followed-up for 6 years and selves with symptoms such as seizures, hydrocephalus and remains asymptomatic. His periodic brain images have not headache. Most often, atypical and tumefactive VRSs are shown any progression of the lesions, which strongly sug- difficult to differentiatefrom a couple of pathologic conditions, gests the diagnosis of atypical VRS. especially from some primary cystic brain tumors and vascular disorders. Sometimes, either follow-up over time with serial Case 3 imaging or a biopsy is needed to establish the correct diagnosis A 49-year-old female patient was admitted to our service with – and the most appropriate management.1 11,25 reentrant epileptic seizures. In her past medical history, it was reported that she had diabetes, hypertension, and drug-resis- Case Reports tant epilepsy for 10 years secondary to a right frontal lobe lesion. She had been previously submitted to a stereotactic Case 1 biopsy in an external service with inconclusive findings. She A 25-year-old female patient, without any past medical history, underwent an MRI that revealed a small right frontal lesion, was admitted to the service complaining of early onset of short with hyperintense signal on FLAIR and T2-weighted images, focal seizures with fast bilateral tonicclonic progression. In that mild hyperintense signal on T1 images, reasonable diffusion time, her clinical history and semiology features were very restriction, infiltrative behavior, minor mass effect and no suggestive of frontal lobe epilepsy and her neurological exami- contrast enhancement. Adjacent to these, there were multiple Arquivos Brasileiros de Neurocirurgia Vol. 39 No. 4/2020 Atypical Virchow-Robin Spaces Mimicking Cystic Primary Brain Tumor Picarelli et al. 313 Fig. 1 Case 1. Type 2 atypical enlarged VRS in the cerebral convexity mimicking a cystic primary tumor. The MRI of the brain demonstrates a cystic lesion on the left frontal lobe. Visually, the signal intensity of the cystic contents is identical to those of CSF with all pulse sequences. The sign intensity of the brain parenchyma surrounding is slightly higher than the normal tissue and there is no gadolinium enhancement. (A) Coronal T2-weighted image, (B) Axial T2-weighted brain slice, (C)Axialfluid-attenuated inversion-recovery (FLAIR) view. Fig. 2 Histological characterization of the enlarged Virchow Robin Space. (A) photomicrograph showing cystic dilation of the Virchow-Robin space around a capillary vessel (arrow). Surrounding the dilatation, normal brain tissue is observed. (B): photomicrograph showing immunohistochemical marker (CD34) delineating the vascular contour within a cystic dilation (arrow). (C): NeuN showing normal neuronal organization
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