Zoster vasculopathy is an uncommon consequence of varicella zoster infection of the skin or eyes. It results in infection of the intracranial blood vessels leading to focal stenosis and subsequent strokes. Although conventional angiography has traditionally been used to identify the large vessel stenoses, intracranial vessel wall imaging (VWI) – commonly referred to as ‘black blood’ sequences – can be used to demonstrate areas of vessel wall enhancement associated with vasculitides as can be found in zoster vasculopathy.

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We present two cases of intracranial zoster vasculopathy with associated vessel wall enhancement that resolved following the administration of acyclovir, even though the antiviral was administered months after the initial cutaneous and ophthalmologic infections. Both patients initially presented with recurrent strokes approximately six months after a zoster infection, and after administration of acyclovir, neither patient experienced any strokes in the subsequent six months.

We propose utilizing VWI to assist in the diagnosis of zoster vasculopathy and to monitor treatment response. Our cases also reinforce the importance of providing a trial of intravenous acyclovir to patients with suspected zoster vasculopathy, as clinical and radiographic improvement can occur even months after the initial infection.