Intracerebral hemorrhages as an atypical radiographic presentation of herpes simplex encephalitis on CT scan: An analysis of 23 patients

Abstract

Objectives: To find out the effect of the atypical presentation of herpes encephalitis in the form of intracerebral Hemorrhage on the morbidity and mortality of patients

Methodology: It is basically retrospective study conducted at radiology department Dow University of Health Sciences Civil Hospital, Karachi from 2009 to 2011. Total numbers of patients presented with clinical diagnosis of encephalitis were109 and underwent CT scan plain and post contrast study. Physical diagnosis was based on fever, fits and altered level of consciousness. Laboratory diagnosis was based on pleocytosis with predominant lymphocytes, low glucose and high proteins and confirmation by polymerase chain reaction test (PCR) and empirical use of acyclovir.

Results: Total cases presented with clinical diagnosis of viral encephalitis and presented as hypo density with focal edema on CT scan were 109, out of which 23 cases presented with intracerebral hemorrhages. Hemorrhagic encephalitis was found in 21% of the cases. On plain CT scan brain, five cases showed isolated bilateral basal ganglia and thalamic hemorrhages. In seven cases bilateral temporofrontal region showed hemorrhages. Nine cases showed unilateral temporoparietal region (six cases were on right side and three cases were on left side) hemorrhages and in three cases unilateral right frontoparietal and basal ganglia hemorrhages were found on CT scan. In five cases leptomeningeal enhancement was associated with bilateral temporoparietal encephalitis. Hemorrhage size ranged from 2-5 cm. In nineteen cases, post contrast enhancement was seen in areas of encephalitis.

Conclusion: In appropriate clinical setting of encephalitis with CT SCAN diagnosis of intracerebral unilateral or bilateral hemorrhages and post contrast enhancement with CSF positive criteria for viral infection, diagnosis of herpes encephalitis should be on top of differential diagnosis. An early use of acyclovir without waiting for further tests can save the life of patients and significantly reduce the mortality and morbidity of patients.