Diagnosis:
Clinical: large artery or small vessel ischemic stroke, recurrent, protracted course. Rash may be absent or occur months before
MRI, CT: large artery or small vessel ischemic stroke, typically at grey-white junction. Imaging is sensitive but not specific
Anti-VZV IgG & VZV PCR: IgG is more sensitive for VZV vasculopathy, also reduced serum/CSF ratio of VZV IgG
CSF: pleocytosis occurs but isn’t sensitive,
Pathology:
- Multinucleated giant cells, lymphocytes & histiocytes in the artery walls
- Avidin-biotin-peroxidase staining: VZV antigen staining in Cowdry A inclusions (large with halo) in cytoplasm of histiocytes in the artery walls
- Immunohistochemistry: Anti-VZV Ig, stains positive in the arterial wall
- EM: viral particles
Treatment:
- Acyclovir for 3 weeks