Aneurysmal vasculopathy in human-acquired immunodeficiency virus-infected adults: Imaging case series and review of the literature

Characteristics and evolution of cerebral aneurysms among adults living with HIV: A retrospective, longitudinal case series

OBJECTIVE

Previous research indicates an increased risk of cerebral aneurysm formation in adults living with human immunodeficiency virus (ALWH), however there are few longitudinal studies on the risk factors for and outcomes of cerebral aneurysms in this population. We aim to describe the characteristics and evolution of cerebral aneurysms in a large cohort of ALWH.

MATERIALS AND METHODS

A chart review was completed for all adults evaluated at an urban, safety-net U.S. hospital between January 1, 2000, and October 22, 2021, with history of both HIV and at least one cerebral aneurysm.

RESULTS

A total of 82 cerebral aneurysms were identified amongst 50 patients (52% female sex). Forty-six percent of patients with a nadir CD4 count less than 200 cells/mm³ (N=13) and 44% of patients with maximum viral load >10,000 copies/mL (N=18) developed new aneurysms or were found to have aneurysm growth over time compared with 29% of patients with a CD4 nadir above 200 cells/mm³ (N=21) and 22% of patients with maximum viral load </= 75 copies/mL (N=9). New aneurysms were found, or existing aneurysms grew in 67% of those not on antiretroviral therapy (ART) at time of aneurysm diagnosis (N=6), 38% of those with inconsistent ART use (N=8), and 21% of those with consistent ART (N=19).

CONCLUSIONS

Among ALWH, lower CD4 nadir, higher zenith viral load, and inconsistent ART use may contribute to aneurysm formation or growth. Further studies are needed to more thoroughly characterize the association between immunologic status and cerebral aneurysm formation.

Convexal Subarachnoid Hemorrhage Caused by Infective Endocarditis in a Patient with Advanced Human Immunodeficiency Virus (HIV): The Culprits and Bystanders

BACKGROUND Convexal subarachnoid hemorrhage (cSAH), a rare form of non-aneurysmal subarachnoid hemorrhage, is confined to cerebral convexities without extension into basal cisterns or ventricles. Typical presentation includes thunderclap/progressive headache or transient focal neurological symptoms; rare manifestations include seizures, intractable vomiting, or altered mental status. Here, we report the first case of convexal subarachnoid hemorrhage and multifocal ischemic lesions caused by infective endocarditis (IE) in a treatment-naïve advanced HIV patient. CASE REPORT A 52-year-old HAART-naïve, HIV-positive, African American man presented with altered mental status, shortness of breath, nonproductive cough, and generalized weakness. His past medical history was significant for congestive heart failure, chronic obstructive pulmonary disease, and end-stage renal disease (noncompliant with hemodialysis). Head computed tomography (CT) showed an isolated sulcal hemorrhage in the mid-left frontal lobe. Fluid-attenuated inversion recovery/gradient recalled echo sequences confirmed a hemorrhage in the left-mid-frontal sulcus, and diffusion-weighted imaging revealed multifocal bilateral ischemic lesions. Transesophageal echocardiography exhibited mitral valve vegetations. Multifocal ischemic lesions and cSAH caused by infectious endocarditis were confirmed. Initiation of intravenous vancomycin and piperacillin-tazobactam allowed the patient to have resolution of his altered mental status. A head CT 5 days later revealed the resolution of cSAH. CONCLUSIONS Infective endocarditis should be considered as an underlying etiology of cSAH, especially when present with multifocal ischemic lesions. Risk factors contributing to the development of cSAH in the IE patient population should be explored in future studies. HIV has not been previously reported in this subgroup and its prevalence should be considered. The prognosis for cSAH in relation to IE is generally favorable.

Ruptured Fisher grade 3 blister aneurysms have a higher incidence of delayed cerebral ischemia than ruptured Fisher grade 3 saccular aneurysms

BACKGROUND

Blister aneurysms are a rare subclass of aneurysms, which remain challenging to treat both with open cerebrovascular and endovascular techniques, and clinicians continue to see poor outcomes in some cases despite improvements in technology. Based on our clinical observations, we hypothesized that patients with a Fisher grade 3 subarachnoid hemorrhage (SAH) from a ruptured anterior circulation blister aneurysm are significantly more likely to develop poor outcome due to delayed cerebral ischemia than patients with a Fisher grade 3 SAH from a ruptured anterior circulation saccular aneurysm.

METHODS

In this consecutive case series, we reviewed management, outcomes, and rates of delayed cerebral ischemia for all ruptured anterior circulation blister aneurysms from 2012 to 2018 at our institution and compared them to a concurrent cohort of ruptured saccular anterior circulation aneurysms. A blister aneurysm was defined as an aneurysm that arises from a nonbranching point and demonstrates hemispherical anatomy on diagnostic angiography.

RESULTS

We identified 14 consecutive ruptured anterior circulation blister aneurysms. Thirteen aneurysms were treated operatively- 5 with clip remodeling and 8 with flow diversion embolization. While clip remodeling had a high intraoperative rupture rate (80%), there was only one (12.5%) intraoperative rupture with flow diversion embolization. Outcomes were worsened by delayed cerebral ischemia from vasospasm in patients with Fisher 3 hemorrhages from blister aneurysms (86%). The rate of delayed cerebral ischemia from vasospasm was significantly higher for ruptured blister aneurysms than for a concurrent cohort of ruptured saccular aneurysms (8.6%, P = 0.0001).

CONCLUSION

Ruptured Fisher grade 3 anterior circulation blister aneurysms have a significantly higher incidence of delayed cerebral ischemia from vasospasm compared to saccular aneurysms, regardless of the treatment modality.

The dynamic natural history of cerebral aneurysms from cardiac myxomas: A review of the natural history of myxomatous aneurysms

We describe two contrasting patients with multiple cerebral aneurysms and a previous history of resected cardiac myxomas with no cardiac recurrence on follow-up echocardiography. Both patients presented with stroke- like symptoms; one with a left visual defect and the other with right hemiplegia. Magnetic resonance imaging of the brain of both patients showed the presence of multiple cerebral aneurysms that was later confirmed on conventional angiography. Both patients' aneurysms were managed conservatively. Serial angiograms were performed during their follow-up, which spanned several years. One patient's aneurysms remained static while the evolution of the other patient's aneurysms displayed a dynamic quality with some increasing in size while others diminished. This is the first description in which some aneurysms progressed while others regressed simultaneously in the same patient. Aneurysms in patients with a history of cardiac myxoma can be active years after primary tumor resection and it is difficult to predict how they will develop. We reviewed the literature of all patients with multiple myxomatous aneurysms who were treated conservatively to better understand the natural history of this rare disease. Long-term follow-up of these patients may be necessary.