15/1/2017

ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

ImaginginHerpesEncephalitis
Updated:Jul14,2015
Author:MaheshRPatel,MDChiefEditor:JamesGSmirniotopoulos,MDmore...

OVERVIEW

MagneticResonanceImaging
Thediagnosisofherpesencephalitiscanbestronglysuggestedbythetypicalappearanceof
medialtemporalabnormalitiesthatdonotrespecthippocampalborders.
Inadults,T2weightedMRIrevealshyperintensitycorrespondingtoedematouschangesinthe
temporallobes(seethefirst2imagesbelow),inferiorfrontallobes,andinsula,withapredilection
forthemedialtemporallobes.FociofhemorrhageoccasionallycanbeobservedonMRI(seethe
thirdimagebelow).

Axialprotondensityweightedimageina62yearoldwomanwithconfusionandherpesencephalitisshowsT2
hyperintensityinvolvingtherighttemporallobe.

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ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

AxialgadoliniumenhancedT1weightedimagerevealsenhancementoftherightanteriortemporallobeand
parahippocampalgyrus.Attherightanteriortemporaltipisahypointense,crescenticregionsurroundedby
enhancementconsistentwithasmallepiduralabscess.

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AxialnonenhancedT1weightedimageshowscorticalhyperintensity(arrows)consistentwithpetechial
hemorrhage.Ingeneral,thisisacommonpathologicfindingbutlesscommonlydepictedinherpes
encephalitis.

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MRIispreferredforimagingandfollowupstudiesofherpesencephalitis.Typically,temporallobe
T2hyperintensitysparesthebasalganglia.Althoughthisappearancewaspreviouslybelievedto
bepathognomonicforherpesinvolvement,similarfindingscanbeobservedinprogressive
multifocalleukoencephalopathyandprimaryCNSlymphoma.Patchyparenchymalorgyral
enhancementcanbeobserved(seetheimagebelow).[21,22,23,24,25,26]
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ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

AxialgadoliniumenhancedT1weightedimagerevealsenhancementoftherightanteriortemporallobeand
parahippocampalgyrus.Attherightanteriortemporaltipisahypointense,crescenticregionsurroundedby
enhancementconsistentwithasmallepiduralabscess.

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Inonestudyof251casesoftemporallobeencephalitisidentifiedbyMRI,43%wereofan
infectiousetiology(60caseswereherpessimplexencephalitis)and16%noninfectious.Therefore,
inadditiontoherpessimplex,otherinfectiousandnoninfectiouscausesshouldbeconsideredin
thedifferentialdiagnosisoftemporallobeencephalitis.[27]
Reportsofrestricteddiffusioninherpesencephalitisexist(seethefirstimagebelow),with
correspondingT2hyperintensityreflectingedema(seethesecondimagebelow).Reportssuggest
diffusionweightedimaging(DWI)maybemoresensitiveinthedetectionofHSVinvolvementthan
conventionalMRIsequencesandmaymimicaninfarctwithinvolvementofthecorticalregionsof
thetemporallobe.[28]

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ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

Axialdiffusionweightedimagerevealsrestricteddiffusionintheleftmedialtemporallobeconsistentwith
herpesencephalitis.Thispatientalsohadapositiveresultonpolymerasechainreactionassayforherpes
simplexvirus,whichisbothsensitiveandspecific.Inaddition,thepatienthadperiodiclateralizedepileptiform
dischargesonelectroencephalogram,whichsupportsthediagnosisofherpesencephalitis.

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CoronalT2weightedimagerevealshyperintensityinthelefttemporallobe(arrows)inadistributionsimilarto
therestricteddiffusionabnormalityseeninthepreviousimage.Thisfindingistypicalforherpesencephalitis.In
patientswithHHV6infection,oneseriesnotedthatinadditiontomesialtemporallobeabnormality,abnormal
T2hyperintensityhasbeenseenintheinsularandinferiorfrontalregion,whichmaysuggestthediagnosis.
Therearefelttobe2typicalimagingappearances:oneseeninolderadultsinvolvesT2hyperintensity
confinedtothemedialtemporallobeinyoungadults,amorevariedpatternhasbeendescribedthatincludes
fociofrestricteddiffusionwithanotherwisenormalmagneticresonance,diffusecorticalnecrosis,orsmallfocal
regionsofabnormalT2hyperintensity.

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ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

Immunocompromisedpatientsmayhaveatypicalmanifestationsincludingwidespreadcortical
involvement,brainsteminvolvement,orcerebellarinvolvement.[29]Inthepediatricpopulation,
diffusionweightedimagesarethoughttobethemostsensitive,andthecingulumwasless
frequentlyeffectedwhencomparedwithadults.[30]
Inneonates,T2weightedMRIshowshyperintensityoftheperiventricularwhitematter,withthe
medialtemporalandinferiorfrontallobesspared.Meningealenhancementalsomaybeobserved.
[31]

Inpatientswhodevelopedneonatalherpessimplexencephalitiswithin28daysafterbirth,cortical
lesionswerethemainfindingsonDWI.Bilateraldeepcerebrallesionsbyday7werehigh
indicatorsofpooroutcomesinmotorandcognitiveabilities.[32]
AdvancedMRtechniquesarebeingincreasinglyusedtostudyherpesencephalitis.MR
spectroscopyusingprotonspectroscopicMRIhasdemonstratedareductionoftheN
acetylaspartate(NAA)tocholineratio.AdecreasedNAApeakhasbeenreported714weeksafter
onset,andinsomecases,anelevatedcholinepeakisseen.Occasionally,thelactatepeakmaybe
elevated.TheNAAdecreaseisbelievedtoreflectneuronalinjury.NAArecoveryhasbeennotedto
parallelclinicalimprovement.[33,34]Diffusiontensorimaginghasanemergingroleindelineating
areasofinvolvementofnormalappearingwhitematterinthecontralateralhemispheretovisible
lesions.[35]
Gadoliniumbasedcontrastagentshavebeenlinkedtothedevelopmentofnephrogenicsystemic
fibrosis(NSF)ornephrogenicfibrosingdermopathy(NFD).Formoreinformation,seethe
MedscapeReferencetopicNephrogenicSystemicFibrosis.NSF/NFDhasoccurredinpatientswith
moderatetoendstagerenaldiseaseafterbeinggivenagadoliniumbasedcontrastagentto
enhanceMRIorMRAscans.Formoreinformation,seeFDAInformationonGadoliniumBased
ContrastAgentsorMedscape.
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ImaginginHerpesEncephalitis:Overview,ComputedTomography,MagneticResonanceImaging

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