Multiple cerebral aneurysms caused by HIV-associated vasculopathy

Contrasting Cases of HIV Vasculopathy Associated Fusiform Aneurysms

Background

Human Immunodeficiency Virus (HIV) vasculopathy encompasses the development of aneurysms, stenosis and vessel occlusions. Intracranial fusiform aneurysms in Human Immunodeficiency Virus (HIV) were originally described in children; however, HIV-associated aneurysms are increasingly recognized in adults. Purpose: We present two cases to highlight the spectrum of severity and outline instructive clinical courses.

Results

Case one is a 52-year-old woman with HIV, Acquired Immunodeficiency Syndrome (AIDS)-defining progressive multifocal leukoencephalopathy (PML) and an 18 years course of cerebral aneurysms, aneurysm thrombosis and the development of right middle cerebral artery (MCA) moyamoya pattern collaterals. Case two is a 55-year-old man with AIDS-defining cerebral toxoplasmosis, complicated by IRIS and anterior and posterior circulation fusiform aneurysm formation. Conclusions: The combination of both fusiform abnormalities and Moyamoya, discussed in our first case has not been previously described. In comparison, our second case actually demonstrated improvement in vasculopathy after nine-months of antiretroviral therapy (ART) adherence.

Cerebral aneurysms associated with human immunodeficiency virus in adults: literature review and new perspectives

INTRODUCTION

the treatment of human immunodeficiency virus (HIV) infection has been decreasing patient morbidity and mortality by opportunistic infections and, thus, survival has increased. This new reality has been changing the spectrum of diseases affecting such patients.

OBJECTIVE

to discuss the association between HIV and the emergence of aneurysmal brain injuries.

METHOD

it was performed a literature review using medical database. The following descriptors were searched: "Intracranial Aneurysms and HIV", "Intracranial Aneurysms and Acquired Immunodeficiency Syndrome," "aneurysm and brain and HIV".

RESULTS

after performed a literature review, it was observed that the relationship between HIV infection and the formation of aneurysms appears to be real, however, it still lacks data to confirm the pathophysiology of this condition and its best treatment.

CONCLUSION

there are new signs and symptoms that should be studied and researched relating HIV with other changes not previously known.

Human Immunodeficiency Virus-Associated Cerebral Aneurysmal Vasculopathy: A Systematic Review

BACKGROUND

Human immunodeficiency virus (HIV)-associated cerebral aneurysmal vasculopathy is a rare complication of HIV affecting pediatric and adult patients and has been the subject of many case reports and case series.

METHODS

We performed a systematic literature search of PubMed, EMBASE, Scopus, Web of Science, Science Direct, and Google Scholar up to April 10, 2015. Our inclusion criteria encompassed all reported original case series and reports of HIV-associated cerebral aneurysms diagnosed radiologically. We analyzed the clinical characteristics and management of the reported cases.

RESULTS

We identified 61 patients reported in the literature (45 pediatric and 16 adult patients). The median age was 9.8 years for pediatric patients and 36.5 years for adult patients. Weakness was the most common presenting symptom in adult and pediatric patients. The most common affected artery was the middle cerebral artery. Approximately 87.2% of pediatric patients and 42.9% of adult patients were on antiretroviral therapy (ART) at presentation. The mortality rate was 60% and 35.7% among pediatric and adult patients, respectively. The optimal management is not well established. Variable response to ART was reported with possible survival benefits when ART was initiated early.

CONCLUSIONS

HIV-associated cerebral aneurysmal arteriopathy is associated with high mortality. The optimal management is not well established, but early initiation of ART may improve the survival rate.

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

BACKGROUND

Intracranial vasculopathy in adult patients with human-acquired immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a rare but increasingly recognized disease entity.

OBJECTIVE

We aimed to contribute to and summarize the adult literature describing patients with HIV/AIDS who have intracranial vasculopathy.

METHODS

A retrospective review of adult patients with HIV/AIDS undergoing diagnostic cerebral angiography at our institution from 2007-2013 was performed. A literature review of relevant existing studies was performed.

RESULTS

Five adult patients with HIV-related aneurysmal and occlusive vasculopathy were diagnosed and/or treated at our institution. A comprehensive review of the literature yielded data from 17 series describing 28 adult patients with HIV/AIDS and intracranial vasculopathy. Our review suggests that low CD4 count, motor weakness, and meningismus may be associated with the sequelae of intracranial vasculopathy/vasculitis in patients with HIV/AIDS.

CONCLUSION

Patients with HIV/AIDS who have aneurysmal and stenotic vascular disease may benefit from earlier surveillance with the onset of neurological symptoms. The roles of medical, open surgical, and endovascular therapy in this unique entity will be further defined as the pathological basis of the disease is better understood.

Perinatally HIV-infected youth presenting with acute stroke: progression/evolution of ischemic disease on neuroimaging

BACKGROUND AND PURPOSE

Although HIV infection is decreasing in infants and children, there is a steady cohort of perinatally HIV-infected (PHIV) children that are growing older. Increased risk of acute stroke has been reported in PHIV children. Our goal was to evaluate evolution/progression of neuroimaging findings in PHIV youth initially presenting with acute stroke.

MATERIALS AND METHODS

The medical records of PHIV pediatric patients (n = 179) from 1996 to 2010 were reviewed and patients with clinical documentation of acute stroke referred to the neuroradiology service were eligible for the study. Neuroimaging (brain CT, MRI, and MRA) and charts were evaluated; clinical and neuroimaging findings at the initial acute stroke and at the last presentation to the neuroradiology service were documented and analyzed.

RESULTS

Eight PHIV patients with clinical findings of acute stroke referred to the neuroimaging were identified. CT and MRI findings of infarction were found in all (8/8) patients in their first and/or last neuroimaging study; including basal ganglia-thalami (BGT) infarction (7/8), focal cortical infarction (4/8), and internal capsule infarction (4/8). Imaging depicted cortical atrophy (5/8), BGT calcification (3/8), and posterior reversible encephalopathy syndrome, wallerian degeneration, and periventricular white matter hyperintense T2 signal each in one patient. No tumors or infectious masses, cysts or abscesses were identified. Subsequent available neuroimaging revealed progression of the cerebrovascular disease in seven patients, 5/7 in the absence of new clinical signs or symptoms. Segmental occlusion, narrowing or narrowing/dilatation in the circle of Willis was found in 6/6 patients who underwent MR angiography and fusiform aneurysms were detected in three of them, a saccular aneurysm in one patient.

CONCLUSION

Asymptomatic progression of cerebrovascular disease was found in PHIV adolescents with prior stroke. These findings may have implications for long-term risk and outcomes for this patient population. There should be a low threshold to evaluate for CNS pathology even with minor symptoms in this population. More studies are necessary to determine if there is a benefit from screening of asymptomatic patients.

Characteristics of intracranial aneurysms associated with extracranial carotid artery disease in South Korea

OBJECTIVE

Although it is hypothesized that inflammatory signals and/or hemodynamic stress resulting from carotid disease increase the risk of aneurysm formation and growth, a relationship between intracranial aneurysms and extracranial carotid artery disease (ECAD) has not been explored. Here, we examined the characteristics of intracranial aneurysms associated with ECAD.

METHODS

A total of 606 consecutive patients with stenosis of 50% or more of the proximal internal carotid artery (pICA) were enrolled. Stenosis was identified by conventional angiography between January 2003 and December 2009. We determined the prevalence of intracranial aneurysms in this population. The characteristics of the aneurysms were analyzed according to the degree and laterality of stenosis. The changes in the aneurysms were tracked for the evaluation of stability.

RESULTS

In 86 patients (14.2%), 120 aneurysms were detected in association with pICA stenosis. In this group, 97 were associated with unilateral pICA stenosis. The distribution of aneurysms was independent of the laterality of stenosis, but aneurysms were more prevalent in the contralateral side as the stenosis grade increased (P<0.001). All aneurysms with an imaging follow-up (28.9 ± 14.3 months) were stable, and the course was not affected by treatment of the carotid stenosis. In 23 aneurysms associated with bilateral pICA stenosis, there was only one case that increased in size during a 41-month period.

CONCLUSION

Intracranial aneurysms were most likely associated with ECAD, but were evenly distributed irrespective of the laterality of the stenosis. The distribution was related to the severity of the contralateral pICA stenosis. The low incidence of aneurysm growth or rupture in patients with significant ECAD indicates that these aneurysms do not require immediate intervention more than other conditions.

Successful endovascular treatment of three fusiform cerebral aneurysms with the Pipeline Embolization Device in a patient with dilating HIV vasculopathy

Dilating HIV vasculopathy can be a cause of ischemic and hemorrhagic stroke in patients with HIV. Although first identified in children, this condition is increasingly being recognized in adults and has a dismal natural history under medical or expectant management. Vessel wall invasion by varicella zoster virus, HIV or Mycobacterium avium intracellulare complex (MAI) has been postulated as a possible etiology. We present a case of an adult patient with HIV and chronic disseminated MAI infection who presented with ischemic stroke and three fusiform cerebral aneurysms that were successfully treated with the pipeline embolization device (PED). Flow diversion may be a viable treatment option for patients presenting with this serious neurovascular condition when aneurysm location precludes parent vessel sacrifice or surgical bypass. In addition, platelet function testing with VerifyNow may be valuable in selecting the appropriate P2Y12 receptor antagonist to be used in order to prevent PED thrombosis, since some of the antiretroviral drugs may inhibit clopidogrel or prasugrel metabolism.