A 48-year-old man with known symptomatic epilepsy reported diarrhea and fever for some days. This was followed by a series of focally beginning secondary generalized seizures. Thus the emergency physician administered 7.5 mg midazolam intravenously and admitted the patient to the neurological department. On admission, the patient was sedated and presented residual aphasia. A meningeal irritation was not noted. The neurological signs and symptoms were interpreted as postictal. There were no visible injuries, therefore a series of seizures due to afebrile infection was presumed. The patient was observed under intermediate care aspects. The next 2 days the patient's condition improved, he was afebrile and no focal neurological deficits were present. The medication with levetiracetam was augmented to a dosage of 1500 mg/daily. Electroencephalography showed slightly slowed focal activity on the left temporal side on the background of normal alpha wave activity. The day before the planned discharge from inpatient care, the patient suffered with sudden onset of a series of epileptic seizures progressing to a convulsive status with high fever of 40°C. Oral intubation and mechanical ventilation became necessary in order to treat status epilepticus. As anticonvulsive agents phenytoin, levetiracetam, midazolam, and propofol were applied, the Cranial computed tomography (CCT) scan at this time revealed hyodensities in the right temporal lobe and the right insular cortex []. The left sided hypodensity is related to a former head injury. The following cerebrospinal fluid (CSF) analysis showed elevated lymphocytic cell count (27/μL; normal < 4) with normal glucose but elevated protein (699 mg/dl (normal < 450)), indicating an inflammatory CSF syndrome. Polymerase chain reaction (PCR) assay for HSV-1 was tested positive. A treatment regimen was implemented with acyclovir (10 mg/kg body weight) three times daily for 21 days. After 4 days of ventilation the patient could be extubated and improved clinically successful. Cranial magnetic resonance imaging (MRI) on day 10 showed extended encephalitic changes in the right frontal and temporal lobe []. After a rehabilitation program, follow-ups took place as an outpatient. Yet due to neuropsychological impairments he cannot work in his profession as a carpenter anymore. Under the current antiepileptic therapy (levetiracetam 1500 mg daily), the patient is seizure-free.
A 40-year-old left-handed Caucasian female with chronic headaches, along with a 20-pack-year smoking history, presented to an outside facility with one week of diffuse, generalized headache, fever, nausea, emesis, and photophobia. Her physical exam was without any focal neurological deficit. Initial cranial imaging was negative for hemorrhage. A lumbar puncture was performed and cerebrospinal fluid (CSF) studies demonstrated 558 white blood cells/mm3 with 100% monocytes, protein 115 mg/dL, and glucose 55 mg/dL. Polymerase chain reaction (PCR) of the CSF was positive for HSV-2. Taken together, the lymphocytic pleocytosis with elevated protein, along with CSF-PCR-positive staining for HSV, established the diagnosis of HSV-2 encephalitis.\nAcyclovir was initiated, and one week later while still hospitalized, she developed an acute altered mental status and left-sided weakness with cranial imaging showing a large right temporal lobe hemorrhage with significant midline shift. She was transferred to our facility where a computed tomography angiography (CTA), performed on arrival and shown in Figure , was negative for any underlying vascular lesion. There was again the demonstration of a large right temporal lobe intracerebral hemorrhage that was displacing the right middle cerebral artery superiorly as well as midline shift. Informed patient consent was waived due to her condition upon admission.\nShe was taken to the operating room for a decompressive unilateral (right) hemicraniectomy and temporal lobectomy. We had the operating room prepared for a possible vascular lesion despite the initial negative study. Figure -C demonstrates intraoperative images. A 15 x 12 cm (AP x lateral) craniectomy was measured out and performed, ensuring to stay within 2 cm off of the midline to avoid superior sagittal sinus bleeding []. The dura was opened in a cruciate fashion. A large red vein was noted superficially and coursed anterior-inferiorly toward the Sylvian fissure. A right temporal lobectomy was performed, measuring 5 cm posterior to the temporal tip. The parenchyma was noted to be very friable. The hematoma was removed, and there were no intraoperative complications. As the brain was decompressed, the red superficial vein normalized to the typical blue color commonly encountered. A postoperative angiogram was performed and demonstrated no vascular lesion as well as a normal alignment of the middle cerebral artery as is seen in Figure .\nPostoperative imaging is shown in Figure , which demonstrates good decompression and highlights the appropriate size of the craniectomy.\nHistopathological studies are shown in Figure and are consistent with herpes encephalitis, showing perivascular lymphocytic infiltrate, neuronophagia, and hemorrhage.\nShe had no postoperative complications and completed a three-week course of acyclovir. She was discharged to acute rehab with plans to return at a later date for cranioplasty.