Ischemic Stroke due to Virologically-Confirmed Varicella Zoster Virus Vasculopathy: A Case Series

J Stroke Cerebrovasc Dis. 2019 Feb;28(2):338-343. doi: 10.1016/j.jstrokecerebrovasdis.2018.10.001. Epub 2018 Nov 2.

Abstract

Background: Limited data are available regarding the characteristics and prognosis of patients with stroke due to varicella zoster virus (VZV) vasculopathy.

Methods: We studied 4 patients (2 men and 2 women; age, 38-63 years) from a single center who developed acute ischemic stroke due to VZV vasculopathy. The virological diagnosis was confirmed by detecting VZV DNA and/or the IgG antibody to VZV in the cerebrospinal fluid.

Results: Three patients were taking immunosuppressive agents, including prednisolone and/or methotrexate, at baseline. Each patient had a characteristic skin rash prior to stroke, with the interval from rash to stroke onset ranging from 13 to 122 days. Two patients experienced antecedent cranial nerve palsies; one had the third, seventh, ninth, and 10th nerve palsies and the other had the fourth nerve palsy before stroke. Cerebral infarctions were located in the anterior circulation lesion (n = 1), in the posterior circulation lesion (n = 2), and in both lesions (n = 1). Intracranial arterial stenosis was only identified in one patient on magnetic resonance angiography. A high plasma d-dimer level was detected in 1 patient, whereas high β-thromboglobulin and platelet factor 4 levels were detected in 2 patients. As a result of combined therapies with acyclovir, steroid, and antithrombotic agents, neurological symptoms markedly improved in 3 patients, whereas 1 patient was left with moderate hemiplegia.

Conclusions: Cranial nerve palsies may be prodromal symptoms of VZV-associated stroke. Increased levels of thrombotic markers may support the use of antithrombotic agents, although the benefit of combined treatment should be determined through larger studies.

Keywords: Antithrombotic therapy; cranial nerve; ischemic stroke; varicella-zoster virus; vasculopathy.

Publication types

  • Case Reports

MeSH terms

  • Acyclovir / therapeutic use
  • Adult
  • Antiviral Agents / therapeutic use
  • Brain Ischemia / diagnostic imaging
  • Brain Ischemia / drug therapy
  • Brain Ischemia / virology*
  • Cranial Nerve Diseases / virology
  • Diffusion Magnetic Resonance Imaging
  • Female
  • Fibrinolytic Agents / therapeutic use
  • Herpesvirus 3, Human / drug effects
  • Herpesvirus 3, Human / pathogenicity*
  • Humans
  • Magnetic Resonance Angiography
  • Male
  • Middle Aged
  • Retrospective Studies
  • Steroids / therapeutic use
  • Stroke / diagnostic imaging
  • Stroke / drug therapy
  • Stroke / virology*
  • Treatment Outcome
  • Varicella Zoster Virus Infection / complications
  • Varicella Zoster Virus Infection / diagnosis
  • Varicella Zoster Virus Infection / drug therapy
  • Varicella Zoster Virus Infection / virology*

Substances

  • Antiviral Agents
  • Fibrinolytic Agents
  • Steroids
  • Acyclovir