IntroductionVirchow –Robin spaces (VRS) are pial-lined, interstitial fluid-filled perivascular spaces that surround the perforating cere-bral vessels. These normal anatomical structures are thoughtto be involved in the drainage of interstitial fluid and also toplay an immunomodulatory role by hosting macrophages [2,21].Theirroleinmultiplesclerosis,seniledementia,andsmallvessel disease in the elderly has recently been addressed invarious studies [3, 29, 30]. VRS are normally less than 2 mmin diameter and can be visible in basal ganglia and/orsupratentorial white matter on high-resolution magnetic reso-nance (MR) imaging of all healthy individuals [12, 26].When VRS become focally expanded, they can causeneurological symptoms resulting from mass effect. VRSdilations occur in all age groups although their frequencyand size (particularly in supratentorial white matter andbasal ganglia) was found to increase with age [8, 30].They appear in typical anatomical locations either unilat-erally or bilaterally, can be solitary or multiloculated, andmay cause non-specific neurological symptoms like head-ache. When located in mesencephalothalamic region, theycause hydrocephalus and can be misdiagnosed as cysticneoplasms [23]. Here, we briefly review relevant literatureon VRS cysts focusing on natural history, radiologicalimaging, differential diagnosis, and management options,and report on long-term follow-up of a patient withmultiloculated VRS cyst in the dorsal brainstem causinghydrocephalus and requiring surgery.Clinical presentationVRS dilations are asymptomatic unless they grossly enlargeandcauseasubsequentmasseffect[23]. The prevalence ofdilatedVRSinhealthypopulationisestimatedtobeashighas1.6–4.8 % in different studies enrolling asymptomatic indi-viduals who underwent brain imaging [7, 26]. Despite highprevalence, they are rarely seen by clinicians because mostindividuals with VRS dilations are asymptomatic.Clinical presentation depends on the degree of expansion andspace-occupying effect of the cysts. Generally, symptomsreflect the anatomical location. Nearly half of the patientssuffer from non-specific headache [23]. Vertigo, cognitiveimpairments, pyramidal and extrapyramidal signs, ataxia, vi-sual changes, oculomotor abnormalities, and seizures werealso reportedto beassociatedwith VRS cysts. Pediatric casesmay also present with developmental delay, macrocephaly,and hydrocephalus signs [4, 23].It is worth noting that VRS cysts in supratentorial whitematter, even if present across large areas, do not lead to severesymptoms in most cases. A great portion of the cases is asymp-tomaticandsomewerefoundtocauserelativelymildsymptomslike headache, memory disturban ces, hemifacial tics, dementia,seizures,etc.[7, 15, 16] However, cysts that occur inmesencephalothalamic region almost exclusively cause obstruc-tive hydrocephalus due to the compression of the third ventricleand/or aquaductus cerebri. These giant VRS cysts can alsopresentwithcranialnervesignsduetomasseffect.Theliteraturesearch through Medline (via PubMed) yielded 17 studies inwhich a total of 26 patients were reported to have giant VRScysts resulting in hydrocephalus and thus requiring surgicalintervention [1, 4–6, 9–11, 13, 14, 17, 19, 20, 22–25, 29]. Aclinico-radiological summary of these cases is given in Table 1.Radiological imaging and anatomical locationMagneticresonanceimaging(MRI)isthemodalityofchoiceforimaging VRS. Technical advances leading to high-spatial-