Chapter 110 - Varicella Zoster Virus and Stroke

Abstract

Varicella zoster virus (VZV) is an exclusively human alphaherpesvirus that causes varicella on primary infection after which virus establishes latency in ganglionic neurons along the entire neuraxis. VZV reactivates to produce zoster, as well as VZV vasculopathy. VZV vasculopathy can present as transient ischemic attacks, stroke, aneurysm, sinus thrombosis, and giant cell arteritis. Characteristic features include imaging and angiographic abnormalities. Diagnosis can be challenging due to the delay from rash to symptoms and signs, as well as the absence of rash, cerebrospinal fluid (CSF) pleocytosis, and VZV DNA in CSF of many cases. The best test for diagnosis is detection of anti-VZV IgG antibody in the CSF. Treatment consists of intravenous acyclovir and corticosteroids. Because >90% of individuals are infected with VZV and are at risk for reactivation, VZV vasculopathy should be considered in the evaluation of stroke patients, particularly in the elderly and immunocompromised, as antiviral treatment can be effective.