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 [
[1]
]. 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).Keywords
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Article Info
Publication History
Published online: June 14, 2019
Accepted:
June 13,
2019
Received in revised form:
June 13,
2019
Received:
May 14,
2019
Identification
Copyright
© 2019 Elsevier B.V. All rights reserved.
