Introduction: Varicella zoster is thought to lie quiescent in the trigeminal ganglion following an episode of chicken pox.  Viral reactivation occurs with retrograde infection of the first division of the trigeminal nerve and the clinical phenomenon of Herpes zoster ophthalmicus (HZO).  Direct and indirect mechanisms affecting the neurovascular bundle are implicated in the aetiology of post-varicella angiopathy arterial ischaemic stroke (AIS) although pathological evidence is limited to. 

Case:  A five year old girl with a history of chicken pox at four weeks of age was diagnosed with HZO of the left eye (Fig 1). This remained indolent in the left eye despite treatment. Ten weeks after initial diagnosis, she presented with right sided choreoathetosis.  MRI and MRA demonstrated left basal ganglia signal change, narrowing of the terminal left internal carotid artery (ICA), proximal anterior and middle (MCA) cerebral arteries (Fig 2). Ultrasound angiology revealed abnormal velocities of the left MCA and ICA.  Protein S and C levels were transiently low. Further investigations were normal.  She received a second course of HZO treatment and Dipyridimole.  Choreoathetosis and MRI changes resolved however there was persistent narrowing of the vessels.

Conclusion:  We propose HZO related AIS is the clinical equivalent to shingles of the brain supporting a peri-infectious, immune mediated inflammatory basis for the condition.  We suggest pathology targeted treatments such as Acyclovir and corticosteroids be considered and that further research is required in this area.