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Gross atrophy of the right temporal lobe (grey and white matter) with ex-vacuo dilatation of the right temporal horn.  Surrounding T2 brightening indicative of gliosis. Herpes simplex encephalitis is a devastating infection and if not treated early can cause severe destruction of brain tissue leading to gross atrophy as evidenced by this case. A 29 yo married female brought unconscious to casualty with history of mild fever and headache since 3days. MRI brain Diffusion and axial FLAIR images show insular and medial temporal faint abnormal T2 hyper intensity with restricted diffusion on Dw images.
Infarct ruled out as there is no intra cranial major vessel stenosis or occlusion on MR Angio particularly the MCA.
Location wise typically involves Limbic system in that commonly involves temporal lobes, insula, subfrontal area and cingulate gyri. Atypical patterns seen in infants and children where involvement of cerebral hemispheres noted primarily. HSV-l reactivation may occur spontaneously or be precipitated by various factors like Local trauma, immunosuppression, hormonal fluctuations, emotional stress. Children often present with nonspecific symptoms like Behavioral changes, fever, headaches, seizures, even coma and death. Early diagnosis and treatment with antiviral agents can decrease mortality, may improve outcome.

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Coloured coronal magnetic resonance imaging (MRI) scans of the brain of a 25-year-old patient with herpes encephalitis.
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This is an inflammation of the brain caused by an infection with the herpes simplex virus, and has resulted in a large lesion (orange).
FLAIR and DWI are the most sensitive sequences sufficient for diagnosis when patient is non co operative.
The lesion is in the brain's right temporal lobe, which is at left in these views from the front.
The scans move from the front of the brain to the back, and are arranged in two rows from upper left to lower right. Inflammation of the brain and its surrounding membranes may result in severe bleeding and cell death in the brain. Early diagnosis and treatment with anti-viral medication is essential, as the condition has a high mortality rate.

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