CNS MR and CT Findings Associated with a Clinical Presentation of Herpetic Acute Retinal Necrosis and Herpetic Retrobulbar Optic Neuritis: Five HIV-Infected and One Non-Infected Patients
Robert J. Berta,
Ranji Samawareerwab and
Elias R. Melhema
a Boston Medical Center, Jamaica Plain, MA
b Boston VA Medical Center, Jamaica Plain, MA
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FIG 1. Images from 1988 obtained in a patient with AIDS with CMV-induced ARN preceding retrobulbar optic neuritis.
A, CT scan shows a shrunken left globe with bilateral avidly enhancing sclera (arrowheads) and enhancement of both optic nerves (arrows).
B, T2-weighted image shows increased signal intensity in the optic tracts (top arrows) and geniculate bodies (bottom arrows).
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FIG 2. MR images obtained in patient 2.
A, T2-weighted coronal image shows both increased (left) and decreased (right) signal in the optic tracks (arrows).
B, Contrast-enhanced T1-weighted image shows enhancement of the left optic nerve and low signal intensity in the right optic nerve (arrows).
C and D, Contrast-enhanced T1-weighted images show enhancement of the right optic tract (arrow in C) and chiasm (arrowhead in D).
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FIG 3. Images obtained in patient 3 with HZV-induced progressive outer retinal necrosis preceding retrobulbar optic neuritis, CNS extension, and eventual demise.
A, Coronal T2-weighted gradient-echo image suggests hemorrhage in the right lateral geniculate body, with increased signal intensity involving the optic radiation through the temporal lobe (arrowhead) and extending caudad along the lateral midbrain (large arrow) to the cerebellum (small arrow).
B, Axial T2-weighted turbo spin-echo image shows increased signal intensity along the right optic tract (white arrow) and lateral geniculate body (black arrow).
C and D, Proton density–weighted images demonstrate abnormally high signal intensity along the right hemipons (thin arrow in C), right midbrain, and superior colliculus (arrow in D), occipital (visual) cortex (thick arrow in C), and optic radiation in the temporal lobe (arrowheads in D).
E, T1-weighted contrast-enhanced image shows enhancement in similar regions: optic tract (white arrow) and lateral geniculate body (black arrow). Postmortem immunofluorescence stains (not shown) demonstrated HZV in these areas.
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FIG 4. Patient 4 with HZV-induced progressive outer retinal necrosis and retrobulbar optic neuritis after herpes ophthalmicus. T1-weighted contrast-enhanced image shows enhancement of the optic nerves (right distal, left proximal) and optic chiasm (arrows). Compare the thickened, avidly enhancing right chorioretina with the normally enhancing left retina (arrowheads).
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FIG 5. Axial images obtained in elderly HIV-negative woman with HZV ophthalmicus preceding retrobulbar optic neuritis and mental status changes.
A and B, Nonenhanced and enhanced T2-weighted FLAIR images at the level of the pons show minimal abnormal high signal intensity in A and avid enhancement in B in the left ambient cistern, supracerebellar cistern, cerebellar vermis and adjacent subarachnoid space along the tentorium (arrowheads).
C–E, Axial images at the level of the midbrain. Contrast-enhanced conventional T1-weighted image in C shows minimal enhancement. Nonenhanced (D) and enhanced (E) T2-weighted FLAIR images show avid enhancement of the optic nerves, chiasm, tracts, and pericavernous region (black arrowheads), right lateral geniculate body (white arrowhead), interpeduncular cistern (black arrow), and supracerebellar cistern (white arrow).
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