PMC5625746_01
(Day 1) noncontrast CT head showing encephalomalacia on the left hemisphere without hemorrhage.
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fig1
Noncontrast computed tomography (CT) head showed an old left hemisphere encephalomalacia without any acute intracranial pathology (Figure 1).
(Day 2) ((a) and (b)) noncontrast MRI of the brain: Diffusion Weighted Imaging (DWI) demonstrates increased signal in the right temporal lobe (a) and right insula (b), consistent with cytotoxic edema. Restricted diffusion is less intense as compared to infarction. These imaging findings in combination with clinical scenario are highly suggestive of herpes simplex encephalitis. ((c) and (d)) Noncontrast MRI of the brain: FLAIR sequence demonstrates asymmetrical involvement of the right medial temporal lobe (c) and the insular cortex (d). Unlike in middle cerebral territory infarct, basal ganglia is spared. Arrows in (a) refer to increased signal in right temporal lobe, in (b) increased signal in right insula, in (c) FLAIR sequence demonstrating involvement of right medial temporal lobe, and in (d) FLAIR sequence demonstrating involvement of right insular cortex.
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fig2
Subsequently noncontrast magnetic resonance imaging (MRI) of the brain showed right temporal lobe involvement suggestive of HSV encephalitis (Figure 2).
(Day 12) (a) noncontrast CT of the brain demonstrates interval development of acute hemorrhage within medial right temporal lobe, a rare complication of herpes simplex encephalitis. (b) CT angiogram with IV contrast: coronal MIP reconstruction demonstrates patency of the intracranial circulation, with widely patent intracranial arteries, including middle cerebral arteries. Arrows in (a) refer to area of acute hemorrhage within the right medial temporal lobe.
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fig3
CT of the brain demonstrated interval development of acute hemorrhage within medial right temporal lobe, a rare complication of herpes simplex encephalitis. Computed tomography angiography (CTA) done at the same time was negative for any underlying vascular lesion (Figure 3).