Images in Neurology: Giant Tumefactive Perivascular Spaces Associated with Pediatric Hemiplegic Migraine

Abstract

A 17 year old right handed female with a past medical history of migraine presented with left hemisensory paresthesias and transcient hemiparesis lasting 2 hours. Diffusion MRI revealed no evidence of acute infarction. Additional MRI sequences demonstrated large non-enhancing cystic structures of the left cerebellum and pons. The patient was placed on daily Topiramate migraine prophylaxis without reoccurrence of symptoms at 2 years. Giant tumefactive perivascular spaces, otherwise known as prominent Virchow-Robin spaces, are pial-lined structures containing interstitial fluid and penetrating arteries/arterioles.1-2 They may be confused with cystic neoplasms and can occasionally be associated with headache and hydrocephalus. This case illustrates the importance of distinguishing enlarged perivascular spaces from a vascular malformation or cystic neoplasm; obviating the need for neurosurgical intervention.