Discussion

Perivascular spaces are normal findings found on MRI and are located along penetrating vessels. The finding is more pronounced in the elderly and patients with small vessel disease [1]. The manifestations occur as a result of the mass effect of these enlarging lesions. Headache (the most common complaint), vision changes, vertigo, balance difficulties, impaired cognitive function, and seizures have been observed in affected individuals [2]. MRI is the gold standard for diagnosis and to differentiate from more serious conditions like cystic neoplasms, cryptococcosis, mucopolysaccharidosis, cystic infarction, arachnoid, and neuroepithelial cysts [3]. Characteristic findings on MRI are well-demarcated, non-enhancing, cystic lesions, displaying signal intensity identical to cerebrospinal fluid (CSF) on all sequences along perforator vessels [4]. Conservative management in the form of a “wait and watch” strategy and regular follow-up imaging is employed for asymptomatic cases, while surgical intervention is indicated for cysts that produce symptoms from obstructive hydrocephalus [2]. Endoscopic procedures are preferred over open surgery as it is relatively safer (decreased risk of hemorrhage), does not involve an exogenous shunt, and allows to obtain tissue biopsy if required [5].