Letter to the Editor
Acute cerebral haematoma in the course of herpes simplex encephalitis: a rare complication
Hematoma cerebral agudo en la evolución de una encefalitis por virus herpes simple tipo 1. Una complicación infrecuente
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Una complicación infrecuente" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "80" "paginaFinal" => "82" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Acute cerebral haematoma in the course of herpes simplex 1 encephalitis. A rare complication" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1810 "Ancho" => 2925 "Tamanyo" => 531605 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A y B) Cortes transversales de la TC inicial de cabeza. Se observan hallazgos sospechosos de encefalitis herpética con hipodensidad corticosubcortical de la zona basal anterior del lóbulo temporal derecho (flecha negra). También destaca la hipodensidad con tumefacción de la amígdala y uncus temporales que condiciona efecto masa y herniación uncal (flecha blanca). C-H) Imágenes de la RM encefálica a los 3 días de inicio del cuadro con hallazgos característicos de encefalitis herpética por VHS-1. C) Imagen transversal de secuencia T2 TSE demostrando hiperintensidad por edema con tumefacción de la zona anteromedial del lóbulo temporal derecho (flecha negra) y del hipocampo. D) Imagen coronal de secuencia FLAIR donde se observa la extensa afectación tumefactiva del córtex del lóbulo temporal derecho (*) con extensión de la hiperintensidad a la ínsula (flecha hueca) e hipotálamo derechos (flecha blanca). E) Imagen transversal de la secuencia de susceptibilidad en la zona de mayor afectación temporal, sin demostrar hemorragia petequial a los 3 días de la evolución (flecha negra). La secuencia de difusión (F) y mapa de ADC (G) evidencian extensa hiperintensidad por efecto T2 en el lóbulo temporal derecho, mayor en el córtex de las circunvoluciones laterales y con focos puntiformes de mayor señal en la secuencia de difusión (flechas negras), que coinciden con zonas de restricción de la difusión, hipointensas en el mapa de ADC (flechas blancas). H) Imagen sagital de secuencia T1 TSE tras la administración de contraste intravenoso donde se demuestra captación leptomeníngea en la zona basal del lóbulo temporal derecho (flechas huecas).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "D. Veiga Canuto, J. Carreres Polo, F. Aparici Robles, A. Quiroz Tejada" "autores" => array:4 [ 0 => array:2 [ "nombre" => "D." "apellidos" => "Veiga Canuto" ] 1 => array:2 [ "nombre" => "J." 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Veiga Canuto, J. Carreres Polo, F. Aparici Robles, A. Quiroz Tejada" "autores" => array:4 [ 0 => array:4 [ "nombre" => "D." "apellidos" => "Veiga Canuto" "email" => array:1 [ 0 => "dianaveigac@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J." "apellidos" => "Carreres Polo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Aparici Robles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "Quiroz Tejada" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Área Clínica de Imagen Médica, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitari i Politècnic La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hematoma cerebral agudo en la evolución de una encefalitis por virus herpes simple tipo 1. Una complicación infrecuente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1810 "Ancho" => 2925 "Tamanyo" => 531605 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) and B) Transverse sections from the initial head CT scan, showing findings suggestive of herpes virus encephalitis, with cortico-subcortical hypodensity in the anterior basal area of the right temporal lobe (black arrow). The images also show hypodensity with tumefaction of the amygdala and temporal uncus, resulting in mass effect and uncal herniation (white arrow). C-H) Brain MRI study obtained 3 days after symptom onset showing characteristic signs of herpes simplex encephalitis. C) T2-weighted TSE sequence (transverse plane) showing hyperintensity due to oedema, with tumefaction of the right anteromedial temporal lobe (black arrow) and hippocampus. D) FLAIR sequence (coronal plane) showing extensive cortical tumefaction of the right temporal lobe (asterisk) and extension of the hyperintensity to the right insula (hollow arrow) and hypothalamus (white arrow). E) Susceptibility-weighted imaging sequence (transverse plane) of the area of most intense involvement in the temporal lobe, with no evidence of petechial haemorrhage at 3 days of progression (black arrow). The diffusion sequence (F) and ADC map (G) show extensive right temporal hyperintensity due to the T2 effect, which is more pronounced in the cortex of the lateral gyri, with punctiform hyperintensities on the diffusion-weighted sequence (black arrows), which coincide with areas of diffusion restriction and hypointensity on the ADC map (white arrows). H) Contrast-enhanced, T1-weighted TSE sequence (sagittal plane) showing leptomeningeal contrast uptake in the basal area of the right temporal lobe (hollow arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes simplex encephalitis is the most frequent type of sporadic viral encephalitis in immunocompetent adults, with herpes simplex virus 1 accounting for over 90% of cases. Symptoms include focal encephalopathy with headache, fever, impaired consciousness, and psychiatric symptoms due to the involvement of limbic structures. The diagnostic technique of choice is a polymerase chain reaction assay of a CSF sample.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> As false negatives or late diagnosis may delay treatment onset, imaging studies play a fundamental role both in early diagnosis and in analysing the absence of symptom improvement in the weeks following treatment onset.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 45-year-old woman with no relevant history who attended the emergency department with headache and fever of 3 days’ progression, and no signs of encephalopathy. The physical examination revealed a Glasgow Coma Scale score of 15, with no focal neurological signs. A head CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) detected hypodensity and tumefaction of the right anterior temporal pole. CSF analysis identified lymphocytosis, and empirical treatment was started with intravenous aciclovir. An MRI scan performed 3 days after symptom onset (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) showed involvement of the right temporal lobe and gyrus rectus, with no signs of petechial haemorrhage, and no haemorrhagic foci in other areas. A polymerase chain reaction assay returned positive results for herpes simplex virus 1 in the CSF.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient’s level of consciousness decreased on day 10 after symptom onset, with a score of 10 on the Glasgow Coma Scale. A head CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) showed an intraparenchymal haemorrhage in the right temporal lobe, measuring 3.6 cm in diameter, surrounded by an area of oedema, and uncal herniation. We administered mannitol and hyperosmolar therapy; the possibility of neurosurgical treatment was considered, but we decided against performing decompressive craniectomy due to a favourable treatment response. Radiological and clinical progression were favourable, with the patient displaying fatigue during activities of daily living a year after the episode.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Imaging studies of herpes simplex encephalitis show unilateral onset in the anteromedial temporal lobe and orbitofrontal gyri, with subsequent asymmetrical bilateral posterior progression.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Initial CT findings are normal in 25% of patients; the typical finding is cortico-subcortical hypoattenuation with mass effect. MRI is more sensitive for detecting the disease, with T2-weighted sequences showing hyperintensity due to oedema and inflammation; diffusion-weighted sequences may show restriction due to cytotoxic oedema, which is associated with poorer prognosis. Gyral and leptomeningeal contrast enhancement are also common MRI findings.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> As the disease progresses, both tests may detect foci of microbleeds due to petechial haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Petechial haemorrhages in the cortex and subcortical white matter are typical anatomical pathology and radiology findings. Intraparenchymal haematoma in the affected area is a very rare complication<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>; a literature review identified 27 cases,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–11</span></a> with a mortality rate of 5.2%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The aetiology of this complication is unknown. Possible causes suggested in the literature include endothelial damage secondary to small-vessel vasculitis induced by the infection; an immune-mediated inflammatory reaction; and increased intracranial pressure, which peaks at 10–12 days.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Untreated herpes simplex encephalitis presents a mortality rate of up to 70%, decreasing to 20%–30% with the administration of aciclovir<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a>; empirical treatment with intravenous aciclovir at 10 mg/kg/8 h is therefore recommended.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Given the non-specific nature of the symptoms, the fundamental role of imaging studies during the progression of herpes simplex encephalitis is to optimise therapeutic management in the event that symptoms show no change or worsen, as these techniques enable us to distinguish between treatment resistance, aciclovir-induced toxicity, and haemorrhagic complications.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">If the predominant sign is intracranial hypertension, it is essential to control this through osmotherapy, sedatives, and even barbiturates and other third-line measures.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The use of systemic corticosteroids is controversial.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Surgical treatment should be considered if intracranial hypertension is refractory to medical treatment or if imaging findings suggest brainstem compression due to the mass effect of the temporal lobe; however, some reviews have not demonstrated significant differences in long-term outcomes between patients with intraparenchymal haemorrhage receiving medical and surgical treatment.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,15</span></a> Treatment decisions should be made on an individual basis, with surgical treatment used as a rescue measure in selected cases.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, intraparenchymal haemorrhage is a rare but plausible complication of herpes simplex encephalitis in patients showing no clinical improvement or worsening of symptoms in the weeks after treatment onset. Imaging studies performed immediately after admission enable early diagnosis and optimised management.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Veiga Canuto D, Carreres Polo J, Aparici Robles F, Quiroz Tejada A. Hematoma cerebral agudo en la evolución de una encefalitis por virus herpes simple tipo 1. Una complicación infrecuente. Neurología. 2021;36:80–82.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1810 "Ancho" => 2925 "Tamanyo" => 531605 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A) and B) Transverse sections from the initial head CT scan, showing findings suggestive of herpes virus encephalitis, with cortico-subcortical hypodensity in the anterior basal area of the right temporal lobe (black arrow). The images also show hypodensity with tumefaction of the amygdala and temporal uncus, resulting in mass effect and uncal herniation (white arrow). C-H) Brain MRI study obtained 3 days after symptom onset showing characteristic signs of herpes simplex encephalitis. C) T2-weighted TSE sequence (transverse plane) showing hyperintensity due to oedema, with tumefaction of the right anteromedial temporal lobe (black arrow) and hippocampus. D) FLAIR sequence (coronal plane) showing extensive cortical tumefaction of the right temporal lobe (asterisk) and extension of the hyperintensity to the right insula (hollow arrow) and hypothalamus (white arrow). E) Susceptibility-weighted imaging sequence (transverse plane) of the area of most intense involvement in the temporal lobe, with no evidence of petechial haemorrhage at 3 days of progression (black arrow). The diffusion sequence (F) and ADC map (G) show extensive right temporal hyperintensity due to the T2 effect, which is more pronounced in the cortex of the lateral gyri, with punctiform hyperintensities on the diffusion-weighted sequence (black arrows), which coincide with areas of diffusion restriction and hypointensity on the ADC map (white arrows). H) Contrast-enhanced, T1-weighted TSE sequence (sagittal plane) showing leptomeningeal contrast uptake in the basal area of the right temporal lobe (hollow arrows).</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 819 "Ancho" => 1305 "Tamanyo" => 105852 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Transverse sequences from the head CT scan performed 10 days after onset, when symptoms worsened. The images are similar to those from the original study, showing a large intraparenchymal haematoma in the right temporal lobe, in the area initially affected by herpes simplex encephalitis (asterisks). The images also show perilesional vasogenic oedema and a considerable mass effect, with effacement of the adjacent sulci and greater herniation of the temporal uncus than in the initial study.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Central nervous system infections of herpesvirus family" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Bulakbasi" 1 => "M. 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