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 CenterDepartment 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) demonstratemultifocal acute/subacute infarcts in the right cerebral hemisphere.

Axial diffusion-weighted images (right) and ADC maps (left) demonstratemultifocal acute/subacute infarcts in the right cerebral hemisphere.

Initial MRI findings

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 M2segments of the right middle cerebral artery (MCA).

Time-of-flight MR angiogram

Intracranial arterial wall imaging with high-resolution 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

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

High-resolution vessel wall imaging

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.

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