Varicella zoster CNS vascular complications. A report of four cases and literature review

Abstract

This study explored the neurologic vascular complications of varicella zoster virus (VZV). We describe four patients presenting at our institution with neurologic involvement by VZV. MR and MRA studies of the intracranial arterial circulation in the head were read by board-certified radiologists using standard clinical procedures. On MRI, three patients had acute infarcts and in two instances irregularities and narrowings of vessels were visible. Many of these complications are recognized to be due to a vasculopathy affecting small or large vessels and resulting in cerebral infarctions and rarely hemorrhages. The pattern of cerebral infarction and vascular abnormalities is not specific and resembles those of vasculitis/vasculopathy from other causes. The central nervous system (CNS) vascular complications of VZV should be considered in the patients with simultaneous primary or prior VZV infection whose imaging studies show cerebral infarction and/or vasculitic appearing intracranial arteries.

Keywords: MRI; complication; imaging; varicella zoster; vasculitis.

Figure 1

A) TOF 3D reconstruction shows severe stenosis (≥70% stenosis) of the right MCA at its origin, moderate irregular stenosis of the left MCA and bilateral stenosis of the A1 segments, worse on the right. B) FLAIR axial image shows abnormal hyperintensity in the right centrum semiovale.

Figure 2

A) Axial T2-weighted image shows increased signal intensity in the posterior pons anteriorly to the 4^th ventricle. B) Pre (left) and post contrast-enhanced (right) sagittal images show heterogeneous enhancement of the lesion in the posterior pons. Note post-operative cerebellar changes from previous medulloblastoma resection. C) DWI image shows the high signal focus in the posterior pons corresponding to the area of infarction. The ADC maps did not show restricted diffusion suggesting an subacute infarct.

Figure 3

A) Axial FLAIR image shows abnormal hyperintensities in the caudate head bilaterally and in the left lentiform nucleus. B) DWI image shows a hyperintense signal in corresponding regions. The ADC maps showed restricted diffusion suggesting an acute infarct. C) TOF 3D reconstruction of the brain shows severe stenosis (≥70% stenosis) at the distal M1 segment of the right MCA and A1 segment of the left ACA.

Figure 4

A) Sequential DWI images show a high signal in the left caudate and putamen and restricted diffusion in the ADC maps consistent with acute infarcts. B) TOF 3D reconstruction shows no abnormality of the intracranial vessels.