Transcript herpes zoster

High-Resolution Vessel Wall MR
Imaging Findings in Varizella-Zoster
Virus Vasculitis
Yafell Serulle, MD, PhD, Ravishankar Shivashankar, MBBS,
Dheeraj Gandhi, MBBS
University of Maryland Medical Center
Department of Radiology
EE - 04
Disclosures
• The authors have no relevant relationships to
disclose.
Background and Purpose
• Varizella Zoster virus (VZV) vasculitis presenting
with acute stroke is a rare but known entity
• We describe a case of a patient who presented
with acute stroke several months following an
episode of herpes zoster ophthalmicus (HZO),
with ipsilateral vascular territory involvement
• High resolution vessel wall MR imaging played an
instrumental part in raising suspicion for
vasculitis, later confirmed with CSF positivity for
VZV
Case Presentation
• 69-year-old female presented with what she
described as new left arm tingling and left
lower extremity paresis.
• She was afebrile, alert and well oriented.
Mental status was normal.
• On physical exam she demonstrated left lower
facial droop and left hemiparesis. NIH stroke
scale was 8. Of note, patient was daily aspiring
81 mg and Plavix 75 mg since a prior stroke
Cont. Case Presentation
• Systemic work up for stroke was largely
negative including a normal transesophageal
echocardiogram
• Laboratory test for Plavix resistance was
normal (Clopidrogel 2C19 genotype *1/*2;
phenotype: intermediate metabolizer)
• Upon further interview, patient reported to
have HZO 6 months prior to the current
admission
Initial MRI findings
Axial diffusion-weighted images (right) and ADC maps (left) demonstrate
multifocal acute/subacute infarcts in the right cerebral hemisphere.
Initial MRI findings
Axial diffusion-weighted images (right) and ADC maps (left) demonstrate
multifocal acute/subacute infarcts in the right cerebral hemisphere.
Time-of-flight MR angiogram
Time-of-flight angiogram demonstrated diffuse asymmetric irregularity of the
right anterior cerebral artery (ACA) with stenosis involving the A1 and A2 segments,
as well well additional focal areas of stenosis involving the distal M1 and proximal M2
segments of the right middle cerebral artery (MCA).
Intracranial arterial wall imaging with highresolution 3T contrast-enhanced MRI - protocol
• T1-weighted MRI performed using a 2-D spin
echo sequence with following parameters:
– repetition time (TR)/echo time (TE)=746/11 ms
– Field of view = 12 cm
– Matrix size= 159 x 159
– Number of signal averages = 2
– Slice thickness = 2 mm
High-resolution vessel wall imaging
Pre (left) and post- (right) contrast images demonstrate circumferential wall enhancement
in the areas of vessel narrowing with the right right MCA
High-resolution vessel wall imaging
Corontal pre- (left) and post- (right) contrast images demonstrate circumferential wall
enhancement Involving the areas of vessel narrowing within the right MCA and ACA
Cerebrospinal fluid analysis
• Protein: 62 mg/dL
• Glucose: 51 mg/dL
• White blood cells: 23
– Lymphocytes: 82%
• Quantitative VZV PCR: 4500 copies/ml
Treatment
• Patient was started on acyclovir and then
subsequently discharged from the hospital in
stable condition
Discussion
• Central nervous system complications of VZV include
encephalitis, aseptic meningitis, myelitis, acute cerebellar
ataxia, Reye syndrome, Ramsay Hunt syndrome and stroke.
All of these complications are recognized to be due to
vasculitis affecting small or large vessels.
• VZV is thought to spread directly along the intracranial
branches of the trigeminal nerve to the ipsilateral arterial
walls in patients with HZO, presenting with delayed
contralateral hemiparesis
• The latent period between the onset of HZO and neurologic
complains can be a few days to up to 6 months.
Discussion
• With the advent of higher field strength magnets
and higher spatial resolution imaging, arterial
wall
characteristics
of
thickening
and
enhancement have been described for
intracranial arterial diseases
• Several studies have shown that inflammatory
conditions are associated with concentric,
circumferential
wall
thickening
and
enhancement, whereas atherosclerotic disease is
frequently eccentric
Summary
• In this report we have described a case of cerebral
infarctions due to VZV vasculitis confirmed with positive
CSF analysis
• High resolution vessel wall MR imaging played an
instrumental part in raising suspicion for vasculitis
• High resolution vessel wall imaging can help differentiate
between different vascular pathologies which would
otherwise could appear similar on routine MR imaging
• To our knowledge this is the first case of VZV vasculitis
studied and characterized with high resolution VWI.
References
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