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Table of Contents    
Year : 2011  |  Volume : 59  |  Issue : 4  |  Page : 594-596

Herpes simplex virus encephalitis complicated by intracerebral hematoma

1 Department of Neurosurgery, National Defense Medical College, Saitama, Japan
2 National Hospital Organization Disaster Medical Center, Tokyo, Japan

Date of Submission18-Feb-2010
Date of Decision28-Dec-2010
Date of Acceptance17-Jan-2011
Date of Web Publication30-Aug-2011

Correspondence Address:
Satoru Takeuchi
Department of Neurosurgery, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.84344

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 » Abstract 

Herpes simplex virus (HSV) encephalitis complicated by cerebral hematoma is extremely rare. We report a 54-year-old man with hepes simplex encephalitis complicated by intracerebral hematoma and review the literature and describe the characteristics of HSV encephalitis complicated by intracerebral hematoma

Keywords: Encephalitis, herpes simplex virus, intracerebral hematoma

How to cite this article:
Takeuchi S, Takasato Y. Herpes simplex virus encephalitis complicated by intracerebral hematoma. Neurol India 2011;59:594-6

How to cite this URL:
Takeuchi S, Takasato Y. Herpes simplex virus encephalitis complicated by intracerebral hematoma. Neurol India [serial online] 2011 [cited 2023 Dec 1];59:594-6. Available from:

 » Introduction Top

Herpes simplex virus (HSV) encephalitis is the most common cause of sporadic encephalitis, with a mortality of 70% if untreated. Treatment with acyclovir is associated with reduced mortality. Petechial cortical hemorrhages are common in HSV encephalitis, whereas frank hematoma is extremely rare; only 10 cases have been reported in the literature. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] We report another case of HSV encephalitis complicated by intracerebral hematoma and review the literature.

 » Case Report Top

A 54-year-old man was admitted with a 2-day history of fever, difficulty in walking, and mental confusion. He had a general seizure at admission. He was being treated for hypertension. His vitals were: temperature, 39.7°C; blood pressure, 170/143 mmHg; pulse rate, 179 beats/min; and respiratory rate, 30 breaths/min. On neurologic examination, he was in coma with left hemiparesis. Laboratory workup revealed the following: C-reactive protein, 0.1 mg/L; white cell count (WBC), 13,700/mm 3 , and cerebrospinal fluid (CSF) analysis on day 2, WBC count of 86 cells/mL (69% mononuclear cells); protein, 56.3 mg/dL; and glucose, 90 mg/dL. CSF samples were positive for HSV-DNA by polymerase chain reaction. Brain computed tomography (CT) on day 2 showed a slightly low-density area in the medial side of the right temporal lobe, with an obscured sulcus [Figure 1]a. He was diagnosed as a case of HSV encephalitis and was started on acyclovir (1500 mg/day, 2 weeks). Brain fluid-attenuated inversion recovery magnetic resonance imaging (MRI) on day 7 showed a focal area of increased signal in the right temporal lobe [Figure 1]b. His neurologic condition recovered gradually. However, brain CT scan on day 10 showed a hematoma in the right medial temporal lobe, without mass effect [Figure 1]c. He was managed conservatively as his condition was stable. The hematoma showed no further progression and gradually resolution. The patient was transferred to another hospital on day 15 for rehabilitation for mild left hemiparesis and short-term memory disturbance.
Figure 1: (a) Brain computed tomography (CT) scan on day 2 showing slightly low-density area in the medial side of the right temporal lobe with obscured sulcus. (b) Brain magnetic resonance image (fluid-attenuated inversion recovery) on day 7, revealing focal area of increased signal in the right temporal lobe. (c) Brain CT scan on day 10, demonstrating a hematoma in the right medial temporal lobe, without mass effect

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 » Discussion Top

HSV encephalitis complicated by intracerebral hematoma is extremely rare and the characteristics of the 11 cases, including the present case, are summarized in [Table 1]. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Only two patients including our patient had higher blood pressure reading at admission. The hematoma location was in the medial temporal lobe in six patients and exhibited a gyral pattern, which differed from spontaneous intracerebral hematoma. Hemorrhagic complication occurred during acyclovir treatment (5-15 days) in six patients, suggesting that initiation of treatment may not affect this complication. Hemorrhagic complication was associated with poor outcome, only three patients had good recovery and six had moderate to disability.
Table 1: Documented findings of herpes simplex virus encephalitis with cerebral hematoma

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The mechanism of hemorrhagic complication in HSV encephalitis is unclear. The possible mechanisms proposed by Fukushima et al. [10] include small vessel rupture due to vasculitis and transient hypertension caused by increased intracranial pressure. Gyral pattern of the hemorrhage may suggest that the hemorrhagic complication in HSV encephalitis may be due to associated vasculitis. Hematoma formation in the cases described here tended to occur at a relatively late stage (mean interval from onset to hematoma formation, approximately 12 days), which supports this hypothesis.

 » References Top

1.Malik A, Goyal M, Mishra NK, Gaikwad SB, Padma V. Intracerebral haematoma formation in herpes simplex encephalitis: A case report. Australas Radiol 1997;41:303-5.  Back to cited text no. 1
2.Hiyama H, Tanaka Y, Kawakami T, Matsuo S, Sawada T, Hori T, et al. A case of fatal herpes encephalitis presenting massive cerebral hematoma. No Shinkei Geka 2001;29:271-6.  Back to cited text no. 2
3.Plantinga EG, Vanneste JA. Mild herpes simplex encephalitis worsening despite acyclovir treatment. J Neurol 2001;248:237-8.  Back to cited text no. 3
4.Erdem G, Vanderford PA, Bart RD. Intracranial hemorrhage in herpes simplex encephalitis: An unusual presentation. Pediatr Neurol 2002;27:221-3.  Back to cited text no. 4
5.Biswas A, Das SK, Roy T, Dhibar T, Ghorai SP. Acute intracerebral haematoma--an unusual presentation of herpes simplex encephalitis. J Assoc Physicians India 2004;52:69-71.  Back to cited text no. 5
6.Kabakus N, Gurgoze MK, Yildirim H, Godekmerdan A, Aydin M. Acute hemorrhagic leukoencephalitis manifesting as intracerebral hemorrhage associated with herpes simplex virus type I. J Trop Pediatr 2005;51:245-9.  Back to cited text no. 6
7.Argyriou AA, Tsota I, Solomou E, Marangos M, Kalogeropoulou C, Petsas T, et al. Intracerebral haemorrhage as a rare complication of HSV-1 meningoencephalitis: Case report and review of the literature. Scand J Infect Dis 2006;38:63-6.  Back to cited text no. 7
8.Shelley BP, Raniga SB, Al-Khabouri J. An unusual late complication of intracerebral haematoma in herpes encephalitis after successful acyclovir treatment. J Neurol Sci 2007;252:177-80.  Back to cited text no. 8
9.Li JZ, Sax PE. HSV-1 encephalitis complicated by cerebral hemorrhage in an HIV-positive person. AIDS Read 2009;19:153-5.  Back to cited text no. 9
10.Fukushima Y, Tsuchimochi H, Hashimoto M, Yubi T, Nakajima Y, Fukushima T, et al. A case of herpetic meningoencephalitis associated with massive intracerebral hemorrhage during acyclovir treatment: A rare complication. No Shinkei Geka 2010;38:171-6.  Back to cited text no. 10


  [Figure 1]

  [Table 1]

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