A Giant Tumefactive Virchow-Robin Space: A Rare Cause of a Homonymous Quadrantanopia

A 53-year-old woman was found to have a left inferior homonymous quadrantanopia. Brain MRI disclosed a giant Virchow-Robin space compressing the right optic tract. After fenestration of this cystic lesion, most of the visual field loss resolved. Giant Virchow-Robin spaces may cause homonymous field defects which, with appropriate management, may improve.

Photo Essay Section Editor: Timothy J. McCulley, MD A Giant Tumefactive Virchow-Robin Space: A Rare Cause of a Homonymous Quadrantanopia Alysse Rivet, MD, Anne-Sophie Gauthier, MD, Marion Chatain, MD, Romain Billon-Grand, MD, Laurent Thines, PhD, Bernard Delbosc, PhD FIG. 1. A. Automated static perimetry shows a left inferior homonymous quadrantic field defect before surgery. B. The visual fields are markedly improved postoperatively. Abstract: A 53-year-old woman was found to have a left inferior homonymous quadrantanopia. Brain MRI disclosed a giant Virchow–Robin space compressing the right optic tract. After fenestration of this cystic lesion, most of the visual field loss resolved. Giant Virchow–Robin spaces may cause homonymous field defects which, with appropriate management, may improve. Journal of Neuro-Ophthalmology 2017;37:75–76 doi: 10.1097/WNO.0000000000000478 © 2017 by North American Neuro-Ophthalmology Society Department of Neurosurgery (AR, RB-G, LT), University Hospital, Besançon, France; Department of Ophthalmology (A-SG, MC, BD), University Hospital, Besançon, France. The authors report no conflicts of interest. Address correspondence to Anne-Sophie Gauthier, MD, Department of Ophthalmology, University Hospital, Besançon, 3 Boulevard Alexandre Fleming, 25030 Besançon, France; E-mail: [e-mail] Rivet et al: J Neuro-Ophthalmol 2017; 37: 75-76 A 53-year-old woman reported a 4-month history of visual field loss impairing her ability to read. Automated perimetry revealed a left inferior homonymous quadrantanopia (Fig. 1). Ophthalmologic and neurologic examinations were otherwise normal. Brain MRI showed a cystic lesion involving the right anterior perforated substance and anterior right optic tract (Fig. 2A). The findings were consistent with giant, tumefactive Virchow-Robin spaces (VRS). Nine months later, there was worsening of the visual field defect and mild weakness of the patient’s left arm. MRI confirmed enlargement of the VRS and arm weakness was due to compression of the internal capsule. The patient underwent a direct opened microsurgical approach with fenestration, which resulted in the immediate shrinking of the cerebrospinal fluid cyst (Fig. 2B). There was marked improvement in the visual field defect (Fig. 1B) and weakness of the left arm totally resolved. VRS are microscopic meningeal sleeves surrounding deep penetrating arteries within the brain. Their dilation 75 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Photo Essay FIG. 2. Axial FLAIR MRI. A. Giant Virchow-Robin spaces (arrow) are compressing the right optic tract. B. After surgery, there is decompression of the enlarged Virchow-Robin spaces. is considered a variant of normal anatomy and, occasionally, are symptomatic. Reports include giant VRS causing noncommunicating hydrocephalus, motor deficits, trigeminal neuralgia, dementia, and impaired ocular motility (1–3). Only 2 cases of visual field deficits associated with enlarged VRS have been reported. Matalia et al (4) documented the case of an 83-year-old man with a left superior homonymous quadrantanopia. A 2.6- · 1.4-cm enlarged VRS was detected on MRI causing mass effect on the right temporal lobe. Zafar et al (5) reported a 55-year-old woman with an intermittent left homonymous field defect due to enlarged VRS in the right parietal lobe in close proximity to the optic radiation. The field disturbance resolved after fenestration of the enlarged VRS. The pathogenesis of giant VRS remains unknown. Proposed mechanisms include mechanical trauma due to cerebrospinal pulsation, abnormality of arterial wall permeability, or ectasia of cerebral vessels (6–9). Bilateral expansion of perivascular spaces is closely related to the presence of cerebral microangioplasty (10). Patients with giant VRS require careful follow-up and one should keep in mind that fenestration of an enlarged VRS might improve the patient’s neurologic deficits, as occurred in our case. Neurosurgical management is on a case-by-case basis. Various cerebrospinal fluid diversion procedures include ventriculocisternostomy, cystogastrostomy, and cystoventriculostomy, and generally are performed using endoscopic techniques, as occurred in our patient. STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: A. Rivet; b. Acquisition of data: M. Chatain; c. Analysis and interpretation of data: R. Billon- 76 Grand and B. Delbosc. Category 2: a. Drafting the manuscript: R. Billon-Grand and B. Delbosc; b. 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Rivet et al: J Neuro-Ophthalmol 2017; 37: 75-76 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.