Case of the Week
Section Editors: Matylda Machnowska1 and Anvita Pauranik2
1University of Toronto, Toronto, Ontario, Canada
2BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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December 24, 2020
Cerebellar Tumefactive Perivascular Space
- Background:
- Pia-lined perivascular spaces in the brain can become so enlarged (tumefactive) that they may easily be mistaken for a cystic neoplasm and may cause local mass effect.
- Have characteristic MRI features, so important to recognize
- Clinical Presentation:
- Often asymptomatic
- Patients can present with nonspecific symptoms such as headache, dizziness, visual changes, balance disturbance, and so forth, but causation has not been established between tumefactive perivascular spaces and this varied symptomatology, and more often they are incidental findings.
- Key Diagnostic Features:
-
CT: low-attenuation cystic lesions with no contrast enhancement
-
MRI: displays CSF signal intensity in all pulse sequences with no diffusion restriction or postcontrast enhancement
-
Most commonly located in the mesencephalothalamic region and the cerebral white matter, and least frequently in the cerebellum
-
- Differential Diagnoses:
- Cystic neoplasm: most commonly does not follow CSF signal on all sequences and may show enhancement
- Neuroepithelial cysts: difficult to differentiate on imaging alone; signal characteristics may slightly vary from CSF
- Cryptococcal meningitis: mainly seen in immunodeficient patients; often associated with hydrocephalus and leptomeningeal enhancement
- Neurocysticercosis: cyst with dot sign; thickened enhancing wall
- Lacunar infarct: rim of gliosis (best seen on FLAIR); neutral or negative mass effect
- Cystic encephalomalacia: associated gliosis and volume loss with some surrounding hyperintensity on FLAIR sequence
- Ventricular diverticula: continuous with ventricular system
- Treatment:
- Surveillance
- Treatment of any complications such as hydrocephalus
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