Contrasting Cases of HIV Vasculopathy Associated Fusiform Aneurysms

Abstract

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.

Keywords: HIV Vasculopathy; fusiform aneurysm; moyamoya.

Figure 1.

(1A and B) This axial maximum intensity projection (MIP) from a CT angiogram (CTA) of the head (1A) and coronal MI (1B) shows a fusiform aneurysm of the cavernous and supraclinoid segments of the right internal carotid artery (ICA) (arrow) and the anterior communicating artery (A-com) which extends into the A2 segment of the left anterior cerebral artery (ACA) (serrated arrow). (2A and B) This axial MIP from a CTA head shows calcification and non-opacification of the ICA aneurysm secondary to thrombosis (arrow). The A-com aneurysm may have minimally decreased in its extension into the A2 segment of the left ACA (serrated arrow). (3A) This axial diffusion weighted sequence of an MRI brain shows right insular, temporal and parietal infarcts in the right middle cerebral artery distribution. (3B) This axial susceptibility weighted sequence of an MRI brain shows linear susceptibility within the posterior right Sylvian fissure suspicious for intraluminal thrombus in the territory of infarct. (4A) This coronal MIP from a CTA head demonstrates CTA Head moyamoya-like collateralization of the R MCA (arrow head), unchanged thrombosis of the ICA (arrow) and decreased size of the A-com aneurysm. (4B) This coronal MIP from an MR angiogram using time of flight technique demonstrates non-visualization of the right ICA due to known thrombus (arrow) and non-visualization of the MCA collaterals due to delayed mean transit time (arrow head). There is decreased size of the A-com aneurysm and severe narrowing of the A2 branch of the left ACA (serrated arrow).

Figure 2.

(1A) This axial T1-weighted postcontrast sequence of an MRI brain demonstrates a rim-enhancing lesion toxoplasmosis abscess centered in the in the right basal ganglia. (1B) This axial T2-FLAIR sequence of an MRI brain demonstrates a right basal ganglia toxoplasmosis abscess with extensive vasogenic edema in the right basal ganglia and insula (arrow head). The left parietal vasogenic edema (serrated arrow) is from an additional toxoplasmosis abscess not in the field of view. (2A and 2B) This axial maximum intensity projection (MIP) from a CT angiogram (CTA) of the head (2A) and coronal MIP (2B) show fusiform aneurysms in the bilateral M2 branches (serrated arrows) and M3 branches (arrow) of both middle cerebral arteries. (3A and 3B) This axial MIP from a CTA of the head (3A) and coronal MIP (3B) after 9 months of antiretroviral therapy show the shows the fusiform aneurysms in the bilateral M2 branches (serrated arrows) and M3 branches (arrow) have decreased in size.