Article Figures & Data
Figures
- Figure 1
A lateral view of the internal carotid artery distribution from the initial cerebral angiogram shows vasculopathic changes. Black arrows indicate saccular aneurysms on branches of the anterior cerebral artery. White arrows indicate vasculopathic changes on another branch of the anterior cerebral artery. Black arrowheads indicate the pattern of vascular narrowing and fusiform aneurysms on a branch of the middle cerebral artery.
- Figure 2
A lateral view of the internal carotid artery distribution from the followup cerebral angiogram done 91 days after the initial study shows marked improvement of the vasculopathic changes. White arrows indicate substantial improvement in the vasculopathic changes on a branch of the anterior cerebral artery compared to Figure 1. Black arrowheads indicate improvement of the vasculopathic changes in the branch of the middle cerebral artery compared to Figure 1.
Tables
- Table 1
Characteristics of patients with fusiform intracranial vasculopathy and HIV infection.
Study Age (yrs), Sex CD4 (cells/mm3) Viral Load (copies/ml) History Presentation Laboratory Findings Imaging Therapy Clinical Outcome Our Patient 38 F CD4 < 1, viral load 79,074 None Right hemiparesis See text@ Head CT: ischemia of bilateral basal ganglia, hemorrhage of right frontal and occipital lobes.
Angiogram: multiple intracranial fusiform and saccular aneurysms in anterior and posterior circulationSteroids, started ARV, anti-CMV therapy for retinitis New hemorrhage on day 39.
Followup angiogram showed resolution. No new events at 18 mo followupModi9 37 M CD4 = 164 None Severe cognitive impairment CSF: protein 1.06 g/1, glucose 2.7 mmol/1, 3 neutrophils/ml, 41 lymphocytes/ml. CSF India ink negative, adenosine deaminase normal, syphilis serology negative, MTB culture negative Angiogram: fusiform aneurysmal dilatation of bilateral ACA and MCA Treated for presumed TB meningitis. No ARV Lost to followup 43 M CD4 = 172 On therapy for pulmonary TB Headache, meningismus, confusion — Head CT: SAH. Angiogram/surgery: Bilateral MCA fusiform aneurysms Unable to repair right MCA aneurysm. No ARV Died of renal failure 43 M CD4 = 17 On therapy for pulmonary TB Generalized tonic-clonic seizures CSF: protein 0.82 g/1, glucose 2.0 mmol/1, no cells. CSF adenosine deaminase normal. Serum ESR 130 mm/h CT angiogram: multiple fusiform intracranial aneurysms. + aneurysmal dilatation of ascending aorta Started ARV Lost to followup Hamilton12 34 M CD4 = 66, viral load “undetectable” Endstage renal disease Headache, fever left hemiparesis — Head CT: diffuse SAH. CT angiography: diffuse vasculopathy of all major cerebral vessels with multiple fusiform and giant saccular aneurysms Unclear treatment Discharged after 7 days Ake11 CD4 = 15, VL 191,429 Recurrent VZV infections Cognitive and language deficits CSF: WBC 44 cells/mm3 (86% neutrophil ,11% lymphocyte, 1 % monocyte, 2% eosinophils), RBC 305,000 cells/mm3, glucose 24 mg/dl, Negative CSF bacterial culture, fungal culture, AFB culture. Negative CSF DNA PCR for CMV, Epstein-Barr virus, human herpes virus-6 and -8, herpes simplex virus, VZV. CSF HIV RNA <30 copies/ml. CSF VDRL and cryptococcal antigen negative. ESR 38 mm/h Head CT: hemorrhage in Sylvian fissure, lateral ventricle; SAH. Angiogram: Diffuse fusiform aneurysms and stenoses in anterior and posterior circulations Continued noncompliance with ARV Fatal subarachnoid hemorrhage 3 weeks after presentation Tipping5 27 F CD4 = 14 None Right hemiparesis CSF: 7 lymphocytes/mm3 3 polymorphs/mm3, protein 1.0 g/1, glucose 41 mg/dl. Negative CSF cryptococcal antigen, rapid plasma reagin, and cultures for bacteria, fungi, and tuberculosis CT: left basal ganglia infarct and fusiform dilation of L MCA, L ACA and distal basilar artery _ Died of pneumonia 25 days after presentation Kossorotoff6 23 M CD4 = 496 2 previous MCA strokes Recurrent left MCA stroke CSF normal MRI: recurrent L MCA infarct. Angiogram: large L terminal ICA aneurysm; multiple ectasias alternating w/stenotic lesions on medium-size arteries Continued ARV Alive at 9 yrs 32 CD4 = 338 Recurrent VZV infections Chronic headache CSF: WBC 13/mm3, protein 1.09 g/dl, glucose 2.1 mmol/1. CSF PCR VZV negative. Serologies positive for Epstein-Barr virus, human herpes virus-8, and CMV MRI: R MCA infarct Angiogram: multiple ectasia and focal stenoses on medium and small cerebral arteries Aspirin. Continued ARV Alive at 1 year. Followup MRA at 1 yr unchanged O’Charoen7 36 M CD4 = 43, VL 298,000 Polycystic kidney disease Dysarthria, right-side weakness CSF: WBC 1/mm3, RBC 8/mm3, protein 65 mg/dl, glucose 49 mg/dl. Negative CSF India ink, bacterial culture, VDRL, cryptococcus agglutination, CMV DNA PCR, VZV DNA PCR. ESR 95 mm/h, mg/dl. CRP 8.2 mg/dl MRI: L internal capsule .lateral thalamus infarct. MRA: fusiform aneurysmal dilation in A2 segments of bilateral ACA, MCA, postcerebral and basilar arteries Did not receive — Berkefeld8 37 M — MCA infarct 3 mo prior to presentation Progressive L hemiparesis and visual field disturbances CSF: 7 WBC/μ1 protein 0.85 g/1. Microbiology examinations of CSF and serum normal. ESR 65 mm/h, CRP 0.9 mg/dl MRA: RICA and MCA showed moderate arterial dilation, thickening, and contrast enhancement of walls. MRI: R MCA infarct Penicillin G, corticosteroids (dose not given), azathioprine. Started ARV Alive at 3 mo 31 M — Serum VZV antibody elevated, serum VZV PCR positive Recurrent TIA, aphasia, right hemiparesis CSF: WBC 9/μ1. Serum VZV antibody elevation and positive serum VZV PCR MRI: L MCA infarcts. MCA aneurysmal dilation, thickening, and contrast enhancement of arterial wall Improved with acyclovir and corticosteroids (decortine 1000 mg for 4 days). Started ARV Alive at 4 mo -
Dash denotes information not given. CT: computed tomography; CMV: cytomegalovirus; CSF: cerebrospinal fluid; MCA: middle cerebral artery; ARV: antiretroviral; TB: tuberculosis; ESR: erythrocyte sedimentation rate; SAH: subarachnoid hemorrhage; PCR: polymerase chain reaction; HIV: human immunodeficiency virus; CRP: C-reactive protein; ACA: anterior cerebral artery; MRI: magnetic resonance imaging; MRA: magnetic resonance angiogram; WBC: white blood cells; RBC: red blood cells; ICA: internal carotid artery; VZV: varicella zoster virus; TIA: transient ischemic attack; MTB: mycobacterium tuberculosis.
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