HSV-Encephalitis Resembling Acute Cerebral Infarction in a Patient With Atrial Fibrillation

Abstract

Introduction: Herpes simplex virus-1 (HSV-1) encephalitis, the most common and potentially life-threatening type of encephalitis, may rarely present as a stroke mimic. Prompt diagnosis is of paramount importance for the timely initiation of antiviral treatment and to avert intravenous thrombolysis.Case Report: A 60-year-old man with a history of lone paroxysmal atrial fibrillation without prior antithrombotic treatment was admitted due to mild gait unsteadiness and intermittent dysarthria of acute onset. On admission, the patient was afebrile, whereas neurological examination revealed only a mild pronator drift on the left. Brain magnetic resonance imaging (MRI) showed an extensive right temporo-occipital and thalamic lesion with restricted diffusion and 3 small-sized hemorrhagic foci. Brain MRangiography did not show large vessel stenosis or occlusion. On the basis of careful observation and the depiction of several imaging discrepancies, such as early vasogenic edema and hemorrhagic transformation, as well as uncus involvement, but also the lack of significant neurological deficits despite the size of the brain lesion we suspected viral encephalitis which was confirmed by the detection of HSV-1 DNA in the cerebrospinal fluid. Conclusion:HSV-encephalitis might occasionally result in the development of unilateral brain MRI lesions with extensive cytotoxic edema, resembling an acute ischemic stroke. Therefore, HSV-encephalitis must be considered in the differential diagnosis of acute ischemic stroke with atypical presentation. The presence of a significant dissociation between the brain MRI lesion volume and the neurological deficits, as well as certain brain MRI imaging discrepancies might serve as "red flags" to extend the diagnostic workup.

Herpes simplex virus encephalitis mimicking acute ischemic stroke

“…[ 18 ] We must say that stroke mimics are a true challenge for neurologists to distinguish from classical strokes and even though there are not seen serious complications after IVT in stroke mimic, it is crucial for the proper diagnosis to be done as soon as possible to avert unnecessary IVT and if HSVE, to initiate antiviral treatment. [ 7 ]…”

“…[18] We must say that stroke mimics are a true challenge for neurologists to distinguish from classical strokes and even though there are not seen serious complications after IVT in stroke mimic, it is crucial for the proper diagnosis to be done as soon as possible to avert unnecessary IVT and if HSVE, to initiate antiviral treatment. [7] Figure 2: Electroencephalographic findings: slow waves and complex discharges were registered in bilaterally the frontal derivations. High index of clinical suspicion, prompt diagnosis, and early treatment are the mainstays of therapeutic success in herpetic encephalitis.…”

Herpes Simplex Virus Encephalitis Complicated by Acute Ischemic Stroke

“…Herpes simplex virus encephalitis is a rare cause of ischemic stroke and must be considered in the differential diagnosis of acute ischemic stroke with atypical presentation. [13] [14] [15]…”

Stroke mimics: A review

“…Treatment of stroke or strokelike syndromes of infectious origin with alteplase administration can be related to a higher hemorrhagic risk and a more extension of the ischemic lesion [46]. Herpes Simplex Virus-1 (HSV-1) encephalitis can mimic stroke when it occasionally shows the development of unilateral brain MRI lesions with extensive cytotoxic edema [47]. Detection of HSV-1 DNA in the cerebrospinal fluid can confirm its diagnosis.…”