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

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 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.

Keywords: AIDS; Cerebrovascular accident; HIV; Imaging; Perinatal; Stroke.

Fig. 1

Patient #8. DWI (A) and ADC map (B) show an acute infarct in the right basal ganglia with restricted diffusion. There is also an old infarct in the right caudate head with volume loss, increased diffusion and ex-vacuo dilatation of the right frontal horn.

Fig. 2

Patient #3. Small focal areas of restricted diffusion consistent with acute infarcts are noted in the left frontoparietal region on DWI and ADC map (A and B) due to left MCA occlusion. On T2-weighted axial image at a lower level (C) left temporal lobe cortical swelling and hyperintense signal are seen. The hypointense fusiform structure in the left slyvian fissure in (C) correlates to an aneurysm at left ICA terminus on MRA image (D).

Fig. 3

Patient #2. T2-weighted axial image shows left frontal and frontoparietal chronic infarcts (A) which resulted in wallerian degeneration in the left cerebral peduncle (B). An old infarct in the left occipital lobe is also shown on image B. MRA shows significant narrowing of the left PCA (C) and focal stenosis in the left A1 segment and inferior M2 segment (D).

Fig. 4

Patient #4.The first row shows representative CT and MRI findings at the first presentation. The second row shows same patient’s CT and MR images at similar levels after 6 years. Note the increase in basal ganglia calcifications, increased number of focal infarcts and increase in cerebral volume loss.

Fig. 5

Patient #1. MRA MIP images show segmental narrowing and dilatation of bilateral MCA and ACA as well as multiple fusiform aneurysms at ACOM, and at bilateral A1 segments (A). Six years later right A1 is occluded or severely stenosed and fusiform aneurysm in the right A1 is not visualized. The remainder of the findings is stable (B).

Fig. 6

Patient #1. Cerebral angiogram (performed at the same time when first MRA was performed in Fig. 5 A). Right ICA injection shows fusiform aneurysm at right A1-A2 junction and focal narrowing in the immediate right A2 (black arrow). Additionally CA shows focal narrowing and fusiform dilatation in the right MCA superior M2 segment (white arrow).