Vasculopathy common in HIV-related stroke

By, Will Boggs, Medicexchange.com, December 11, 2007

The cause of stroke in HIV patients can usually be determined, and many of those patients will have vasculopathy, according to a report in the December issue of the Journal of Neurology, Neurosurgery, and Psychiatry.

"There is still some niggling debate regarding whether HIV causes stroke itself -- we hoped to show that there was clear evidence of a vasculopathy in a significant proportion of HIV-infected stroke patients and thus tilt the evidence more in favor of the HIV/stroke relation," Dr. Brent Tipping from University of Cape Town, South Africa told Reuters Health. "We also wanted to show that the etiology of stroke in younger patients with HIV involves more than the traditional causes of stroke."

Dr. Tipping and colleagues documented the nature of stroke in 67 HIV-infected patients and 1020 non-HIV-infected patients, and further defined HIV-associated vasculopathy.

Mean age of the HIV-infected stroke patients (33.4 years) was considerably lower than the mean age of the patients determined not to be HIV infected (64.0 years), the report indicates, and recent or intercurrent infection was 6.4 times more likely to be associated with HIV-related stroke.

More than a third of HIV-infected stroke patients (37 per cent) had an intercurrent or recent opportunistic infection, the authors report, and somewhat more patients (54 per cent) had CD4 counts above 200 cells/microliter than below (46 per cent).

HIV-positive stroke patients had cardioembolism as a cause of cerebral infarction less commonly than did HIV-negative young stroke patients, but experienced significantly more inpatient confirmed deep venous thrombosis.

In this cohort, 20 per cent of the HIV-infected stroke patients had extracranial (11 per cent) or intracranial (nine per cent) nonaneurysmal vasculopathy, the investigators found, whereas young stroke patients who were not HIV-positive showed no similar vasculopathy on angiography.

"In our stroke unit, HIV-associated stroke affected a young stroke population with a risk factor profile that differed from the HIV-negative young stroke population in that hypertension, diabetes, hyperlipidemia, and smoking were not significant risk factors," the researchers note.

"Patients with stroke and HIV in our setting tended to have comorbid infective diseases that required management in addition to the stroke," Dr. Tipping said. "All HIV positive stroke patients require lumbar puncture because of the comorbid CNS infections."

"Management is also more challenging," Dr. Tipping added, "particularly since those with immunosuppression require antiretroviral therapy, which requires intensive adherence and the logistic challenges of obtaining therapy in our third world setting."

"Given the epidemic of HIV infection and the increasing burden of stroke in Africa, we need large, well designed, prospective, community-based case-control studies, if possible with post-mortem examination," writes Dr. Myles Connor from Queen Margaret Hospital, Dunfermline, UK in a related editorial.

"We also need further investigation of the nature of HIV vasculopathy, and to guard against a blind assumption that HIV infected stroke patients must have a vasculopathy if there is no other obvious cause for their stroke," the editorial concludes.

Dr. Tipping's group concurs, pointing out, "The occurrence of stroke in the younger patient who is HIV positive should not preclude a comprehensive workup, as HIV status may be incidental, particularly in a population with a high HIV seropositive prevalence in the general population."


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