Summary

The clinical hallmark of viral encephalitis is an acute febrile illness, but stroke-like presentations have been rarely described. We report a patient who arrived at A&E with an acute right middle cerebral artery syndrome, without fever. Following thrombolytic treatment, clinical deficit almost disappeared and a critical ipsilateral carotid stenosis was identified. Stenting was implemented and 7 days later the patient started with high fever and reappearance of the initial deficit. Hyperperfusion syndrome and pneumonia were initially considered as the diagnosis but herpetic encephalitis (HE) was the final diagnosis. A very good response to antiviral treatment was achieved. We discuss whether the patient suffered from an unusual sudden stroke-like onset HE without encephalitic features or whether a stroke led to delayed HE.