Clinical and radiological features of childhood cerebral infarction following varicella zoster virus infection

Abstract

The aim of the study was to describe the clinical and radiological features of childhood post-varicella cerebral infarction (PVCI). A retrospective review was undertaken of children with arterial ischaemic stroke (AIS) who had experienced varicella zoster virus (VZV) infection within the preceding year. Twenty-four children (15 males, nine females; age range at time of VZV infection 2mo-6y) were identified, with a median of 4 months between VZV and AIS (range 1wk-12mo). All had infarction in the middle cerebral artery (MCA) territory and abnormalities of the M1 segment; arteriopathy affected other arteries in 10 children. After a median of 27 months, six patients had recurrent transient ischaemic attacks (TIA), with new infarcts in two of 22 children on re-imaging. Arterial disease improved in 11 children, was stable in four, and progressed in seven (of whom four had recurrent TIA and two had re-infarction). PVCI affects young, previously healthy children within a few months of VZV infection and is characterized by MCA territory infarction and proximal MCA disease. One quarter of patients have recurrence, usually, but not inevitably, associated with progressive arteriopathy. Treatable co-existing AIS risk factors should always be excluded. A more comprehensive diagnostic evaluation should be considered in children with AIS who do not fit the clinical and radiological profile outlined, even where there is a history of recent VZV infection.

Ischemic stroke associated with adenoviral infection in a 4-year-old boy

“…Consequently, the stenotic lesion of the artery affected might have been induced by the presence of adenovirus and subsequent inflammatory reaction. Furthermore, magnetic resonance imaging confirmed that the brain area afflicted with AIS in our patient was analogous to the areas involved in reported PVCI patients [13]. Thence, the morphology of the AIS provides additional argument for the proposed pathogenesis in our patient.…”

“…Granulomatous arteritis of the vessel wall causes post-varicella cerebral infarction (PVCI) and AIS after herpes zoster ophthalmicus [13]. Basilar artery aneurysm was also reported after varicella [14].…”

Herpes zoster as a risk factor for stroke and TIA

“…Better control of vascular risk factors in older patients presenting with TIA, which itself increases the risk of stroke, would also explain why, after HZ, the incidence of TIA but not stroke was increased in the THIN patient population as a whole. Together with published data linking stroke in children with recent history of chickenpox, [17][18][19] these results support a significant role for VZV, independently of other vascular risk factors, in the pathogenesis of stroke and cerebrovascular disease in the UK population, particularly at younger ages. The results are corroborated by population cohort studies conducted in Taiwan 4 and Denmark, 20 both of which identified HZ as a risk factor for stroke 4 or stroke plus TIA.…”

Varicella Zoster Virus: A Common Cause of Stroke in Children and Adults

“…While most VZV vasculopathies develop within 6 weeks after zoster, the median interval for stroke is 4 months after varicella (16). Besides stroke and TIAs, patients may develop severe headache, cognitive impairment/confusion or unsteadiness.…”

“…PVA usually occurs in otherwise healthy, immunocompetent children and is usually monophasic, although progressive arteriopathy with recurrent TIA and stroke has been reported (11,16,24). As in adults, the CSF in children with VZV vasculopathy contains amplifiable VZV DNA or anti-VZV antibody, indicative of active infection (Table 1) and consistent with the detection of VZV antigen in granulomatous arteritis lesions of the left MCA of a 4-year-old girl who developed TIAs 8 months after varicella and died of malignant left hemispheric infarction 5 months later (15).…”