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Fousse M, Heit M, Fassbender K, Kaddu-Mulindwa D. PLWH treated with modern ART and high CD4 T cell counts: no evidence of HIV-associated vasculopathy measured by extra- and intracranial ultrasound. Acta Neurol Belg 2024; 124:363-365. [PMID: 37490199 PMCID: PMC10874338 DOI: 10.1007/s13760-023-02339-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Mathias Fousse
- Department of Neurology, Saarland University Medical School, Kirrberger Str. 100, 66421, Homburg, Germany.
| | - Matthias Heit
- Department of Hematology and Oncology, Clinical Immunology, Rheumatology, Saarland University Medical School, Kirrberger Str. 100, 66421, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical School, Kirrberger Str. 100, 66421, Homburg, Germany
| | - Dominic Kaddu-Mulindwa
- Department of Hematology and Oncology, Clinical Immunology, Rheumatology, Saarland University Medical School, Kirrberger Str. 100, 66421, Homburg, Germany
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2
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Sen S, An H, Oakes J, Eron J, Robertson K, Powers W. Effects of early human immunodeficiency virus infection on cerebral white matter blood flow autoregulation. AIDS 2023; 37:359-361. [PMID: 36111546 PMCID: PMC9780146 DOI: 10.1097/qad.0000000000003378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Blood flow autoregulation in cerebral white matter was measured before and after acute nicardipine-induced changes in mean arterial pressure of 10-21% in 21 treatment naïve HIV-positive adults and 32 controls. The autoregulatory index (-% cerebral blood flow change/% mean arterial pressure change) was not different at baseline ( P = 0.71) or after 1 year of treatment ( n = 11, P = 0.17). We found no autoregulatory defect to explain the increased stroke risk or the development of cerebral white damage in people with HIV.
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Affiliation(s)
- Souvik Sen
- University of South Carolina, Columbia, SC
| | - Hongyu An
- Washington University, Saint Louis, MO
| | | | | | | | - William Powers
- University of North Carolina, Chapel Hill
- Duke University, Durham, NC, USA
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3
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Eilam A, Samogalsky V, Elbirt D, Gilad R. Incidence of acute ischemic cerebrovascular events in a cohort of HIV-infected patients. Acta Neurol Belg 2022; 122:417-422. [PMID: 34114141 DOI: 10.1007/s13760-021-01705-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/09/2021] [Indexed: 12/26/2022]
Abstract
The prevalence of vascular diseases in HIV (human immunodeficiency virus)-infected individuals has been comprehensively investigated. However, their incidence of ischemic cerebrovascular events has not been thoroughly examined. Our aim was to examine the rate of ischemic stroke or TIA (transient ischemic attack) in a defined HIV population and to find the risk factors that are characteristic in this population. A case-controlled retrospective cohort study of HIV patients followed up at Kaplan Medical Center between 2009 and 2017 was performed. The study included 300 patients who had been compared to a matched age and gender group. The data were collected by reviewing patients' files and imaging studies. The first goal was to compare the incidence of ischemic cerebrovascular events in both groups. Secondary endpoints were to characterize the types of cerebrovascular events and risk factors in the study group versus the general population. There were more ischemic stroke cases in the study group vs. the control group. After adjusting for vascular risk factors in a multivariate analysis, the odds ratio for a cerebrovascular accident in the HIV patient group was 2.29 (p = 0.057). Notably, in the comparative group, the vascular risk factors' rate (hyperlipidemia, IHD and smoking) was higher than in the HIV group. In this study, ischemic cerebrovascular events were more common in HIV-infected patients than in the control group, in spite of the fact that they had fewer vascular risk factors.
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Affiliation(s)
- Anda Eilam
- Neurology Department, Kaplan Medical Center, Rechovot, Israel. .,Hadassah Medical School, The Hebrew University, Jerusalem, Israel. .,Kaplan Medical Center, 1 Pasternak road, 7661041, Rechovot, Israel.
| | - Volodymyr Samogalsky
- Neurology Department, Kaplan Medical Center, Rechovot, Israel.,Kaplan Medical Center, 1 Pasternak road, 7661041, Rechovot, Israel
| | - Daniel Elbirt
- "Neve Or", Immunology Department, Kaplan Medical Center, Rechovot, Israel.,Kaplan Medical Center, 1 Pasternak road, 7661041, Rechovot, Israel
| | - Ronit Gilad
- Neurology Department, Kaplan Medical Center, Rechovot, Israel.,Hadassah Medical School, The Hebrew University, Jerusalem, Israel.,Kaplan Medical Center, 1 Pasternak road, 7661041, Rechovot, Israel
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4
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Patel UK, Malik P, Li Y, Habib A, Shah S, Lunagariya A, Jani V, Dhamoon MS. Stroke and HIV-associated neurological complications: A retrospective nationwide study. J Med Virol 2021; 93:4915-4929. [PMID: 33837961 DOI: 10.1002/jmv.27010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/30/2021] [Accepted: 04/06/2021] [Indexed: 12/24/2022]
Abstract
There is an increased risk of stroke and other neurological complications in human immunodeficiency virus (HIV) infected patients with no large population-based studies in the literature. We aim to evaluate the prevalence of stroke, HIV-associated neurological complications, and identify risk factors associated with poor outcomes of stroke among HIV admissions in the United States. In the nationwide inpatient sample with adult HIV hospitalizations, patients with primary cerebrovascular disease (CeVDs) and HIV-associated neurological complications were identified by ICD-9-CM codes. We performed a retrospective study with weighted analysis to evaluate the prevalence of stroke and neurological complications and outcomes of stroke among HIV patients. We included 1,559,351 HIV admissions from 2003 to 2014, of which 22470 (1.4%) patients had CeVDs (transient ischemic attack [TIA]: 3240 [0.2%], acute ischemic stroke [AIS]: 14895 [0.93%], and hemorrhagic stroke [HS]: 4334 [0.27%]), 7781 (0.49%) had neurosyphilis, 29,925 (1.87%) meningitis, 39,190 (2.45%) cytomegalovirus encephalitis, 4699 (0.29%) toxoplasmosis, 9964 (0.62%) progressive multifocal leukoencephalopathy, and 142,910 (8.94%) epilepsy. There is increased overall prevalence trend for CeVDs (TIA: 0.17%-0.24%; AIS: 0.62%-1.29%; HS: 0.26%-0.31%; pTrend < .0001) from 2003 to 2014. Among HIV admissions, variables associated with AIS were neurosyphilis (odds ratio: 4.38; 95% confidence interval: 3.21-5.97), meningitis (4.87 [4.10-5.79]), and central nervous system tuberculosis (6.72 [3.85-11.71]). Toxoplasmosis [4.27 [2.34-7.76]), meningitis (2.91 [2.09-4.06)], and cytomegalovirus encephalitis (1.62 [1.11-2.37]) were associated with higher odds of HS compared to patients without HS. There was an increasing trend of CeVDs over time among HIV hospitalizations. HIV-associated neurological complications were associated with the risk of stroke, together with increased mortality, morbidity, disability, and discharge to long-term care facilities. Further research would clarify stroke risk factors in HIV patients to mitigate adverse outcomes.
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Affiliation(s)
- Urvish K Patel
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Preeti Malik
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yingjie Li
- Department of Global Biostatistics and Data Science, School of Public Health and Tropical Medicine, Tulane University, New Orleans, Los Angeles, USA
| | - Anam Habib
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, Kansas, USA
| | - Abhishek Lunagariya
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Vishal Jani
- Department of Neurology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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5
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Ashwitha SK, Jacob PA, Ajaj A, Shirke MM, Harky A. Management of cardiovascular diseases in HIV/AIDS patients. J Card Surg 2020; 36:236-243. [PMID: 33225472 DOI: 10.1111/jocs.15213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022]
Abstract
Human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome, a pandemic in the current population causes severe weakness of the body's immune system making the infected patient more vulnerable to life-threatening conditions. The disease predisposes the infected patient to several cardiovascular diseases and cerebrovascular diseases such as heart failure and stroke. The decline in CD4 cells following HIV infection, vulnerability to opportunistic infections and underlying HIV pathology plays a major role in the development of cardiovascular manifestations, and treatment targeting cardiomyopathy in this specific patient subset is not well recognized. Patients living with HIV (PLWH) also experience discrimination in receiving cardiovascular disease care and this needs to be addressed by strengthening frameworks for monitoring and providing nonjudgmental healthcare. This review aims to study the profile of the cardiovascular disease in HIV patients, treatment, and provide evidence of the disparity in the provision of healthcare with regard to PLWH.
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Affiliation(s)
- Santoshi K Ashwitha
- Department of Medicine, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Preethi A Jacob
- Department of Medicine, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Abdullah Ajaj
- Department of Medicine, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Manasi M Shirke
- Department of Medicine, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Liverpool Heart and Chest Hospital, Department of Cardiovascular Science, University of Liverpool, Liverpool, UK.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, UK
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Cerebrovascular Disease in Children Perinatally Infected With Human Immunodeficiency Virus in Zambia. Pediatr Neurol 2020; 112:14-21. [PMID: 32871411 PMCID: PMC7554106 DOI: 10.1016/j.pediatrneurol.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND High rates of cerebrovascular disease (CVD) have previously been described in pediatric human immunodeficiency virus (HIV). However, little is known about pediatric CVD in the era of antiretroviral therapy or about the contribution of CVD to HIV-associated neurocognitive disorders. METHODS We completed a neuroimaging substudy of the HIV-Associated Neurocognitive Disorders in Zambia study, a prospective cohort study of neurocognitive complications of pediatric HIV. Brain magnetic resonance imaging (1.5 T) was acquired for 34 HIV+ children on antiretroviral therapy and 17 HIV-exposed uninfected children (aged eight to 17 years). Demographics, medical history, neurological examination, and neuropsychologic testing results were collected. Two neuroradiologists, unaware of HIV status and clinical course, read the scans. RESULTS CVD was identified in seven of 34 children with HIV (HIV+ CVD+) and no HIV-exposed uninfected children (21% vs 0%, P = 0.05). Three participants had white matter changes suggestive of small vessel disease, four had infarcts, and two had evidence of intracranial artery stenosis. Age of antiretroviral therapy initiation and exposure to protease inhibitors or efavirenz was not significantly different between children with and without CVD. HIV+ CVD+ children had significantly worse scores on a summary measure of cognition than the HIV+ CVD- group (NPZ8 score -0.57 vs 0.33, P = 0.04). CONCLUSIONS This study demonstrates high rates of CVD in children with HIV despite antiretroviral therapy, and worse cognitive performance in children with CVD. Longitudinal studies are necessary to determine the mechanisms and incidence of new-onset CVD in children with HIV.
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7
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HIV Associated Risk Factors for Ischemic Stroke and Future Perspectives. Int J Mol Sci 2020; 21:ijms21155306. [PMID: 32722629 PMCID: PMC7432359 DOI: 10.3390/ijms21155306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/11/2020] [Accepted: 07/22/2020] [Indexed: 12/12/2022] Open
Abstract
Although retroviral therapy (ART) has changed the HIV infection from a fatal event to a chronic disease, treated HIV patients demonstrate high prevalence of HIV associated comorbidities including cardio/cerebrovascular diseases. The incidence of stroke in HIV infected subjects is three times higher than that of uninfected controls. Several clinical and postmortem studies have documented the higher incidence of ischemic stroke in HIV infected patients. The etiology of stroke in HIV infected patients remains unknown; however, several factors such as coagulopathies, opportunistic infections, vascular abnormalities, atherosclerosis and diabetes can contribute to the pathogenesis of stroke. In addition, chronic administration of ART contributes to the increased risk of stroke in HIV infected patients. Concurrently, experimental studies in murine model of ischemic stroke demonstrated that HIV infection worsens stroke outcome, increases blood brain barrier permeability and increases neuroinflammation. Additionally, residual HIV viral proteins, such as Trans-Activator of Transcription, glycoprotein 120 and Negative regulatory factor, contribute to the pathogenesis. This review presents comprehensive information detailing the risk factors contributing to ischemic stroke in HIV infected patients. It also outlines experimental evidence demonstrating the impact of HIV infection on stroke outcomes, in addition to possible novel therapeutic approaches to improve these outcomes.
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Dlamini N, Pohl K, Eley B, Van Toorn R, Kilborn T, Padayachee S, Pontigon AM, Kirkham FJ, Wilmshurst J. Stroke transcranial Doppler in children with human immunodeficiency virus. Dev Med Child Neurol 2020; 62:735-741. [PMID: 31916251 DOI: 10.1111/dmcn.14439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 11/28/2022]
Abstract
AIMS To describe stroke syndromes and transcranial Doppler (TCD) findings in children with human immunodeficiency virus (HIV) and examine the associations between TCD and clinical and laboratory data. METHOD We enrolled 42 children (24 males, 18 females) with HIV (median age=7y 6mo; 2y 7mo-15y 6mo), with and without stroke who underwent a TCD examination of the anterior and posterior circulations to derive time-averaged maximum mean velocity (TAMMV) measurements for comparison with previous studies. Clinical and laboratory variables were extracted from the medical records. RESULTS Of the 42 children with HIV, five had right-sided hemiparesis, three had chronic lung disease, two occurred post-varicella infection, one after herpetic oral ulceration, and one had a poorly functioning left ventricle. Neuroimaging showed middle cerebral artery (MCA) TAMMV greater than 200cm/s, moyamoya-like arteriopathy, left basal ganglia infarction with ipsilateral stenosis, hygroma consistent with venous thrombosis, and a hyperdense left MCA. Eight neurologically asymptomatic children had atypical TCD. The CD4 cell count was non-significantly lower in 6 out of 30 children with atypical TCD (median=21.5; interquartile range=16.1-26.5) compared with the remainder (median=29; interquartile range=21.3-35.0; p=0.09). INTERPRETATION A variety of stroke syndromes occur in children with HIV. TCD suggests atypical intracranial vessels and/or haemodynamics in some children with HIV infection, consistent with vasculopathy, possibly related directly to immunodeficiency and/or infection. WHAT THIS PAPER ADDS A range of stroke syndromes are found in children with human immunodeficiency virus (HIV). Transcranial Doppler (TCD) velocities in HIV are commonly outside the range for typically developing children. TCD and neuroimaging data in children with HIV suggest intracranial vasculopathy as one mechanism for stroke. CD4 cell count is non-significantly lower in children with HIV and atypical TCD.
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Affiliation(s)
- Nomazulu Dlamini
- Evelina Children's Hospital, London, UK.,The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Brian Eley
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Tracy Kilborn
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
| | | | | | - Fenella J Kirkham
- Developmental Neurosciences Section, UCL Great Ormond Street Institute of Child Health, London, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,Child Health, University Hospital Southampton, Southampton, UK.,Paediatric Neurosciences, King's College Hospital, London, UK
| | - Jo Wilmshurst
- Red Cross War Memorial Hospital, University of Cape Town, Cape Town, South Africa
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Increased Cortical Cerebral Blood Flow in Asymptomatic Human Immunodeficiency Virus-Infected Subjects. J Stroke Cerebrovasc Dis 2016; 25:1891-5. [PMID: 27160382 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/22/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-infected individuals are at high risk for ischemic stroke. To investigate the physiological basis for this risk, we used magnetic resonance imaging (MRI) to measure oxygen extraction fraction (OEF) and cerebral blood flow (CBF) in treatment-naive asymptomatic HIV-infected subjects and controls. METHODS In treatment-naive asymptomatic HIV-infected subjects and age-, gender-, and race-matched controls, OEF was measured by MRI asymmetric spin-echo echo-planar imaging sequences and CBF was measured by MRI pseudocontinuous arterial spin labeling. RESULTS Twenty-six treatment-naive HIV-infected subjects and 27 age-, gender-, race-matched controls participated. Whole-brain, gray matter (GM), and white matter OEF were not different between the groups (all P > .70). Unexpectedly, HIV-infected subjects had significantly higher CBF in cortical GM (72.9 ± 16.2 mL/100 g/min versus 63.9 ± 9.9 mL/100 g/min; P = .01) but not in subcortical GM (P = .25). CONCLUSIONS The observed increase in cortical GM CBF in treatment-naive HIV-infected subjects is unexpected, contrary to CBF decreases reported in HIV-infected subjects on treatment, and may represent an initial increase in metabolic activity due to an HIV-mediated inflammation.
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Chow FC, Boscardin WJ, Mills C, Ko N, Carroll C, Price RW, Deeks S, Sorond FA, Hsue PY. Cerebral vasoreactivity is impaired in treated, virally suppressed HIV-infected individuals. AIDS 2016; 30:45-55. [PMID: 26372478 DOI: 10.1097/qad.0000000000000875] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare cerebral vasoreactivity, a measure of cerebrovascular endothelial function, between treated, virally suppressed HIV-infected individuals and HIV-uninfected controls and to evaluate the effect of HIV-specific factors on cerebral vasoreactivity. METHODS Cross-sectional study of 65 antiretroviral therapy-treated, virally suppressed HIV-infected individuals and 28 HIV-uninfected controls. Participants underwent noninvasive assessment of cerebral vasoreactivity using transcranial Doppler ultrasound and inhaled carbon dioxide (CO2). We used mixed effects multivariable linear regression to determine the association of HIV infection and HIV-specific factors with cerebral vasoreactivity. RESULTS Mean age was 57.2 years for HIV-infected participants and 53.5 years for HIV-uninfected controls. Most participants (95%) were men. Twenty-six per cent of HIV-infected participants were nonwhite compared to 32% of controls. Among HIV-infected participants, mean CD4 cell count was 596 cells/μl, and mean duration of viral suppression was 7.8 years. Cerebral vasoreactivity in response to hypercapnia (cerebral VRhyper) was lower in HIV-infected individuals compared to uninfected controls (3.23 versus 3.81%, P = 0.010). After adjusting for demographic and vascular risk factors, HIV infection was independently associated with lower cerebral vasoreactivity (-0.86%, 95% CI -1.30 to -0.42%, P < 0.001). We did not find a statistically significant effect of recent or nadir CD4 cell count on cerebral vasoreactivity. There was a trend toward higher cerebral vasoreactivity for each additional year of viral suppression. CONCLUSION Treated, virally suppressed HIV infection negatively impacted cerebral vasoreactivity even after adjustment for traditional vascular risk factors. These data highlight the potential contribution of cerebrovascular endothelial dysfunction to the elevated risk of stroke observed in HIV-infected individuals.
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Arentzen M, Jubt F, Evers S, Hesselmann V, Fiori W, Reichelt D, Oelker-Grueneberg U, Schwindt W, Dziewas R, Husstedt IW. Cerebrovascular events in HIV-infected patients: an analysis of a cohort of 3203 HIV+ patients during the times of cART. Int J Neurosci 2014; 125:601-11. [PMID: 25158008 DOI: 10.3109/00207454.2014.956870] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE/AIM Cerebrovascular events (CVE) in HIV infected patients have become an increasingly relevant neurological complication. Data about the prevalence and clinical features of CVE in HIV infected patients since the introduction of combined Anti-Retroviral Therapy (cART) are rare. METHODS A retrospective study of HIV-infected patients with a CVE was performed from 2002 to 2011. During this time period 3203 HIV-infected patients were admitted to the University hospital of Münster, Germany. All patients had access to regular and long term treatment with cART. The clinical features were analyzed and the prevalence of ischemic stroke (IS), transient ischemic attack (TIA) and intracerebral bleeding (ICB) was calculated. RESULTS The total prevalence of all CVE was at 0.6% (95% CI: 0.3, 0.8) (0.4% for IS (95% CI: 0.2, 0.6), 0.2% for TIA (95% CI: 0.0, 0.3) and 0.1% for ICB (95% CI: 0.0, 0.2)) and the crude annual incidence rate at 59 per 100.000 for all events. The median CD4 cell count was 405/μl (25th to 75th percentile: 251-568). The majority of patients had AIDS. The median age was at 49 years (25th to 75th percentile: 40-69). Some events were associated with HIV-associated vasculopathy or viral co-infections. Most patients presented with multiple vascular risk factors. CONCLUSION The study confirms that CVE occur in HIV-infected patients with a good immune status and at a young age. HIV infection has to be considered in young stroke patients. The rate of CVE in this study was constant when comparing to the pre-cART era. HIV associated vasculopathy and viral co-infections need to be considered in the diagnostics of stroke.
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Affiliation(s)
- Max Arentzen
- 1Department of Neurology, University of Münster, Germany
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Silva J, Polesskaya O, Knight W, Zheng JT, Granger M, Lopez T, Ontiveros F, Feng C, Yan C, Kasischke KA, Dewhurst S. Transient hypercapnia reveals an underlying cerebrovascular pathology in a murine model for HIV-1 associated neuroinflammation: role of NO-cGMP signaling and normalization by inhibition of cyclic nucleotide phosphodiesterase-5. J Neuroinflammation 2012; 9:253. [PMID: 23167821 PMCID: PMC3526511 DOI: 10.1186/1742-2094-9-253] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 10/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral blood flow (CBF) is known to be dysregulated in persons with human immunodeficiency virus 1 (HIV-1), for uncertain reasons. This is an important issue because impaired vasoreactivity has been associated with increased risk of ischemic stroke, elevated overall cardiovascular risk and cognitive impairment. METHODS To test whether dysregulation of CBF might be due to virally-induced neuroinflammation, we used a well-defined animal model (GFAP-driven, doxycycline-inducible HIV-1 Tat transgenic (Tat-tg) mice). We then exposed the mice to a brief hypercapnic stimulus, and assessed cerebrovascular reactivity by measuring 1) changes in cerebral blood flow, using laser Doppler flowmetry and 2) changes in vascular dilation, using in vivo two-photon imaging. RESULTS Exposure to brief hypercapnia revealed an underlying cerebrovascular pathology in Tat-tg mice. In control animals, brief hypercapnia induced a brisk increase in cortical flow (20.8% above baseline) and vascular dilation, as measured by laser Doppler flowmetry and in vivo two-photon microscopy. These responses were significantly attenuated in Tat-tg mice (11.6% above baseline), but cortical microvascular morphology and capillary density were unaltered, suggesting that the functional pathology was not secondary to vascular remodeling. To examine the mechanistic basis for the diminished cerebrovascular response to brief hypercapnia, Tat-tg mice were treated with 1) gisadenafil, a phosphodiesterase 5 (PDE5) inhibitor and 2) tetrahydrobiopterin (BH4). Gisadenafil largely restored the normal increase in cortical flow following hypercapnia in Tat-tg mice (17.5% above baseline), whereas BH4 had little effect. Gisadenafil also restored the dilation of small (<25 μm) arterioles following hypercapnia (19.1% versus 20.6% diameter increase in control and Tat-tg plus gisadenafil, respectively), although it failed to restore full dilation of larger (>25 μm) vessels. CONCLUSIONS Taken together, these data show that HIV-associated neuroinflammation can cause cerebrovascular pathology through effects on cyclic guanosine monophosphate (cGMP) metabolism and possibly on PDE5 metabolism.
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Affiliation(s)
- Jharon Silva
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
| | - Oksana Polesskaya
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
| | - Walter Knight
- Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Box MED, Rochester, NY, USA
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, 601 Elmwood Avenue, Box CVRI, Rochester, NY, USA
| | - Johnny Ting Zheng
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
| | - Megan Granger
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
| | | | - Fernando Ontiveros
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 631, Rochester, NY, USA
| | - Chen Yan
- Department of Medicine, University of Rochester Medical Center, 601 Elmwood Avenue, Box MED, Rochester, NY, USA
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, 601 Elmwood Avenue, Box CVRI, Rochester, NY, USA
| | - Karl A Kasischke
- Dept. of Neurology, University of Ulm Medical Center, Ulm, Germany
| | - Stephen Dewhurst
- Department of Microbiology and Immunology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 672, Rochester, NY 14642, USA
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Cruse B, Cysique LA, Markus R, Brew BJ. Cerebrovascular disease in HIV-infected individuals in the era of highly active antiretroviral therapy. J Neurovirol 2012; 18:264-76. [PMID: 22528476 DOI: 10.1007/s13365-012-0092-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2011] [Revised: 02/17/2012] [Accepted: 03/09/2012] [Indexed: 11/30/2022]
Abstract
The widespread use of highly active antiretroviral therapy (HAART) in HIV-infected individuals mostly in developed countries has dramatically improved their prognosis. In such advantaged regions of the world, therefore, many patients are now transitioning from middle into older age, with altered patterns of disease. While previously a rare complication of HIV infection, cerebrovascular disease (particularly that associated with atherosclerosis) is becoming relatively more important in this treated group of individuals. This review summarises the evidence regarding the shifting epidemiology of cerebrovascular diseases affecting HIV-infected individuals. While outlining the association between HIV infection and AIDS and cerebrovascular disease, as well as opportunistic diseases and HIV-associated vasculopathies, the current evidence supporting an increase in atherosclerotic disease in treated HIV-infected individuals is emphasised and a management approach to ischaemic stroke in HIV-infected individuals is presented. Evidence supporting the important role of HAART and HIV infection itself in the pathogenesis of atherosclerotic disease is discussed, together with preventative approaches to this increasingly important disease process as the population ages. Finally, a discussion regarding the significant association between cerebrovascular disease and HIV-associated neurocognitive disorder is presented, together with possible mechanisms behind this relationship.
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Sen S, Rabinstein AA, Elkind MSV, Powers WJ. Recent developments regarding human immunodeficiency virus infection and stroke. Cerebrovasc Dis 2012; 33:209-18. [PMID: 22261608 DOI: 10.1159/000335300] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 11/17/2011] [Indexed: 01/03/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection is strongly associated with ischemic stroke in the young. Data obtained from the Nationwide Inpatient Sample in the United States show an increase in the number of stroke hospitalizations in the HIV-infected population despite an overall decrease in the number of stroke hospitalizations. Few data exist, however, that address the mechanism of HIV-associated stroke. Recent studies have demonstrated that HIV may infect the endothelium and alter cerebrovascular functions. Whether the proposed mechanism alters the stroke risk is undetermined. Epidemiological studies suggest that HIV-related stroke is associated with a risk factor profile that differs from the HIV-negative young stroke population in that HIV-associated strokes are less likely to have hypertension, diabetes, hyperlipidemia and smoking as risk factors. A large population-based study, moreover, suggests an association between antiretroviral therapy and increased cardio- and cerebrovascular risks. Specific antiretroviral agents such as protease inhibitors and non-nucleoside reverse transcriptase inhibitors have been implicated in the metabolic syndrome, accelerated atherosclerosis and an increased risk for ischemic stroke. In addition to discussing these developments, this paper also discusses the implications of recent data for stroke prevention in HIV-infected patients.
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Affiliation(s)
- Souvik Sen
- University of South Carolina, Columbia, S.C., USA. souvik.sen @ uscmed.sc.edu
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Ovbiagele B, Nath A. Increasing incidence of ischemic stroke in patients with HIV infection. Neurology 2011; 76:444-50. [PMID: 21248273 DOI: 10.1212/wnl.0b013e31820a0cfc] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Large-scale epidemiologic data on stroke in HIV-infected persons are scarce, especially in an era of combination antiretroviral therapies, which have prolonged patient survival, but may boost stroke risk. We assessed trends in the proportion of HIV infection among patients with stroke in the United States. METHODS Data were obtained from all states within the United States that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 2006 with a primary discharge diagnosis of stroke (identified by the International Classification of Diseases, Ninth Revision procedure codes) were included. Time trends in the proportion of these patients with HIV diagnosis were computed, and independent predictors of comorbid HIV diagnosis evaluated using multivariable logistic regression. RESULTS Of all (ischemic and hemorrhagic) stroke hospitalizations, patients with comorbid HIV infection constituted 0.09% in 1997 vs 0.15% in 2006 (p < 0.0001). Actual numbers of overall US stroke hospitalizations lessened 7% (998,739 to 926,997), while actual numbers of stroke hospitalizations with coexisting HIV infection rose 60% (888 to 1,425). Patients with comorbid HIV infection comprised 0.08% of ischemic strokes in 1997 vs 0.18% in 2006 (p < 0.0001), but their proportion of hemorrhagic strokes did not significantly change. Factors independently associated with higher odds of comorbid HIV diagnosis were Medicaid insurance, urban hospital type, dementia, liver disease, renal disease, and cancer. CONCLUSION Over the last decade in the United States, there has been a substantial and significant rise in patients hospitalized for stroke with coexisting HIV infection. This has important public health and socioeconomic consequences.
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Affiliation(s)
- Bruce Ovbiagele
- Stroke Center and Department of Neuroscience, University of California at San Diego, 200 West Arbor Drive, MC 8466, San Diego, CA 92103-8466, USA.
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Case of Moyamoya Disease in a Patient With Advanced Acquired Immunodeficiency Syndrome. J Stroke Cerebrovasc Dis 2007; 16:268-72. [DOI: 10.1016/j.jstrokecerebrovasdis.2007.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 06/25/2007] [Accepted: 07/03/2007] [Indexed: 11/21/2022] Open
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Micieli E, Dentali F, Giola M, Grossi P, Venco A, Ageno W. Venous and arterial thrombosis in patients with HIV infection. Blood Coagul Fibrinolysis 2007; 18:259-63. [PMID: 17413763 DOI: 10.1097/mbc.0b013e32808738a3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Thromboembolic complications in HIV-infected patients have been reported. To our knowledge, no case-control studies have compared the prevalence of thromboembolic events between HIV-positive and HIV-negative individuals. One hundred and sixty-nine HIV-infected patients and 180 randomly selected blood donors were enrolled. Selected patients completed a specific questionnaire and were subsequently interviewed. Information was collected on family and personal history of cardiovascular disorders and the presence of personal risk factors for venous and arterial thrombosis. All reported events were adjudicated only if adequate documentation of objective tests was available. Mean age and sex were similar in the two groups. A vascular event was documented in six HIV-infected patients (3.55%) and in none of the controls (P=0.0108). Family history of cardiovascular disorders, cigarette smoking and hypertriglyceridemia were more prevalent in HIV patients than in controls. In multivariate analysis, neither family traditional cardiovascular risk factors nor HIV infection were independently associated with the presence of thromboembolic events. The results confirm the hypothesis that HIV-positive patients have an increased risk of thromboembolic disorders. Whether this increased risk has been provoked by HIV infection itself or by other associated risk factors for cardiovascular events, such as cigarette smoking and hypertriglyceridemia, remain to be clarified.
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Affiliation(s)
- Evy Micieli
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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Vandhuick O, Guias B, De Saint Martin L, Bressollette L. Traitement antirétroviral et risque cardio-vasculaire. ACTA ACUST UNITED AC 2004; 29:192-9. [PMID: 15529082 DOI: 10.1016/s0398-0499(04)96747-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current antiretroviral therapy protocols enable long-term survival of HIV-infected patients, decreasing the risk of infectious complications. Three classes of anti-HIV treatments are available. With longer survival, unusual cardiovascular complications related to iatrogenic biological anomalies (dyslipidemia and impaired glucose tolerance) have appeared among this young population which is exposed to usual risk factors of atherosclerosis. Antiretroviral therapies are suspected to cause these complications, inducing maturity-onset diabetes in 4 to 20% of patients, impaired glucose tolerance in 15 to 60%, hypertriglyceridemia in 15 to 74% depending on the survey, and hypercholesterolemia in 20 to 60%, especially in case of associated lipodystrophia. A lipid battery including total cholesterol, HDL, and triglycerides, and 12-h fasting blood glucose should be obtained before initiating antiretroviral therapy. Any anomalous finding should be followed carefully with regular surveillance every 3 to 6 months and search for other causes of secondary dyslipidemia. In the event of casual and persisting elevation of LDL-cholesterol levels, a statin treatment can be introduced. For secondary prevention, irrespective of the context, recommendations currently merge with the consensus applying to the general population. These patients require careful surveillance of cardiovascular risk factors and a specific care in addition to treatment of their immunodeficiency.
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Affiliation(s)
- O Vandhuick
- Unité d'Echo-Doppler et de Médecine Vasculaire, CHU La Cavale Blanche, 29609 Brest
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Goodkin K, Wilkie FL, Concha M, Hinkin CH, Symes S, Baldewicz TT, Asthana D, Fujimura RK, Lee D, van Zuilen MH, Khamis I, Shapshak P, Eisdorfer C. Aging and neuro-AIDS conditions and the changing spectrum of HIV-1-associated morbidity and mortality. J Clin Epidemiol 2001; 54 Suppl 1:S35-43. [PMID: 11750208 DOI: 10.1016/s0895-4356(01)00445-0] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Older individuals (>50 years of age) now comprise over 11% of patients with AIDS in the United States. This percentage is expected to continue to grow, due both to the improved longevity of patients prescribed highly active antiretroviral therapy (HAART) and to new infections among older individuals. This review focuses on the neuropsychiatric and neurological conditions that are most likely to be affected by advancing age-HIV-1-associated cognitive-motor disorder, peripheral neuropathy, progressive multifocal leukoencephalopathy, primary CNS lymphoma, and risk for cerebrovascular accident. Age associations with incidence of these disorders and with treatment foci are specified. Implications for future changes in management are discussed.
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Affiliation(s)
- K Goodkin
- Department of Psychiatry and Behavioral Sciences, University of Miami School of Medicine, 1400 NW 10th Ave, #803-A, Miami, FL 33136, USA.
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Evers S, Wibbeke B, Reichelt D, Suhr B, Brilla R, Husstedt I. The impact of HIV infection on primary headache. Unexpected findings from retrospective, cross-sectional, and prospective analyses. Pain 2000; 85:191-200. [PMID: 10692618 DOI: 10.1016/s0304-3959(99)00266-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Headache is one of the most important factors influencing the quality of life in patients infected with the human immunodeficiency virus type 1 (HIV). However, only symptomatic headache but not changes or primary headache types during HIV infection have been studied to date. Therefore, we aimed to determine the impact of an HIV infection on frequency and semiology of different primary headache types. Patients with confirmed HIV type 1 infection underwent a neurological examination, neuroimaging or EEG, and a standardized interview. Time pattern and symptoms of headaches (cross-sectional analysis), changes of headaches preexisting to their infection (longitudinal retrospective analysis), and changes of primary headaches during a 2-year follow-up (longitudinal prospective analysis) were evaluated as were the correlations between these headache patterns and different markers of HIV infection. One hundred thirty-one consecutive HIV-infected patients without evidence of a cerebral manifestation except mild encephalopathy were enrolled. The point prevalence of migraine was 16.0% (confidence interval (CI) 10.1-25.4%), of headache with a semiology of tension-type headache 45.8% (CI 33.7-62.2%), and of other headache types 6.1% (CI 3.0-12.5%). During the natural course of infection, the migraine frequency significantly decreased in the retrospective and in the prospective analyses, whereas the frequency of the headache with a semiology of tension-type headache significantly increased in all three analyses. In 20% of all patients, the tension-type headache could be considered as symptomatic due to the infection but not due to focal or general cerebral lesions. Changes of primary headache were significantly associated with different stages of the infection and with the presence of mild encephalopathy but not with antiretroviral treatment or CD4 cell count. HIV infection seems to be associated with a progressive decrease in migraine frequency and intensity which probably is related to the immunological state of the patients. Tension-type headache becomes more frequent during HIV infection. However, this can in part be related to secondary headache caused by the HIV in less than 50% of patients with tension-type headache. The progressing immunological deficiency of HIV-infected patients seems to influence pain processing of primary headache types in different ways.
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Affiliation(s)
- S Evers
- Department of Neurology, University of Münster, Albert-Schweitzer-Strasse 33, D-48129, Münster, Germany.
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