Repeated Vertebrobasilar Strokes Caused by Varicella Zoster Virus Vasculopathy

Recent studies of VZV vasculopathy using high-resolution magnetic resonance imaging (MRI) revealed multifocal intracranial vasculitis and stenosis mostly in ‘anterior circulation’.1 Restricted posterior circulation involvement was seldom reported, and in such circumstances, VZV vasculopathy is barely diagnosed if there is no preceding zosteriform rash.2,3 Here, we report a case of VZV vasculopathy solely involving posterior circulation without preceding rash or vertebrobasilar arterial stenosis. [...]acyclovir and short-term prednisolone (1 mg/kg) were started to treat VZV meningitis and vasculopathy. Direct VZV infiltration to the vessel walls via transaxonal spread is thought to be the mechanism of VZV vasculopathy.4 The anterior and middle cerebral arteries are innervated by nerve fibers originating from the trigeminal ganglia, while the vertebrobasilar arteries and their tributaries are innervated additionally by those from the upper cervical dorsal root ganglia.5 Although uncommon, it had been reported that zoster eruption in cervical dermatone may precede brainstem infarct.2,6 The mechanism was believed to be direct viral invasion via cervical nerve innervation of the vertebral arteries.6 Our case did not show a preceding typical zosteriform rash, but he did experience cervical pain and scalp numbness, suggestive of possible VZV reactivation in cervical dermatomes 2 weeks before the development of neurological symptoms. [...]in stroke patients having neck pain, VZV vasculopathy is another differential diagnosis in addition to arterial dissection.