Stroke in HIV-Infected Patients: A Clinical Perspective

Abstract

The occurrence of stroke in patients with human immunodeficiency virus (HIV) infection has been traditionally associated with opportunistic infections and tumors, and advanced stages of immunosuppression. However, this reality is undergoing major changes. Effective antiretroviral regimens are now able to forestall the progression of HIV infection and avoid early mortality. As HIV-infected patients are growing older, clinicians are facing new challenges, including an increasing incidence of vascular complications. The use of protease inhibitors is associated with a variety of metabolic derangements that could produce accelerated atherosclerosis. Cerebrovascular hemodynamic function is impaired in HIV-infected patients with evidence of abnormal vasoreactivity even in otherwise healthy individuals. The potential contribution from these novel mechanisms should be added to the high incidence of classic vascular risk factors in the HIV-infected population and the cardiac abnormalities frequently observed in these patients. Large-scale epidemiological studies should be carried out to define the true incidence of stroke in HIV-infected patients and the factors associated with its occurrence.

Increasing incidence of ischemic stroke in patients with HIV infection

“…First, combination antiretroviral therapy increases life expectancy and as such inadvertently boosts the risk of ischemic stroke, a condition that is highly age-correlated and occurs with greater length of time exposure to conventional vascular risk factors. 1 In fact, the increase in stroke also coincides with the introduction of combination antiretroviral drugs in the mid-1990s and increased usage of these drugs in subsequent years. Also supporting this notion is the change in the demographics over time, with older, male, and African American subjects encountered later in the study period.…”

Acute Ischemic Stroke in Young Immunocompromised Patient With Hypolipidemia

“…Ischemic stroke in HIV infection can be caused by several possible mechanisms, including opportunistic infection, vasculopathy, cardioembolism, coagulopathy and combination antiretroviral therapies, and so on, although no established theory exists [1]. The current thought is that vasculopathy, due to the direct toxic effect of viral antigen, is an important mechanism of stroke in AIDS patients [8]. HIV infection causes neuronal injury without being found in neurons through the toxicity of viral proteins and chronic proinflammatory state induced by local viral replication [9].…”

Spontaneous artery dissection in a patient with Human Immunodeficiency Virus (HIV) infection

“…Reviews of neuro p athology have documented cerebral infarction in 4% to 29% of HIV infected patients 1 . Among the comm o n o p p o rtunistic infections that take part into blood v e ssel changes and may lead to ischemic strokes are tub e rculosis, toxoplasmosis, aspergillosis, varicella-zost e r, herpes simplex and cytomegalovirus infections, hepatitis B, syphilis, cryptococcosis, candidiasis and others 3,4,[8][9][10] . H I V-related vasculopathy is re g a rded as one of the most important mechanisms of stroke in these patients nowadays 3 .…”

“…Among the comm o n o p p o rtunistic infections that take part into blood v e ssel changes and may lead to ischemic strokes are tub e rculosis, toxoplasmosis, aspergillosis, varicella-zost e r, herpes simplex and cytomegalovirus infections, hepatitis B, syphilis, cryptococcosis, candidiasis and others 3,4,[8][9][10] . H I V-related vasculopathy is re g a rded as one of the most important mechanisms of stroke in these patients nowadays 3 . Vascular lesions are usually characterized by hyaline small-vessel thickening, perivascular space dilatation, rarefaction, and pigment deposition, with vessel wall mineralization and perivascular inflammatory cell infiltrates without definitive evidence of vasculitis.…”

“…It is believed that the use of these medications lead in a long-term period to accelerated athero s c l e ro s i s 3 . This could be the effect of the metabolic abnormalities produced by PIs: dyslipidemia and insulin resistance.…”