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Gadolinium enhancement in perforating arteries in a patient with varicella zoster virus vasculopathy: A case report

      A 35-year-old man was admitted to our hospital because of right hemiparesis. His initial National Institutes of Health Stroke Scale score was 8. He had a 1-week history of fever and headache that had occurred approximately 1 month prior to admission. Diffusion-weighted imaging on admission showed hyperintensities in the left putamen and corona radiata (Supplementary Fig. 1). There were no atherosclerotic changes or findings suggesting intracranial arterial dissection or carotid artery disease on magnetic resonance (MR) angiography. The patient was diagnosed with ischemic stroke and treated with intravenous alteplase and edaravone followed by intravenous argatroban and oral clopidogrel. MR images on day 4 showed gadolinium enhancement of the right lenticulostriate artery on three-dimensional T1-weighted fast spin-echo imaging (volumetric isotropic turbo spin-echo acquisition [VISTA]), which is a high-resolution MR vessel wall imaging modality, suggesting inflammation in the vessel wall of the perforating arteries (Fig. 1). Carotid ultrasonography, transthoracic and transesophageal echocardiography, and 7-day Holter electrocardiography showed no evidence of embolism. Serum antibodies for varicella zoster virus (VZV) by enzyme immunoassay were elevated (immunoglobulin M [IgM], 1.28; IgG, ≥128). The VZV IgG level in the cerebrospinal fluid (CSF) by enzyme immunoassay was also elevated at 5.70. The antibody index for VZV IgG (calculated by the CSF IgG, serum IgG, CSF albumin, and serum albumin levels) was elevated at 5.23 (reference, <1.5), demonstrating increased VZV antibody in the CSF [
      • Reiber H.
      • Lange P.
      Quantification of virus-specific antibodies in cerebrospinal fluid and serum: sensitive and specific detection of antibody synthesis in brain.
      ]. Accordingly, the patient was diagnosed with ischemic stroke secondary to VZV vasculopathy. He was treated with intravenous acyclovir and high-dose methylprednisolone. His symptoms fully resolved after rehabilitation (modified Rankin Scale score of 0), and follow-up MR imaging on day 179 showed no gadolinium enhancement of the right lenticulostriate artery on VISTA (Supplementary Fig. 2).

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