Discussion:

Herpes simplex virus is a neuro-tropic virus that enters the body through the mucosal surface. It travels along the axons through retrograde transport and lies dormant in the sensory ganglia. The exact mechanism of transport to CNS is not described but it is postulated that it is a similar mechanism of retrograde transport along the sensory nerves, given its predilection to mesiotemporal lobe and orbitofrontal cortex(9). Once in the CNS, the manifestations of encephalitis prevail. CNS complications include seizures (38.4%), status epilepticus (5.5%), acute respiratory failure (20.1%), ischemic stroke (5.6%) and intracranial hemorrhage (2.7%)(10). Thus, intracranial hemorrhage being rare but fatal consequence in many instance(10). Untreated, the mortality rate in herpes encephalitis due to its complication can reach to 70% and most of the survivors can have serious neurological deficits like neuropsychiatric or neurobehavior issues. HSE encephalitis needs a prompt treatment with IV acyclovir for the reduction of mortality and morbidity from HSV encephalitis and its complication.
The exact mechanism of hemorrhage has not been found but few theories have been described to show the relationship of HSV encephalitis and lobar hemorrhages. Vasculitis or transient hypertension caused by increased ICP plays a major role in having lobar hemorrage. The hypothesis include the rupture of the small vessels due to these above causes(11). Magnetic resonance imaging (MRI ) of the brain is the preferred imaging study; T2 images may be more helpful than T1 images(12).
Our patient’s presentation was consistent with HSV encephalitis but later he developed brain hematoma. Otherwise, the clinical features of brain hemorrhage were not distinctive and overlapped significantly with those of HSV encephalitis. It is thus difficult to suspect this complication on clinical grounds alone. The lack of clinical improvement or the worsening of initial symptoms, particularly during first to second week of admission, should lead to this suspicion and be followed by a neuroimaging study. If the evidences discard the possibility of structural complication, a lack of improvement with the treatment of acyclovir may raise concern of acyclovir resistance or treatment adverse effect. This scenario may warrant the start or switch the therapy to foscarnet(13).
During management of this complication, supportive care and intensive monitoring was sufficient, and surgical intervention was not required. Mannitol was used for management of raised ICP but corticosteroids were not used, the role of which remains still debatable in this area(14). A multicenter randomized controlled trial was done to study the role of corticosteroid in treatment of HSV encephalitis but was prematurely terminated due to small no of study participants(15). Thus, higher level of evidence to support the use of corticosteroid is lacking. Intensive care physicians involvement in the care team seems imminent as up to 32% require ICU stay and 17% require mechanical ventilation(16). Similarly, need for surgical intervention may be as high as 50% following intracerebral hemorrhage as reported by Sainz et. al(17).The neurological outcome in the non-operated group was similar, although in this case it could be argued that they were less severely affected. Thus, the role of neurosurgery in these patients is still unclear.