Is There a Direct Pathway Linking Herpes Zoster Ophthalmicus to Extra-Axial Hemorrhage?

Abstrak

Introduction: Herpes zoster ophthalmicus (HZO) results from reactivation of latent varicella-zoster virus (VZV) and may involve ocular, neural, and vascular structures. Although VZV vasculopathy is commonly associated with ischemic stroke, hemorrhagic and extra-axial manifestations remain rare. Case Presentation: We report a 57-year-old man who presented with acute speech impairment and right-sided weakness. Neurological examination demonstrated Broca’s aphasia, right upper motor neuron facial palsy, and right hemiparesis. Two weeks before admission, he had been diagnosed with left-sided HZO, which resolved following antiviral therapy. Brain computed tomography revealed a hypodense extra-axial lesion in the left frontotemporal region, suggestive of late subdural hemorrhage, with subdural hygroma considered as a differential diagnosis. The temporal relationship between HZO and the neurological event raised suspicion of VZV-associated vasculopathy with atypical hemorrhagic involvement. Conclusion: This case highlights an uncommon neurological complication of HZO presenting with cortical deficits and extra-axial hemorrhagic pathology rather than the more typical ischemic stroke. Clinicians should maintain a high index of suspicion for both ischemic and hemorrhagic VZV-related vascular complications in patients presenting with new focal neurological deficits after HZO, as early recognition and appropriate neuroimaging are essential for accurate diagnosis and timely management.