Virchow-Robin space enlargement associated with borderline intelligence and behavioral problems in a young male

KP Lakshmi; Prerna Maheshwari; Bindu Menon; Subhash Chandra

doi:10.4103/ijamr.ijamr_31_22

CASE REPORT

Year : 2022 | Volume : 9 | Issue : 2 | Page : 117-119

Virchow-Robin space enlargement associated with borderline intelligence and behavioral problems in a young male

KP Lakshmi¹, Prerna Maheshwari¹, Bindu Menon¹, Subhash Chandra²
¹ Department of Psychiatry, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
² Department of General Medicine, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India

Date of Submission	09-Feb-2022
Date of Decision	06-Sep-2022
Date of Acceptance	24-Sep-2022
Date of Web Publication	30-Nov-2022

Correspondence Address:
Dr. K P Lakshmi
Department of Psychiatry, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijamr.ijamr_31_22

Abstract

A 22-year-old male presented with borderline intelligence, visual and auditory hallucinations, and an obsessive urge to bite. He was investigated for organic pathology in view of visual hallucinations and his magnetic resonance imaging study showed enlarged Virchow-Robin Space, which are fluid-filled spaces that surround small blood vessels and capillaries in the brain. He had no facial dysmorphic features or autistic features. Literature reports that this finding is associated with dementias in elderly, obsessions, and auditory hallucinations, but there is little data on its association with visual hallucinations, or intellectual impairment in the young. He responded well to a combination of medications and psychosocial approaches. Neuroimaging offers a noninvasive, reproducible method to better understand the clinical associations and accumulate evidence base in young patients presenting with intellectual impairment and behavioral problems.

Keywords: Borderline intelligence, hallucinations, obsessions, Virchow-Robin spaces

How to cite this article:
Lakshmi K P, Maheshwari P, Menon B, Chandra S. Virchow-Robin space enlargement associated with borderline intelligence and behavioral problems in a young male. Int J Adv Med Health Res 2022;9:117-9

How to cite this URL:
Lakshmi K P, Maheshwari P, Menon B, Chandra S. Virchow-Robin space enlargement associated with borderline intelligence and behavioral problems in a young male. Int J Adv Med Health Res [serial online] 2022 [cited 2023 Jan 27];9:117-9. Available from: https://www.ijamhrjournal.org/text.asp?2022/9/2/117/362446

Introduction

Virchow-Robin spaces or perivascular spaces are fluid-filled spaces that surround small blood vessels and capillaries in the brain. They are normally seen in healthy individuals. Even if enlarged they are usually asymptomatic, but rarely, they can cause obstructive hydrocephalus. Enlarged Virchow-Robin spaces may be a marker of evolving neurodegenerative diseases such as Alzheimer disease and Parkinson disease, but the relationship remains poorly understood.^[1] Some have considered widened Virchow-Robin spaces as a common aging phenomenon associated with white matter lesions and cognitive function.^[2] All these findings have generated interest in the study of perivascular spaces and their clinical implications. We report the case of a 22-year-old male patient who presented with borderline intelligence, visual and auditory hallucinations, and obsessive urge, with enlarged Virchow-Robin space.

Case Report

A 22-year-old unemployed male, educated up to 9^th standard, presented with complaints of hearing multiple voices conversing about him and calling out his name for 11 years, seeing multiple birds and butterflies around him which his father could not perceive, and repeated intrusive, distressing urges to bite for 5 years. His sleep was disturbed. There was no family history of psychiatric illness and no substance use in the patient. His birth and developmental milestones were unremarkable. Academic difficulties were reported from primary school and his schooling stopped after the 9^th standard. He had tried multiple jobs without persisting in any. His social interaction was sub-optimal and he had one episode of febrile seizure at the age of 7 years; no antiepileptic was instituted. He appeared poorly kempt but had no dysmorphic features. Mental status examination showed anxious mood, decreased psychomotor activity, and decreased talk. He denied any depressive cognitions. Intelligence appeared to be in borderline range. No delusions were noted but there were third person auditory hallucinations, visual hallucinations, and obsessive urge. He reported seeing birds and butterflies flying around him; these were clearly seen and the sensations were not under his control. He had recurrent intrusive urges to bite something, which he described as his own feeling and distressing. He would try to walk fast or pray to relieve the distress with little benefit. No other obsessions/compulsions were noted. He was well-oriented with intact memory. Insight was Grade 3 as he was aware of his issues but attributed the same to unpleasant childhood experiences with his parents. He was evaluated for any organic pathology in view of visual hallucinations and a history of seizure. His regular blood investigations, thyroid function tests, and 8-h video electroencephalogram were normal. Magnetic resonance imaging of the brain showed a cystic focus measuring 5 mm × 4 mm in anterior perforated substance on the right side. The contents of the cyst followed cerebrospinal fluid signal intensity and this feature was consistent with dilated Virchow-Robin space [Figure 1]; rest of the brain parenchyma was normal. Prior imaging study was not available for comparing changes. His IQ score was 85. He was started on Tablet Risperidone for psychotic symptoms and cap. Fluoxetine for the obsessional phenomenon. With psychosocial interventions (supportive psychotherapy, family therapy), 4 mg risperidone and 60 mg fluoxetine, he showed good improvement with minimal residual symptoms at the end of 4 weeks after starting medications. Brief Psychiatric Rating Scale showed mild anxiety. The Yale–Brown Obsessive Compulsive Scale was used to assess obsessions, which showed an initial score of 24 and a score of 6 at the end of 4 weeks of treatment.

Figure 1: MRI brain showing a small cystic focus measuring 5 mm × 4 mm noted in the anterior perforated substance on the right side. MRI: Magnetic resonance imaging. MRI: Magnetic resonance imaging

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Discussion

Virchow-Robin spaces are perivascular fluid filled spaces around small arterioles, venules, and capillaries of the brain. Named after the German pathologist Rudolf Virchow and French anatomist Charles Philippe Robin, they are reported to serve as a lymphatic drainage pathway in the brain, thus playing an immunologic role. Normal size of perivascular spaces are 2 mm; they are usually considered dilated when their size is ≥5 mm or if they have atypical morphology.^[3] Dilated perivascular spaces are seen in 1.6%−3% of healthy individuals.^[3]

Although not very clear, there are multiple theories on how these spaces are dilated such as alterations in arterial wall permeability, perivascular myelin loss, fibrosis/obstruction of lymphatic drainage pathways, or dilation secondary to brain atrophy.^[4] Enlarged Virchow-Robin space has been associated with cognitive impairment and neurodegenerative diseases such as Alzheimer disease and Parkinson disease.^[1] Zhenru et al. have reported a case of obsessive compulsive disorder possibly secondary to dilated perivascular space in left lentiform nucleus.^[5] There have been few reports of enlarged Virchow Robin space presenting with psychotic symptoms in young individuals.^[6],[7] Although a case report described visual field defect associated with enlarged perivascular space,^[8] to the best of our knowledge, there are no reports associating enlarged perivascular spaces with visual hallucinations. Neuroimaging studies have identified white matter changes in psychotic patients but the underlying mechanisms lack clarity. Dilated Virchow-Robin space may be the markers of immune-inflammatory mediated cerebral small vessel disease.^[9] A prior study has shown that microvascular changes, along with deep white matter and periventricular changes, may also be seen in patients with psychosis.^[7]

The index case had intellectual impairment, auditory hallucinations, visual hallucinations, and obsession, along with enlarged Virchow-Robin space in anterior perforator substance on right side. With some evidence supporting the association of enlarged Virchow-Robin space with auditory hallucination,^[6] obsessive–compulsive disorder,^[5] and cognitive impairment,^[1] the possibility of explaining the entire picture with a single diagnosis was considered. The limitation of this approach is that some associations noted could have been incidental; indeed the association between enlarged perivascular spaces and intellectual impairment or visual hallucination has not been reported previously. Moreover, the enlargement in this case is not huge and there was only a single enlarged perivascular space. Nonetheless, microstructural brain abnormalities have been identified as potential neurobiological markers of psychotic disorders.^[10] More studies on Virchow-Robin space abnormalities are needed to shed light on the prevention and management of behavioral problems associated with intellectual impairment in young.

Conclusion

Neuroimaging offers a noninvasive, objective, and reproducible method to better understand the clinical associations and accumulating evidence to better understand the etiology of behavioral problems in young patients with intellectual impairment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgments

We would like to thank the patient and the family who gave consent to publish this case. We would like to thank Dr. Siby Gopinath, Neurology Department, Amrita Institute of Medical Sciences and Research Centre, Kerala, and The Radiology Department, Amrita Institute of Medical Sciences and Research Centre, Kerala, for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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