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Abstract
Stroke is as common as brain tumor in children. The etiology of childhood arterial ischemic stroke (AIS) appears to be multifactorial, resulting from the interaction between genetic predisposition and environmental triggers. The risk factors for AIS in children are markedly different from the atherosclerotic risk factors in adults. Trauma and infections have been identified as associations in previous studies and are exposures of particular interest because of their increased prevalence in the children. The aim of this review article is to provide an overview of the research studies that have addressed the role of infections and trauma in pediatric AIS.
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Affiliation(s)
- Elena Moraitis
- Rheumatology/Infectious Diseases and Immunity Unit UCL Institute of Child Health and Rheumatology Department, Great Ormond Street Hospital for Children, London, UK,
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Translational medicine and varicella zoster virus: need for disease modeling. ACTA ACUST UNITED AC 2015; 2:89-91. [PMID: 26086038 DOI: 10.1016/j.nhtm.2015.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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53
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Morgello S, Murray J, Van Der Elst S, Byrd D. HCV, but not HIV, is a risk factor for cerebral small vessel disease. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2014; 1:e27. [PMID: 25340079 PMCID: PMC4204233 DOI: 10.1212/nxi.0000000000000027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 07/29/2014] [Indexed: 01/18/2023]
Abstract
OBJECTIVES With the aging of HIV populations, vascular contributions to neuropathogenesis are increasingly important. Indirect analyses of cerebral small vessel disease have been performed, but there have been no direct studies of human brain to elucidate risk factors for arteriolar sclerosis. METHODS Mean arteriolar wall thickness (sclerotic index, SI) was measured in the deep cerebral white matter of 126 brains (96 HIV+, 30 HIV-). Correlations with SI were performed for age, sex, race, hypertension, hyperlipidemia, diabetes, obesity, cirrhosis, hepatitis C virus (HCV) infection, herpes infection, HIV infection, HIV risk, cocaine use, CD4 count, plasma HIV load, and combination antiretroviral therapy (cART) at the time of death. RESULTS Age, hypertension, race, HCV, and cirrhosis were associated with SI; of the HIV variables, only cART at death was associated with SI. To address colinearity, partial correlations were run with HCV and cirrhosis, hypertension and race, and hypertension and age. With HCV controlled, cirrhosis lost significance; with hypertension controlled, age lost significance. For the entire sample, HCV, African American race, and hypertension accounted for 15% of SI variance in multivariate analysis. Each was independently associated with SI, and HCV had the largest effect. For the HIV sample, inclusion of cART in the model increased R (2) to 0.205, with only HCV, hypertension, and cART remaining significant or trend level. CONCLUSIONS This tissue-based analysis of cerebral arteriolar disease demonstrates that HCV constitutes an independent risk, in addition to African American race, hypertension, and cART. Further study is needed to understand what aspects of HCV and cART contribute to cerebrovascular neuropathogenesis.
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Affiliation(s)
- Susan Morgello
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jacinta Murray
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah Van Der Elst
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Desiree Byrd
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
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Yasuda C, Okada K, Ohnari N, Akamatsu N, Tsuji S. [Cerebral infarction and intracranial aneurysm related to the reactivation of varicella zoster virus in a Japanese acquired immunodeficiency syndrome (AIDS) patient]. Rinsho Shinkeigaku 2014; 53:701-5. [PMID: 24097317 DOI: 10.5692/clinicalneurol.53.701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 35-years-old right-handed man admitted to our hospital with a worsening of dysarthria, left facial palsy and left hemiparesis for 2 days. Acquired immunodeficiency syndrome (AIDS) was diagnosed when he was 28 years old. At that time, he also was treated for syphilis. After highly active antiretroviral treatment (HAART) was introduced at the age of 35 years old, serum level of human immunodeficiency virus (HIV) was not detected, but the number of CD4+ T cells was still less than 200/μl. He had no risk factors of atherosclerosis including hypertension, diabetes and hyperlipidemia. He had neither coagulation abnormality nor autoimmune disease. Magnetic resonance imaging (MRI) showed acute ischemic infarction spreading from the right corona radiate to the right internal capsule without contrast enhancement. Stenosis and occlusion of intracranial arteries were not detected by MR angiography. Although argatroban and edaravone were administered, his neurological deficits were worsened to be difficult to walk independently. Cerebrospinal fluid (CSF) examination showed a mild mononuclear pleocytosis (16/μl). Oligoclonal band was positive. The titer of anti-varicella zoster virus (VZV) IgG antibodies was increased, that indicated VZV reactivation in the central nervous system (CNS), although VZV DNA PCR was not detected. Therefore, acyclovir (750 mg/day for 2 weeks) and valaciclovir (3,000 mg/day for 1 month) were administered in addition to stroke therapy. He recovered to be able to walk independently 2 month after the admission.Angiography uncovered a saccular aneurysm of 3 mm at the end of branch artery of right anterior cerebral artery, Heubner artery, 28 days after the admission. We speculated that VZV vasculopathy caused by VZV reactivation in CNS was involved in the pathomechanism of cerebral infarction rather than HIV vasculopathy in the case.
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Affiliation(s)
- Chiharu Yasuda
- Department of Neurology, School of Medicine, University of Occupational Environmental Health
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55
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Moritani T, Capizzano A, Kirby P, Policeni B. Viral Infections and White Matter Lesions. Radiol Clin North Am 2014; 52:355-82. [DOI: 10.1016/j.rcl.2013.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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56
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Chernev I, Dado D. Leg paralysis due to herpes zoster: segmental paralysis or viral vasculopathy and stroke? Intern Emerg Med 2014; 9:241-2. [PMID: 23709053 DOI: 10.1007/s11739-013-0958-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/13/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Ivan Chernev
- Physical Medicine and Rehabilitation, Beckley Appalachian Regional Healthcare, Beckley, WV, USA,
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57
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Teo SY, Raha D, Warren D, Hassan A, Monteiro E. Central nervous system–immune reconstitution inflammatory syndrome presenting as varicella zoster virus-mediated vasculitis causing stroke. Int J STD AIDS 2014; 25:683-5. [DOI: 10.1177/0956462413518501] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Accepted: 12/05/2013] [Indexed: 11/17/2022]
Abstract
Varicella zoster virus (VZV)-mediated vasculitis is a rare cause of stroke, but should be considered in HIV patients where vasculitis can occur in association with central nervous system – immune reconstitution inflammatory syndrome (CNS-IRIS). A literature search revealed 7 reports of VZV vasculitis over the years with no unifying management strategy, highlighting the difficulty in managing rare conditions in the absence of clear guidelines. This is the first documented case of VZV-mediated vasculitis presenting as stroke in the United Kingdom. Our patient made a full recovery with multidisciplinary input from HIV, neurology and radiology specialists.
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Affiliation(s)
- SY Teo
- Centre for Sexual Health, Leeds General Infirmary, Leeds, UK
| | - D Raha
- Centre for Sexual Health, Leeds General Infirmary, Leeds, UK
| | - D Warren
- Department of Radiology, Leeds General Infirmary, Leeds, UK
| | - A Hassan
- Department of Neurology, Leeds General Infirmary, Leeds, UK
| | - E Monteiro
- Centre for Sexual Health, Leeds General Infirmary, Leeds, UK
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58
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Varicella zoster virus central nervous system immune reconstitution inflammatory syndrome presenting in a child. Pediatr Infect Dis J 2013; 32:1283-4. [PMID: 24141801 DOI: 10.1097/inf.0b013e31829aa4fc] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A HIV-positive child presented with acute onset of right hemiplegia, facial palsy and dysphasia 4 weeks after commencing highly active antiretroviral therapy. Magnetic resonance imaging confirmed a left-sided cerebral infarct. Cerebrospinal fluid polymerase chain reaction was positive for varicella zoster virus. This is the first reported pediatric case of varicella zoster virus-related immune reconstitution inflammatory syndrome involving the central nervous system.
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The short- and long-term risk of stroke after herpes zoster - a nationwide population-based cohort study. PLoS One 2013; 8:e69156. [PMID: 23874897 PMCID: PMC3714240 DOI: 10.1371/journal.pone.0069156] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 06/05/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Varicella zoster virus (VZV) is known to cause VZV vasculopathy, which may be associated with stroke. A recent study found an increased risk of stroke within one year of herpes zoster. We aimed to investigate the short and long-term effects of herpes zoster on the risk of stroke. METHODS Using Danish national registers, we constructed a cohort consisting of all Danish adults ≥18 years old between 1995 and 2008 (n = 4.6 million; person-years of follow-up = 52.9 million). Individual-level information on prescriptions for herpes zoster antiviral treatment and diagnoses of stroke was obtained from national registers. We compared the risk of stroke in persons who had received the specific dosage of acyclovir for herpes zoster with persons who had never received antiviral treatment by Poisson regression. RESULTS During follow-up, 2.5% received treatment for herpes zoster and 5.0% were diagnosed with stroke. Individuals who had received medication had a 127% (95% CI 83-182%) increased risk the first two weeks, 17% (CI 9-24%) between two weeks and one year, and 5% (2-9%) after the first year. The increased risk was greatest in the youngest age group (<40). To control for healthcare-seeking behaviour, we conducted parallel analyses investigating the risk of selected fractures after herpes zoster and found no similar increased risks. CONCLUSIONS This large nationwide cohort study found an increased risk of stroke after treatment for herpes zoster. Although the short-term risk was particularly high, we cannot rule out the possibility of a small but important long-term risk.
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60
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Singer EJ, Valdes-Sueiras M, Commins DL, Yong W, Carlson M. HIV stroke risk: evidence and implications. Ther Adv Chronic Dis 2013; 4:61-70. [PMID: 23556125 DOI: 10.1177/2040622312471840] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
An estimated 34 million men, women, and children are infected with human immunodeficiency virus type 1 (HIV-1), the virus that causes acquired immunodeficiency syndrome (AIDS). Current technology cannot eradicate HIV-1, and most patients with HIV-1-infection (HIV+) will require lifelong treatment with combined antiretroviral therapy (cART). Stroke was recognized as a complication of HIV-1 infection since the early days of the epidemic. Potential causes of stroke in HIV-1 include opportunistic infections, tumors, atherosclerosis, diabetes, hypertension, autoimmunity, coagulopathies, cardiovascular disease, and direct HIV-1 infection of the arterial wall. Ischemic stroke has emerged as a particularly significant neurological complication of HIV-1 and its treatment due to the aging of the HIV+ population, chronic HIV-1 infection, inflammation, and prolonged exposure to cART. New prevention and treatment strategies tailored to the needs of the HIV+ population are needed to address this issue.
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Affiliation(s)
- Elyse J Singer
- National Neurological AIDS Bank, Department of Neurology, David Geffen School of Medicine at UCLA, 11645 Wilshire Blvd, Suite 770, Los Angeles, CA 90025, USA
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61
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Aseptic meningoencephalitis mimicking transient ischaemic attacks. Infection 2013; 41:485-91. [DOI: 10.1007/s15010-012-0397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 12/22/2012] [Indexed: 11/26/2022]
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Vibha D, Prabhakar S, Khurana D, Khandelwal N. Varicella zoster vasculopathy presenting as lateral medullary syndrome. J Neurovirol 2012; 18:538-40. [DOI: 10.1007/s13365-012-0132-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Revised: 09/18/2012] [Accepted: 09/28/2012] [Indexed: 10/27/2022]
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63
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Lee CC, Su YC, Chien SH, Ho HC, Hung SK, Lee MS, Chou P, Chiu BCH, Huang YS. Increased stroke risk in Bell's palsy patients without steroid treatment. Eur J Neurol 2012; 20:616-22. [DOI: 10.1111/j.1468-1331.2012.03765.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 04/24/2012] [Indexed: 11/30/2022]
Affiliation(s)
- C.-C. Lee
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University; Taipei Taiwan
- Department of Otolaryngology; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- Cancer Center; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- School of Medicine; Tzu Chi University; Hualian Taiwan
| | - Y.-C. Su
- Cancer Center; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- School of Medicine; Tzu Chi University; Hualian Taiwan
- Division of Hematology-Oncology, Department of Internal Medicine; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
| | - S.-H. Chien
- School of Medicine; Tzu Chi University; Hualian Taiwan
- Division of Plastic Surgery, Department of Surgery; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
| | - H.-C. Ho
- Department of Otolaryngology; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- Cancer Center; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- School of Medicine; Tzu Chi University; Hualian Taiwan
| | - S.-K. Hung
- Cancer Center; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- School of Medicine; Tzu Chi University; Hualian Taiwan
- Department of Radiation Oncology; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
| | - M.-S. Lee
- Cancer Center; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
- School of Medicine; Tzu Chi University; Hualian Taiwan
- Department of Radiation Oncology; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
| | - P. Chou
- Community Medicine Research Center and Institute of Public Health, National Yang-Ming University; Taipei Taiwan
| | - B. C.-H. Chiu
- Department of Health Studies; University of Chicago; Chicago IL USA
| | - Y.-S. Huang
- Division of Neurology, Department of Internal Medicine; Buddhist Dalin Tzu Chi General Hospital; Chiayi Taiwan
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64
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HIV/AIDS patients with HIV vasculopathy and VZV vasculitis: a case series. Clin Neuroradiol 2011; 21:145-51. [PMID: 21773670 DOI: 10.1007/s00062-011-0087-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/02/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Stroke is a rising cause of mortality in human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) populations. The etiology of stroke remains at the core of the decision-making process to treat and prevent recurrent events. In this population HIV vasculopathy (HIV-V) and varicella zoster virus (VZV) vasculitis are elusive causes of stroke. This study investigated radiological markers that could help identify possible etiological causes. METHODS A series of nine consecutive patients seen at a large metropolitan hospital who presented with AIDS and stroke with the suspicion of either HIV vasculopathy (HIV-V) or VZV vasculitis (VZV-V) were included. A standardized diagnostic approach was used to for HIV-V and VZV-V. Data on frequencies and typical images are reported. RESULTS Of the nine patients five had VZV-V and four had HIV-V. Patients with VZV-V were generally younger than those with HIV-V; however, no other significant demographic or cardiovascular differences were found. Of the five patients with VZV-V four had small, deep, subcortical ischemic strokes and only one in this group had a large, cortical, hemispheric stroke but in the HIV-V group three patients had large, cortical hemispheric strokes and only one patient had small, subcortical ischemic strokes. CONCLUSIONS In this series VZV-V seemed to present more often with deep-seated ischemic infarcts, while HIV-V appeared to be associated with large, hemispheric stroke. It seems plausible that this difference is related to the type of arteries infected by each virus. These findings are preliminary and should be confirmed with better studies.
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65
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Macrez R, Ali C, Toutirais O, Le Mauff B, Defer G, Dirnagl U, Vivien D. Stroke and the immune system: from pathophysiology to new therapeutic strategies. Lancet Neurol 2011; 10:471-80. [PMID: 21511199 DOI: 10.1016/s1474-4422(11)70066-7] [Citation(s) in RCA: 377] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Stroke is the second most common cause of death worldwide and a major cause of acquired disability in adults. Despite tremendous progress in understanding the pathophysiology of stroke, translation of this knowledge into effective therapies has largely failed, with the exception of thrombolysis, which only benefits a small proportion of patients. Systemic and local immune responses have important roles in causing stroke and are implicated in the primary and secondary progression of ischaemic lesions, as well as in repair, recovery, and overall outcome after a stroke. However, potential therapeutic targets in the immune system and inflammatory responses have not been well characterised. Development of novel and effective therapeutic strategies for stroke will require further investigation of these pathways in terms of their temporal profile (before, during, and after stroke) and risk-to-benefit therapeutic ratio of modulating them.
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Affiliation(s)
- Richard Macrez
- Institut National de la Santé et de la Recherche Médicale (INSERM) U919, Serine Proteases and Pathophysiology of the Neurovascular Unit, UMR CNRS 6232 Ci-NAPs, Cyceron, Université de Caen Basse-Normandie, Caen, France
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66
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Abstract
Primary infection by varicella zoster virus (VZV) typically results in childhood chickenpox, at which time latency is established in the neurons of the cranial nerve, dorsal root and autonomic ganglia along the entire neuraxis. During latency, the histone-associated virus genome assumes a circular episomal configuration from which transcription is epigenetically regulated. The lack of an animal model in which VZV latency and reactivation can be studied, along with the difficulty in obtaining high-titer cell-free virus, has limited much of our understanding of VZV latency to descriptive studies of ganglia removed at autopsy and analogy to HSV-1, the prototype alphaherpesvirus. However, the lack of miRNA, detectable latency-associated transcript and T-cell surveillance during VZV latency highlight basic differences between the two neurotropic herpesviruses. This article focuses on VZV latency: establishment, maintenance and reactivation. Comparisons are made with HSV-1, with specific attention to differences that make these viruses unique human pathogens.
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Affiliation(s)
| | - Aamir Shahzad
- Department for Biomolecular Structural Chemistry Max F. Perutz Laboratories, University of Vienna, Austria
| | - Randall J Cohrs
- Author for correspondence: University of Colorado Denver Medical School, Aurora, CO, USA, Tel.: +1 303 742 4325
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67
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Fan HC, Hu CF, Juan CJ, Chen SJ. Current proceedings of childhood stroke. Stroke Res Treat 2011; 2011:432839. [PMID: 21331325 PMCID: PMC3038616 DOI: 10.4061/2011/432839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 12/04/2010] [Indexed: 12/24/2022] Open
Abstract
Stroke is a sudden onset neurological deficit due to a cerebrovascular event. In children, the recognition of stroke is often delayed due to the low incidence of stroke and the lack of specific assessment measures to this entity. The causes of pediatric stroke are significantly different from that of adult stroke. The lack of safety and efficiency data in the treatment is the challenge while facing children with stroke. Nearly half of survivors of pediatric stroke may have neurologic deficits affecting functional status and quality of life. They may cause a substantial burden on health care resources. Hence, an accurate history, including onset and duration of symptoms, risk factors, and a complete investigation, including hematologic, neuroimaging, and metabolic studies is the key to make a corrective diagnosis. A prompt and optimal treatment without delay may minimize the damage to the brain.
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Affiliation(s)
- Hueng-Chuen Fan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Neihu, Taipei 114, Taiwan
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