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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 6 | Page : 709-711
Virchow-Robin spaces producing visual field defect
Jyoti H Matalia, Vimal Krishna Rajput, Bhujang K Shetty
Department of Pediatric Ophthalmology and Neuro-Ophthalmology, Narayana Nethralaya-2, Bommasandra, Bangalore, Karnataka, India
|Date of Submission||12-Dec-2014|
|Date of Decision||14-Dec-2014|
|Date of Acceptance||17-Dec-2014|
|Date of Web Publication||16-Jan-2015|
Jyoti H Matalia
Department of Pediatric Ophthalmology and Neuro-Ophthalmology, Narayana Nethralaya-2, Bommasandra, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Matalia JH, Rajput VK, Shetty BK. Virchow-Robin spaces producing visual field defect. Neurol India 2014;62:709-11
Virchow-Robin spaces (VRS) are perivascular, fluid-filled canals that surround perforating arteries and veins in the parenchyma of the brain.  They may be enlarged to a diameter of five millimeters in healthy humans and are usually harmless. When enlarged, they can disrupt the function of the brain regions into which they project.  There is no case report in literature where these spaces had increased in size to produce visual field defects. We report a case of dilated atypical VRS affecting the optic radiations producing changes in visual field.
An 83-year-old man came to the neuro-ophthalmology clinic for a routine eye examination. His best corrected visual acuity (BCVA) was 6/9 in right eye and 6/6 in left eye, with refractive error of + 3.5/-1.5 × 90 o in both eyes. Pupils were normal in size and reacting briskly to light in both eyes. Slit lamp evaluation showed grade II nuclear sclerotic changes in both the lens. Intraocular pressure (IOP) by applanation tonometry was 12 mm of Hg in both eyes. On fundus, disc measured 2.2 mm with cup to disc ratio (CDR) of 0.7 in both eyes with healthy neuroretinal rim. Humphrey's visual field analyzer (24-2 program) revealed right superior quadrantanopia [Figure 1]a and b. Contrast magnetic resonance imaging (MRI) of brain showed multiple perivascular non-enhancing empty spaces [Figure 2]a and b in left temporal lobe, largest measuring approximately 2.6 × 1.4 centimeters [Figure 2]c and d, without associated mass effect correlating with the field defect. They were hypointense on T1 and fluid-attenuated inversion-recovery (FLAIR) sequence, hyperintense on T2 consistent with diagnosis of VRS.
|Figure 1: Automated visual field on Humphrey's visual field analyzer (24-2 program) of right eye (a) and (b) left eye showing right superior quadrantanopia (pie in the sky)|
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|Figure 2: Magentic resonance imaging of brain with intravenous contrast showing multiple non-enhancing CSF density lesions in left temporal lobe (green arrow) that are (a) hyperintense on axial T2 weighted image and (b) hypointense on axial FLAIR image obtained at the same level and showing the largest lesion measuring 2.6 × 1.4 centimeters without associated mass effect in medial temporal lobe (green arrow) that is (c) hyperintense on axial T2 weighted image and (d) hypointense on axial FLAIR image|
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The appearance of VRS was first noted in 1843 by Durand Fardel.  These spaces are gaps containing interstitial fluid that span between blood vessels and the brain matter which they penetrate.  Use of the scanning electron microscope has determined that VRS surrounding blood vessels in the subarachnoid space are not continuous with the subarachnoid space because of the presence of pia mater cells joined by desmosomes. 
VRS are best seen on T2-weighted MRI due to their characteristic appearance of distinct round or oval entities with signal intensity equivalent to that of cerebrospinal fluid in the subarachnoid space. , Normally, VRS are seen in every subject using high-resolution three-dimensional MRI with one-third of them having a size of 3 mm.  Normally, a VRS has no mass effect and is located along the blood vessel around which it forms.  They are most commonly located in the basal ganglia, thalamus, midbrain, cerebellum, hippocampus, white matter of cerebrum and along the optic tract.  With advancing age, VRS are found with increasing frequency and of larger size. VRS may be enlarged to a diameter of five millimeters in healthy humans without causing any harm. With further enlargement, they can disrupt the function of the brain regions into which they project.  Dilatation can occur on one or both sides of the brain.  Extreme dilation has been associated with several specific clinical symptoms. In cases of severe dilation in only one hemisphere, symptoms reported include a non-specific fainting attack, hypertension, positional vertigo, headache, early recall disturbances, and hemifacial tics. Symptoms associated with severe bilateral dilation include ear pain, dementia and seizures.  Other general symptoms associated with dilated VRS (dVRS) include headaches, dizziness, memory impairment, poor concentration, dementia, visual changes, oculomotor abnormality, tremors, seizures, limb weakness, and ataxia.  The only reported neuro-ophthalmologic sign caused by dVRS was the presence of papilledema. ,,, Papayannis et al., reported a patient with a large dVRS in the midbrain inducing an acute obstructive hydrocephalus due to compression of aqueduct of Sylvius while Salzman et al., and Kanamalla et al., published similar reports of giant VRS producing mass effect and papilledema. The MR images of dVRS must be distinguished from those of other neurological illnesses like cystic neoplasms, lacunar infarctions, cystic periventricular leukomalacia, cryptococcosis, multiple sclerosis, mucopolysaccharidoses, neurocysticercosis and arachnoid cysts.  In our case, atypical VRS (clusters of type II enlarged VR spaces that may be predominantly involving one hemisphere)  were found in the left temporal lobe that were dilated to a size of 2.6 × 1.4 centimeters, producing the characteristic defect in the superior visual field (pie in the sky). As per literature search, this is the first report of dVRS causing visual field defect. A judgement on whether dVRS in an individual patient is a normal variant or part of a disease process can be made by taking into account the mass effect on the adjacent tissues on MRI with clinical correlation. 
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[Figure 1], [Figure 2]
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