Stroke In HIV-infected Patients Research Articles

HIV Associated Risk Factors for Ischemic Stroke and Future Perspectives.

Although retroviral therapy (ART) has changed the HIV infection from a fatal event to a chronic disease, treated HIV patients demonstrate high prevalence of HIV associated comorbidities including cardio/cerebrovascular diseases. The incidence of stroke in HIV infected subjects is three times higher than that of uninfected controls. Several clinical and postmortem studies have documented the higher incidence of ischemic stroke in HIV infected patients. The etiology of stroke in HIV infected patients remains unknown; however, several factors such as coagulopathies, opportunistic infections, vascular abnormalities, atherosclerosis and diabetes can contribute to the pathogenesis of stroke. In addition, chronic administration of ART contributes to the increased risk of stroke in HIV infected patients. Concurrently, experimental studies in murine model of ischemic stroke demonstrated that HIV infection worsens stroke outcome, increases blood brain barrier permeability and increases neuroinflammation. Additionally, residual HIV viral proteins, such as Trans-Activator of Transcription, glycoprotein 120 and Negative regulatory factor, contribute to the pathogenesis. This review presents comprehensive information detailing the risk factors contributing to ischemic stroke in HIV infected patients. It also outlines experimental evidence demonstrating the impact of HIV infection on stroke outcomes, in addition to possible novel therapeutic approaches to improve these outcomes.

Increased HIV infection in patients with stroke in Spain. A 16-year population-based study

IntroductionAn increased incidence of stroke in HIV-infected patients has already been reported, suggesting that HIV infection may be a cerebrovascular risk factor. The objective of this study was to assess temporal trends in the proportion of HIV infection among patients with stroke in Spain. MethodsData were obtained from the minimum basic dataset (MBDS) of all patients hospitalized in Spain between 1997 and 2012 with a primary or secondary diagnosis of stroke. The annual proportion of HIV infection and time trends (stratifying by type of stroke and HIV stage) were calculated, and predictors of HIV infection and the social and economic impact of HIV-infected (HIV+) and non-infected (HIV−) patients were analyzed. ResultsOf 857,371 patients hospitalized with an incident stroke, 2134 (0.25%) had HIV infection. A 2.5% year-on-year increase (OR 1.025, 95% CI 1.015–1.036, p<0.0001) of the proportion of HIV-infected patients was observed due to an increase in the asymptomatic stage of the infection (per year OR 1.077, 95% CI 1.057–1.097, p<0.0001), as the proportion of patients with AIDS remained stable. Factors independently associated with HIV infection and stroke were active smoking, stimulating drugs and hepatitis C virus (HCV) infection. A higher mortality rate, longer hospital stay and a higher cost per hospitalized patient was observed among HIV+ patients. ConclusionsFrom 1997 to 2012, there was an increase in the proportion of HIV infection among patients hospitalized with stroke irrespective of the classical vascular risk factors, reinforcing the role of HIV infection as a cerebrovascular risk factor.

Increased HIV infection in patients with stroke in Spain. A 16-year population-based study

IntroductionAn increased incidence of stroke in HIV-infected patients has already been reported, suggesting that HIV infection may be a cerebrovascular risk factor. The objective of this study was to assess temporal trends in the proportion of HIV infection among patients with stroke in Spain. MethodsData were obtained from the minimum basic dataset (MBDS) of all patients hospitalized in Spain between 1997 and 2012 with a primary or secondary diagnosis of stroke. The annual proportion of HIV infection and time trends (stratifying by type of stroke and HIV stage) were calculated, and predictors of HIV infection and the social and economic impact of HIV-infected (HIV+) and non-infected (HIV−) patients were analyzed. ResultsOf 857,371 patients hospitalized with an incident stroke, 2134 (0.25%) had HIV infection. A 2.5% year-on-year increase (OR 1.025, 95% CI 1.015–1.036, p<0.0001) of the proportion of HIV-infected patients was observed due to an increase in the asymptomatic stage of the infection (per year OR 1.077, 95% CI 1.057–1.097, p<0.0001), as the proportion of patients with AIDS remained stable. Factors independently associated with HIV infection and stroke were active smoking, stimulating drugs and hepatitis C virus (HCV) infection. A higher mortality rate, longer hospital stay and a higher cost per hospitalized patient was observed among HIV+ patients. ConclusionsFrom 1997 to 2012, there was an increase in the proportion of HIV infection among patients hospitalized with stroke irrespective of the classical vascular risk factors, reinforcing the role of HIV infection as a cerebrovascular risk factor.

HIV infection does not influence stroke outcomes in HIV-infected patients: A prospective study

BackgroundHuman immunodeficiency virus (HIV) infection, opportunistic infections and antiretroviral therapy contribute to the pathogenesis of stroke, yet, little is known about the influence of HIV infection on outcome in stroke patients. The aim of this study was to compare the outcome of stroke in HIV-infected patients with that of HIV-negative patients at the Douala General Hospital (DGH). Patients and methodsA prospective cohort study was carried out at the Neurology unit and the Intensive Care Unit of the DGH from January 2010 to December 2015. All patients aged 15 years and above, admitted for stroke confirmed by brain imaging were included. HIV testing was systematically prescribed for all stroke patients. HIV-infected patients were then compared with HIV-uninfected patients. Quantitative variables were expressed as means while qualitative variables were expressed as frequencies, and were compared with the Chi2 test or the Fisher test and the Student test respectively. Stroke outcome was evaluated by the mortality, in-hospital stay and functional outcome at 6 months post-stroke. Kaplan–Meyer method was used to determine survival. ResultsForty of the 608 patients with stroke were HIV-positive, giving an in-hospital HIV prevalence of 6.6%. Mean age of the HIV-infected stroke patients was 51.3±10.4 years as against 59.6±13.53 in the HIV-uninfected group (P=0.001). The proportion of dyslipidemia in HIV-infected stroke patients with was greater than that in HIV-uninfected stroke patients (57.5% vs 8.9%, P<0.001). The most common type of stroke was ischemic in two-thirds of the patients in both groups. HIV-infected stroke patients had a mean hospital stay longer than that of HIV-uninfected patients (10.3±8.1 days vs 8.1±6.3 days, P=0.042). Post-stroke infections were more frequent in HIV-infected patients (17.5% vs 6.9%, P=0.014). The cumulative mortality rates at 6 months were 37.5% and 34.5% for the HIV-infected and the HIV-uninfected groups respectively (P=0.471). The functional outcome was similar in both groups at the 6th month post-stroke (Rankin score>2: 38.5%vs 38.8%, P=0.973). There was no difference in survival between the two groups. ConclusionHIV infection does not affect in-hospital mortality and functional outcome in stroke patients a part the length of hospital stay.

Ischaemic stroke in HIV-infected patients: a case-control study.

The aim of the study was to provide insights into the contributions of HIV infection stage, antiretroviral therapy (ART) and vascular risk factors to the occurrence of ischaemic stroke in HIV-infected patients. We performed a case-control study of HIV-infected patients followed in our clinic. We compared patients hospitalized between January 2006 and June 2014 with an ischaemic stroke or transient ischaemic attack to age- and gender-matched controls without stroke. Of 2146 patients followed in our clinic, we included 23 cases (20 men and three women; mean age 51.3 years) and 23 controls. Eighty-three per cent of cases had had a stroke and 17% a transient ischaemic attack. According to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, small-vessel occlusion was the most frequent aetiology, followed by large-artery atherosclerosis and cardioembolism. Compared with controls, stroke was statistically significantly associated with diabetes, smoking and low concentrations of high-density lipoprotein (HDL) cholesterol. Illegal drug use, a low CD4 count and a high viral load were also associated with ischaemic cerebral events. There were no statistically significant differences between cases and controls in Centers for Disease Control and Prevention (CDC) HIV stage, CD4 count nadir and HIV infection time-to-event. No statistically significant differences were found concerning ART or treatment compliance. In our single centre study, we found associations of illegal drug use, HIV replication and some traditional vascular risk factors with the occurrence of ischaemic cerebral events. The paradigm of the care of HIV-infected patients is changing. Concomitant diseases in the ageing patient with HIV infection, including cerebrovascular disease, must also be addressed in view of their impacts on morbidity and mortality. Apart from controlling the HIV infection and immunosuppression with ART, vascular risk factors must also be addressed.

A meta-analysis investigating incidence and features of stroke in HIV-infected patients in the highly active antiretroviral therapy era.

Recent studies have suggested a close biological and clinical association between HIV infection and risk of myocardial infarction, whereas contrasting data have been reported about incidence of stroke and its clinical predictors. Studies including HIV-infected patients developing a cerebral ischemic event were systematically searched for in MEDLINE/PubMed. Baseline, treatment and outcome data were appraised and pooled with random-effects methods computing summary estimates (95% confidence intervals). Five studies comprising 89,713 participants were included: they were young [46 (46-50) years, mainly male (70% (68-79)] with a moderate prevalence of diabetes [19% (14-21)]. Atrial fibrillation and history of previous coronary artery disease were observed in 3% (2-5) and 18% (15-22), respectively. All patients were on highly active antiretroviral therapy (HAART) and had been treated for a mean of 5 (2-6) years. After a median of 4 (3-5) years of follow-up, 1245 ischemic strokes occurred [1.78% (0.75-2.81)]. Traditional risk factors such as age (five studies), hypertension (three studies), smoking (two studies), hyperlipidemia (one study), atrial fibrillation (one study) and diabetes (one study) were identified as independent predictors of stroke. In one study, RNA viral load [log of odds ratio = 1.10 (1.04-1.17)] and CD4+ cell count less than 200/μl were clinically related to stroke, whereas HAART therapy showed a neutral effect. Stroke represents a relatively common complication in young, HAART-treated HIV patients. Apart from traditional cardiovascular risk factors, HIV-RNA viral load may help to target and manage patients at risk.

Immune Dysfunction in HIV infected stroke patients: Role of low CD&lt;sub&gt;4&lt;/sub&gt; counts

Whether or not low CD 4 count directly contributes to stroke among HIV infected stroke patients is yet to be elucidated. This study aimed to ascertain the role of low CD 4 count in the pathophysiology of stroke in HIV infection. This was a hospital-based, case-control study. Sixty five (65) consecutive stroke patients (36 males and 29 females) aged 20-68 years and sixty five (65) age-and-sex matched controls were enrolled. A structured questionnaire was administered. Neurological examination was performed and computed tomography scan of the brain done. Blood samples were taken for HIV 1&2 screening using ELISA method. Positive test using two different kits constituted a positive result. CD 4 count was determined by western blot method. The mean CD 4 count of HIV positive stroke patients (224.92 cells/cm 3 ) is significantly lower (P <0.001) than that of HIV negative patients (690.67 cells/cm 3 ). Nine out of thirteen (9/13, 69%) HIV positive stroke patients have CD4 <200 cells/μl. In addition to the conventional risk factors for ischemic stroke in HIV-infected patients, immune dysfunction (low CD 4 count) is an important and significant modifiable risk factor of ischemic stroke event among HIV infected adult population of Northeastern Nigeria. Consequently, better understanding and awareness of the role of low CD 4 count in the pathogenesis of stroke among HIV adults in this environment may provide a roadmap for controlling one of the deleterious non-opportunistic neurologic complication of HIV infection Keywords: CD 4 count, HIV, Immune Dysfunction, Stroke

HIV Infection and Acute Stroke: A Case Report and a Review of the Literature

Background. In the United States, ischemic stroke in HIV-infected patients has increased by 60%. However, unexpected cardiovascular events in relatively young patients have been observed. Clinical Vignette. A 31-year-old male who presented with a 5-hour history of sudden onset slurred speech and left hemiplegia. He has medical history of HIV infection for 2 years taking ARTs. On exam, a significant left hemiparesis was noticed. Brain MRI showed right anterior corona radiata and basal ganglia acute infarction. Discussion. Several mechanisms have been proposed for the relationship between HIV infection and cardiovascular risk. (i) HIV-associated dyslipidemia: HIV-infected patients tend to develop decrease in HDL-c and LDL-c levels. ART was associated with an increase in LDL-c but little change in HDL-c. (ii) Endothelial dysfunction: certain antiretroviral agents may independently contribute to endothelial damage. (iii) Hypertension: systolic blood pressure is higher in those using ART for greater than five years. (iv) Insulin resistance and diabetes have been noticed with ART. (v) Chronic inflammation. (vi) Hypercoagulability: decrease in proteins C and S was associated with HIV infection. Conclusion. Poorly controlled HIV infection and/or the introduction of ATR might be risk factors for cardiovascular events. More studies needed to address this medical dilemma.

HIV and aging

HIV and aging

HIV and Stroke

Although HIV infection and specific antiretroviral agents have been linked to cardiovascular disease, little is known about the incidence of stroke in HIV-infected patients. To explore this topic, investigators examined time trends in the proportion of hospitalized stroke patients who have HIV infection. The researchers analyzed data from the Nationwide Inpatient Sample, which includes discharge information on a large number of patients hospitalized …

Stroke in HIV-infected patients

The spectrum of human immunodeficiency virus infection (HIV) is changing. New drug treatments have reduced morbidity and mortality of this disease, therefore it is necessary to start treating the HIV infection as a chronical disease. The association of the stroke with the HIV infection was inicially thought to be a result of other opportunistic infeccions and tumors. However, the vascular disease associated with HIV infection has been a subject of research and debate. New evidence shows that the vascular diseases could be a threat for the pacients doing highly active antirretroviral therapy (HAART). In this paper, we review the association between the HIV infection and stroke. Furthermore, we have done an analysis of the risk for the stroke on pacients with HIV infection considering the changes of the infection spectrum by the introduction of HAART.

Mechanisms of ischemic stroke in HIV-infected patients

To evaluate the types and mechanisms of stroke in a large population of HIV-infected patients. We reviewed records of consecutive HIV-infected patients with acute stroke admitted to a large metropolitan hospital between 1996 and 2004. Stroke mechanism was defined by consensus between two cerebrovascular neurologists using TOAST classification. A total of 82 patients were included, 77 with ischemic stroke and 5 with intracerebral hemorrhage. Mean age was 42 years and 89% were African American. Previous diagnosis of HIV infection was documented in 91% and AIDS diagnosis in 80%. Mean CD4 count was 113 cells/mm(3) and 85% had CD4 count <200 cells/mm(3). A total of 61% of patients had received combination antiretroviral treatment (CART). The mechanism of ischemic stroke was large artery atherosclerosis in 12%, cardiac embolism in 18%, small vessel occlusion in 18%, other determined etiology in 23%, and undetermined in 29% (including 19% with incomplete evaluation). Vasculitis was deemed responsible for the stroke in 10 patients (13%) and hypercoagulability in 7 (9%). Protein S deficiency was noted in 10/22 (45%) and anticardiolipin antibodies in 9/31 (29%) tested patients. When comparing patients with large or small vessel disease (atherothrombotic strokes) vs the rest of the population, there were no differences in exposure to CART or CD4 count, but patients with non-atherothrombotic strokes were younger (p = 0.04). Recent cocaine exposure was less common among patients with atherothrombotic strokes (p = 0.02). Strokes were fatal or severely disabling in 35% of cases. Stroke mechanisms are variable in HIV-infected patients, with a relatively high incidence of vasculitis and hypercoagulability. In our population of severely immunodepressed patients, exposure to combination antiretroviral treatment did not significantly influence the mechanism of stroke.

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

The relationship between human immunodeficiency virus infection and stroke may be attributed in some cases to an underlying vasculopathy such as in spontaneous cervical arteries dissections. We report the case of an HIV-infected patient who developed a Wallemberg's syndrome due to a vertebral artery dissection. Screening laboratory exams showed hyperhomocysteinemia and also high C-reactive protein plasma levels. This is the first case describing the association between arterial dissection (AD) and HIV-infection. We suggest that AD should also be remembered as a possible mechanism of ischemic stroke in HIV-infected patients.

Abstracts of Literature

Abstracts of Literature

Human immunodeficiency virus infection and stroke in young patients.

To determine the association between human immunodeficiency virus (HIV) infection and stroke among young persons. Retrospective case-control study. Large, inner-city public hospital. All patients aged 19 to 44 years with a diagnosis of stroke, whose HIV status was determined, admitted from January 1990 through June 1994. Controls matched for age and sex were selected from patients who were admitted during the same period for status asthmaticus whose HIV status was known. The associations of HIV infection with all strokes and with cerebral infarction, after adjustment for other cerebrovascular risk factors, were evaluated by Mantel-Haenszel stratified analyses. The subtypes and causes of stroke in HIV-infected patients were compared with HIV-seronegative patients. The HIV infection was associated with stroke (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0-5.3) and cerebral infarction (OR, 3.4; 95% CI, 1.1-8.9), after adjustment for other cerebrovascular risk factors. Among patients with stroke, cerebral infarction was more frequent in HIV-infected patients than in HIV-seronegative patients (20 [80%] of 25 vs 48 [56%] of 88, P = .04). The frequency of cerebral infarctions associated with meningitis (P < .001) and protein S deficiency (P = .06) was higher in HIV-infected patients than in seronegative patients. Our study suggests that HIV infection is associated with an increased risk of stroke, particularly cerebral infarction in young patients. This risk is probably mediated by increased susceptibility of HIV-infected patients to meningitis and protein S deficiency.