Endoscopic infratentorial supracerebellar approach for the mesencephalic enlarged Virchow Robin space fenestration, an alternative minimally invasive route

Abstract

Background: Virchow–Robin spaces (VRS) or peri-vascular spaces (PVS) are normal anatomical structures within the brain, typically small in size and asymptomatic. Rarely, they can enlarge, adopt bizarre single or multi-cystic configurations and become pathological lesions that may necessitate surgical intervention to relieve mass effect or hydrocephalus. Case report: We present the case of a 41-year-old female who presents with epilepsy, Parkinsonism symptoms, diplopia, and gait imbalance. She was diagnosed with mesencephalic giant tumefactive perivascular spaces exerting significant focal mass effect but causing no hydrocephalus. The patient underwent a direct cyst fenestration via the endoscopic Infratentorial Supracerebellar (ITSC) approach. Postoperative follow-up was uneventful. Clinically, symptoms improved with evidence of some decrease in cystic size. Discussion and conclusion: Accepted surgical strategies to address symptomatic mesencephalic Virchow robin spaces dilation include conventional ventriculoperitoneal or cysto-peritoneal shunting to neuroendoscopic decompression with cystocisternotomy or ventriculocystostomy. We report the first application of a purely endoscopic ITSC approach for the fenestration of a mesencephalic enlarged Virchow robin space. This minimally invasive approach provided great exposure and adequate access to the lesion. Unlike the endoscopic trans-ventricular approach, this alternative technique poses no risk to the fornices and can be applied regardless of ventricular size, resulting in a decrease in the size of the cyst and a diminishment of symptoms.

Keywords

• enlarged Virchow Robin space
• Mesencephalon
• Endoscopic fenestration
• Supracerebellar infratentorial approach