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Perinatally HIV-Infected Youth Presenting with Acute Stroke: Progression/Evolution of Ischemic Disease on Neuroimaging
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Since the introduction of HAART in 1996, HIV has become a chronic, manageable disease with marked reduction in morbidity and mortality [2]. Consequently, there is an aging cohort of infected children that are now adolescents and young adults who have been living with HIV infection and are now developing the sequelae of long-term infection. This cohort, who did not succumb to early manifestations of disease, including encephalopathy and opportunistic infections during the first years of life, has been exposed to years of treatment including serial mono- and dual antiretroviral therapy, followed by suboptimal and often unpalatable antiretroviral combinations that have resulted in nonadherence and multi-drug resistant virus that is challenging to treat. Longstanding HIV infection, particularly when not adequately treated, leads to unchecked viral replication, immunologic deterioration, and resultant inflammation in the body and specifically in the vasculature, places individuals at risk for sequelae including malignancy, atherosclerosis, and specifically for this report, central nervous system (CNS) pathology [12, 13].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3725563/
Abstract
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 7 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.
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