Dilated Virchow-Robin spaces in cryptococcal meningitis associated with AIDS: CT and MR findings

We present two patients with AIDS complicated by cryptococcal meningitis who displayed focal hypodense nonenhancing lesions in CT in the basal ganglia with corresponding areas of increased T2 and decreased T1 signal on magnetic resonance (MR). These lesions corresponded precisely to the distribution of the perforating arteries. Review of pathological specimens showed these lesions to be small cystic collections of cryptococcal organisms in the perivascular spaces of the arteries with minimal or no inflammatory reaction. The cryptococcal organisms spread from the basal cisterns through the Virchow-Robin spaces, dilating these spaces, to ultimately propagate in the basal ganglia, internal capsule, thalamus, and brain stem. Such lesions have been described as characteristic for cryptococcosis in the pathology literature before the AIDS epidemic, but the radiological manifestations have not been reported previously. The changes appear characteristic for cryptococcosis, which generally incites no host response in the form of perifocal edema or enhancement. These findings in a young adult, with otherwise normal CT or MR scans, may be the first indication that the patient has AIDS. The T2-weighted image sequences are more sensitive in the detection of these lesions when compared to CT or T1-weighted MR images.