Unexplained Stroke and Multifocal Intracranial Stenosis due to Varicella Zoster Virus Vasculopathy

The classical prototype of Varicella Zoster Virus (VZV) associated vasculopathy is contralateral hemiplegia after herpes zoster ophthalmicus. We describe a 30-year-old patient with no vascular risk factors who presented with a lacunar stroke and was found to have focal intracranial stenosis. He presented again one and a half months later with new findings suggestive of progressive multifocal intracranial stenoses. Although vasculitis was suspected initially, varicella zoster virus reactivity raised the possibility of VZV associated vasculopathy. This case serves as a reminder to suspect this type of vasculopathy even in immunocompetent patients with no cutaneous manifestations. Intracranial stenosis affecting M1 of the middle cerebral artery and the distal portion of the internal carotid artery is common in VZV vasculopathy and should hint toward the diagnosis as shown in this case.