1. 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

2. Disclosures
The authors have no relevant relationships to disclose.

3. 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

4. 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

5. 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

6. Initial MRI findings
Axial diffusion-weighted images (right) and ADC maps (left) demonstrate
multifocal acute/subacute infarcts in the right cerebral hemisphere.

7. Initial MRI findings
Axial diffusion-weighted images (right) and ADC maps (left) demonstrate
multifocal acute/subacute infarcts in the right cerebral hemisphere.

8. 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).

9. 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

10. 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

11. 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

12. Cerebrospinal fluid analysis
Protein: 62 mg/dL
Glucose: 51 mg/dL
White blood cells: 23
Lymphocytes: 82%
Quantitative VZV PCR: 4500 copies/ml

13. Treatment
Patient was started on acyclovir and then subsequently discharged from the hospital in stable condition

14. 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.

15. 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

16. 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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