Nagel MA, Cohrs RJ, Mahalingam R et al. Neurology 2008; 70:853-860.
Review article of 30 patients, the first large review in about 30 years, busts some myths about VZV stroke. Among them:
1. Rash occurred in only 63 %, often many months prior to the stroke (mean 4 months)
2. CSF pleocytosis occurred in only 67 %
3. Angiography was abnormal in only 70 %
4. Large arteries were involved with small arteries (50%) or small arteries were involved alone (37% ) whereas large arteries alone occurred in only 13 %.
5. VZV DNA was found in only 30 %
6. The best lab test, by far, was CSF anti VZV IgG antibody with reduced IgG index (serum : CSF) confirmed intrathecal synthesis. The only 2 negative cases out of 30 were children who developed vasculopathy after chickenpox.
7. Case series was not large enough to determine optimal treatment (acyclovir v. acyclovir + steroids); however, some cases relapsed and then improved when either acyclovir course was extended or steroids were addded to acyclovir. Overall in the small series, 2/3 improved with acyclovir alone, and 3/4 with acyclovir + steroids.
8. 11 patients out of 30 were immunocompromised (2 AIDS, 3 HIV +, 2 leukemia, 1 CREST s, 1 lymphoma, 1 low CD4 count, and 1 treatment for RA/SLE).
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