Herpes Zoster Ophthalmicus With Contralateral Hemiplegia Riccardo Pratesi, MD; Frank R. Freemon, MD; James L. Lowry, MD \s=b\ A 48-year-old man developed left hemiparesis nine weeks after herpes zoster skin lesions had appeared over the right forehead. Cerebral angiography showed bilateral changes consistent with cerebral arteritis. The patient's condition worsened after the angiographic procedure. Reports from the literature as well as the present case suggest that arteritis and ischemia best explain contralateral neurological symptoms that occur suddenly following herpes zoster ophthalmicus. (Arch Neurol 34:640-641, 1977) Hemiplegia occurring a few weeks after and contralateral to herpes zoster ophthalmicus forms a well-de¬ scribed syndrome.1'7 Angiography has suggested an arteritic intracranial process,8·9 and temporal artery biopsy has shown inflammation in an ipsilat- eral extracranial vessel.10 We describe a patient in whom repeated angiography showed a spreading of the process, eventually affecting cerebral vessels bilaterally. Accepted for publication May 9, 1977. From the Neurology Service, Nashville (Tenn) Veterans Administration Hospital. Dr Pratesi is now with the Department of Pediatrics, Primeiro Hospital Distrital de Brasilia (Brazil). Dr Lowry is now in private practice in Albuquerque, New Mexico. Reprint requests to Departamento de Pediat- ria, Primeiro Hospital Distrital de Brasilia, D.F. 70.000, Brazil (Dr Pratesi). Substantial worsening followed the second angiographie procedure. REPORT OF A CASE A 48-year-old man in good health devel¬ oped severe pain around the right eye, followed by a vesicular rash on the right forehead. An ophthalmologist diagnosed herpes zoster and prescribed corticosteroids. During the next four weeks, the pain subsided and the rash faded, but mental changes developed. Examination showed mild right eyelid edema and severe confu¬ sion. A radionuclide brain scan, a compu¬ terized tomographic scan, and skull roent¬ genograms were normal. An EEG showed right-sided slow activity. A lumbar punc¬ ture disclosed xanthochromic spinal fluid with a protein concentration of 116 mg/100 ml but no cells. Bilateral carotid arteriograms ten weeks after onset of the vesic¬ ular rash showed narrowing of the right posterior cerebral artery (Fig 1). The day following the angiogram, left hemiparesis was noted. The patient improved slightly during the next two weeks and was transferred to the Nashville (Tenn) Veterans Hospital. He was slightly lethargic and the right eyelid was edematous. The patient had decreased memory for recent events, with a short attention span. Impairment of abduction and elevation of the right eye and a fixed and dilated right pupil were found. The remainder of the cranial nerves and the optic fundus were normal. The left side Downloaded From: http://archneur.jamanetwork.com/ by a Michigan State University User on 06/15/2015 severely paretic, with limbs barely moved against gravity. Muscle stretch reflexes were more active on the left with a left Babinski sign. Normal values on admission included blood cell count with differential cell count, urinalysis, latex fixation, antinuclear antibody, six- and 12factor automated blood chemistry analysis, VDRL, ECG, and chest and skull roentgen¬ ograms. Lumbar puncture showed clear, colorless fluid with no cells, a glucose level of 83 mg/100 ml and a protein level of 79 mg/100 ml. Radionuclide scan was normal. An EEG showed continuous slow activity on the right. Little change occurred in the patient's clinical condition during the next month. was Fig 1.—Initial right carotid arteriogram. Posterior cerebral artery shows irregu¬ larity consistent with arteritis. Anteroposterior view (not shown) showed no middle cerebral artery involvement. and hence if continued corticosteroid ther¬ apy was necessary. Following the initial injection into the right common carotid artery, the patient immediately com¬ plained of intense right facial pain with flushing. Concomitantly, the left-sided weakness changed to a dense hemiplegia with the addition of a left homonymous hemianopsia. After an hour the procedure was continued without further difficulty. Narrowing of the proximal right middle cerebral artery, with stasis in one ascend¬ ing frontoparietal branch, was evident (Fig 2). No filling occurred in the right anterior cerebral and posterior cerebral arteries. Proximal narrowing of the left middle cerebral artery was seen. Bilater¬ ally, the internal carotid arteries were normal. In the ensuing months, with corticoste¬ roid therapy, the patient showed improve¬ ment in mental status and slight improve¬ ment in the hemiplegia. COMMENT Fig 2—Second carotid arteriogram. Anteroposterior projections of right (top) and left (bottom) carotid arteriograms demon¬ strate proximal segmental narrowing of both middle cerebral arteries. He received prednisone in a dosage varying between 120 mg/day and 50 mg every other day since his first hospitalization, and we suspected that delusional thinking might be due in part to this medication. Bilateral carotid angiograms via femoral approach were performed to determine if vasculitis was still present, The reported cases of herpes zoster ophthalmicus with contralateral hemi¬ plegia form a characteristic syn¬ drome.17 Vesicles appeared over half the forehead and sometimes over the ipsilateral nose and cheek; some patients complained of unilateral blurred vision due to corneal ulcéra¬ tion. Contralateral hemiplegia oc¬ curred in each patient, usually a few weeks after the eruption. In individ¬ uals with a right hemiplegia, aphasia frequently accompanied the motor symptoms. Every patient demon¬ strated a Babinski sign on the same side as the hemiplegia, and three had bilateral upgoing toes. In three cases there was an associated dysfunction of cranial nerve III ipsilateral to the involved cranial nerve V. Cerebrospi¬ nal fluid, though frequently normal, sometimes contained a few mononuclear cells and a slight elevation of protein concentration. Walker and colleagues8 were the first to demon¬ strate angiographie changes in the cerebral arteries. Their patient showed segmental constriction in the proximal middle cerebral and anterior cerebral arteries with stasis, findings similar to those in our patient. Subse¬ quently, Gilbert9 described a patient demonstrating segmental narrowing of the right interal carotid siphon. Our case is distinctive in that bilateral changes along the course of the prox¬ imal middle cerebral arteries were demonstrated. Victor and Green1" found inflammation but no viral parti¬ cles in a temporal artery biopsy speci¬ men. Granulomatous or giant cell arteritis has been found in many cere¬ bral vessels in two patients following herpes zoster ophthalmicus.1112 Corticosteroids are usually used in treat¬ ment, although some patients have developed the hemiparesis while al¬ ready receiving this medication in high dosages. In the present case, hemiparesis day after a cere¬ bral angiogram, although there is no was first noted the evidence that these two events were causally related. There was an imme¬ diate adverse reaction to the second angiogram, with flushing and severe pain ipsilateral to the injection, on the side of the herpes zoster. This was probably a "vasomotor" rather than an urticarial or anaphylactoid allergic reaction.13 Patients with this syn¬ drome may not have an increased risk of adverse angiographie reaction; nev¬ ertheless, it seems that the clinical picture of a hemispheric stroke a few weeks following herpes zoster oph¬ thalmicus is well enough established that angiography can be avoided in the future. References 1. Gordon IRS, Tucker JF: Lesions of the central nervous system in herpes zoster. J Neurol Neurosurg Psychiatry 8:40-46, 1945. 2. Hughes WN: Herpes zoster of the right trigeminal nerve with left hemiplegia. Neurology 1:167-169, 1951. 3. Cope S, Jones AT: Hemiplegia complicating ophthalmic zoster. Lancet 2:898-899, 1954. 4. Anastasopoulos G, Routsoms K, Tersdiakonou CS: Ophthalmic herpes zoster with contra-$ lateral hemiplegia. J Neurol Neurosurg Psychiatry 21:210-212, 1958. 5. Laws HW: Herpes zoster ophthalmicus complicated by contralateral hemiplegia. Arch Ophthalmol 63:273-280, 1960. 6. Acers TE: Herpes zoster ophthalmicus with contralateral hemiplegia. Arch Ophthalmol 71:371-376, 1964. 7. Norris FH, Leonards R, Gelanchini PR, et al: Herpes zoster meningoencephalitis. J Infect Dis 122:335-338, 1970. 8. Walker RJ, Gammal TE, Allen MG: Cranial arteritis associated with herpes zoster. Neuroradiology 107:109-110, 1973. 9. Gilbert GJ: Herpes zoster ophthalmicus and delayed contralateral hemiparesis. JAMA 229:302-304, 1974. 10. Victor DI, Green WR: Temporal artery Downloaded From: http://archneur.jamanetwork.com/ by a Michigan State University User on 06/15/2015 biopsy in herpes zoster ophthalmicus with delayed arteritis. Am J Ophthalmol 82:628-630, 1976. 11. Kolodny EH, Rebeiz JJ, Caviness VS, et al: Granulomatous angiitis of the central nervous system. Arch Neurol 19:510-524, 1968. 12. Rosenblum WI, Hadfield MG: Granulomatous angiitis of the nervous system in case of herpes zoster and lymphosarcoma. Neurology 22:348-354, 1972. 13. Zweiman B, Mishkin MM, Hildreth EA: An approach to the performance of contrast studies in contrast material reactive persons. Ann Intern Med 83:159-162, 1975.