Stroke in patients with human immunodeficiency virus infection

An autopsy case of cerebral hemorrhage in an HIV-infected patient with suspected HIV-associated cerebrovascular disease

A male in his late 30s was found dead in his home. He was diagnosed with human immunodeficiency virus (HIV) about six years prior. The HIV infection was well controlled before his death. He was 166 cm in height and 75 kg in weight. Aside from discoloration of the skin on the right lower patellar, there were no obvious injuries. His brain weighed 1456 g. A cut surface of the brain revealed left thalamic hemorrhage. Histologically, infiltration of phagocytic cells was observed in the bleeding site. Thalamic hemorrhage was considered to be his cause of death in this case. Due to the effects of anti-HIV therapy, the mortality rate from HIV infection has decreased and the causes of death of HIV-infected persons have changed. HIV-infected persons have been suggested to be associated with cerebrovascular disease, especially juvenile ischemic stroke. Patients with acquired immunodeficiency syndrome (AIDS) have an increased risk of cerebrovascular disease. Possible mechanisms of cerebrovascular disease in HIV-infected individuals include coagulopathy, secondary effects of embolism and central nervous system infection, and direct vascular disease due to HIV. At the time of autopsy, his post-mortem interval was estimated to be approximately two weeks. Therefore, it was difficult to clarify histologically the cerebrovascular disorder that caused his cerebral hemorrhage. In recent years, anti-HIV therapy has reduced the number of AIDS-related deaths, but deaths in HIV-infected people from cardiovascular disease are increasing. This case is considered to be a valuable forensic autopsy case of an HIV-infected patient who actually died due to cerebral hemorrhage in Japan.

Stroke as the index presentation of traditional cardiovascular risk factors and Human Immunodeficiency Virus in a South African population

OBJECTIVES

We sought to identify what proportion of each cardiovascular risk factor and Human Immunodeficiency Virus (HIV) was first diagnosed at the time of stroke, compared to those that were diagnosed prior to the event, and to explore if this had any impact on the severity of stroke.

METHODS

Adult patients presenting with a new stroke to a quaternary hospital in Johannesburg between 2014 and 2017 were prospectively recruited. Patients were investigated for undiagnosed traditional cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, atrial fibrillation, obesity and smoking), as well as HIV infection. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS).

RESULTS

346 patients were included. Stroke was the index presentation for at least one risk factor in 199 (57.5 %) patients. Dyslipidaemia was newly diagnosed in 76.0 % of all dyslipidaemics (95 out of 125). Newly-diagnosed dyslipidaemia was associated with a more severe neurological deficit (Median NIHSS of 12 (8-16) vs 7 (4-12), p=0.0007) and younger age on presentation (53 (44-63) years vs 62 (51-71) years, p=0.02) as compared to previously-diagnosed dyslipidaemia.

CONCLUSIONS

More than half of patients had previously undiagnosed modifiable risk factors at the time of their stroke. Dyslipidaemia was undiagnosed in a very high proportion, and this was associated with a higher stroke severity and younger age of presentation.

The epidemiology, mechanisms, diagnosis and treatment of cardiovascular disease in adult patients with HIV

More than 1.2 million people in the United States have Human Immunodeficiency Virus (HIV) infections but 13% of these people are unaware of their HIV infection. Current combination antiretroviral therapy (ART) does not cure HIV infection but rather suppresses the infection with the virus persisting indefinitely in latent reservoirs in the body. As a consequence of ART, HIV infection has changed from a fatal disease in the past to a chronic disease today. Currently in the United States, more than 45% of HIV+ individuals are greater than 50 years of age and 25% will be greater than 65 years of age by 2030. Atherosclerotic cardiovascular disease (CVD), including myocardial infarction, stroke, and cardiomyopathy, is now the major cause of death in HIV+ individuals. Novel risk factors, including chronic immune activation and inflammation in the body, antiretroviral therapy, and traditional CVD risk factors, such as tobacco and illicit drug use, hyperlipidemia, the metabolic syndrome, diabetes mellitus, hypertension, and chronic renal disease, contribute to cardiovascular atherosclerosis. This article discusses the complex interactions involving HIV infection, the novel and traditional risk factors for CVD, and the antiretroviral HIV therapies which can contribute to CVD in HIV-infected people. In addition, the treatment of HIV+ patients with acute myocardial infarction, stroke, and cardiomyopathy/heart failure are discussed. Current recommended ART and their major side effects are summarized in table format. All medical personnel must be aware of the increasing incidence of CVD on the morbidity and mortality in HIV infected patients and must be watchful for the presence of CVD in their patients with HIV.

Cardiovascular disease and risk assessment in people living with HIV: Current practices and novel perspectives

Human immunodeficiency virus (HIV) infection represents a major cardiovascular risk factor, and the cumulative cardiovascular disease (CVD) burden among aging people living with HIV (PLWH) constitutes a leading cause of morbidity and mortality. To date, CVD risk assessment in PLWH remains challenging. Therefore, it is necessary to evaluate and stratify the cardiovascular risk in PLWH with appropriate screening and risk assessment tools and protocols to correctly identify which patients are at a higher risk for CVD and will benefit most from prevention measures and timely management. This review aims to accumulate the current evidence on the association between HIV infection and CVD, as well as the risk factors contributing to CVD in PLWH. Furthermore, considering the need for cardiovascular risk assessment in daily clinical practice, the purpose of this review is also to report the current practices and novel perspectives in cardiovascular risk assessment of PLWH and provide further insights into the development and implementation of appropriate CVD risk stratification and treatment strategies, particularly in countries with high HIV burden and limited resources.

Extensive myocardial infarction complicated with stroke as the first presentation of HIV in A young sudanese male: A case report

Introduction

Case presentation

Discussion

Conclusion

•

HIV infection can be associated with significant cardiovascular and neurological complications.

•

The presentation of acute coronary syndrome in a young patient should raise suspicion of uncommon causes.

•

Known HIV Patients should be screened periodically with electrocardiogram.

Prevalence and Characteristics of HIV-Associated Stroke in a Tertiary Hospital Setting in South Africa

BACKGROUND AND OBJECTIVES

Antiretroviral treatment (ART) era HIV-associated stroke data from sub-Saharan Africa are limited. We determined the prevalence of HIV in patients presenting with acute symptomatic stroke and compared risk factors, clinical characteristics, and brain imaging with age-matched stroke patients without HIV.

METHODS

We conducted a retrospective study of adults presenting with any type of stroke to Tygerberg Hospital in a 12-month period. Patients living with HIV (PLWH) and HIV-uninfected (HIV-) patients were matched based on age group (1:2 ratio). Patients were identified by keyword search, while HIV status was ascertained from laboratory data. Clinical and imaging data were extracted from medical records.

RESULTS

Among 884 patients presenting with acute strokes, the minimum prevalence of HIV infection was 9.3% (95% CI: 7.4%-11.2%), with 496 patients (56.1%) with negative HIV status and 306 patients with unknown HIV status (34.6%). The mean age at presentation in PLWH was 46 (±11) years compared with 55 (±14) years in HIV- patients (p < 0.001). Smoking was less prevalent in PLWH with an adjusted relative risk ratio of RR = 0.58 (95% CI: 0.39-0.86). Concurrent infection was more prevalent in PLWH (25.6% vs 4.9%, p ≤ 0.001) with an adjusted relative risk ratio of RR = 2.07 (95% CI: 1.49-2.84), largely in patients with a CD4 count <200 cells/μL. PLWH with higher CD4 counts (≥200 cells/μL, 51.3%) had more traditional risk factors and less concurrent infection. Among PLWH, 68.3% were on ART, and 39.3% of them had been started or restarted on ART within the past 6 months. Basal ganglia infarcts (35.6% vs 18.3%, p = 0.014) and multiple vascular territory involvement (25.4% vs 7.7%, p = 0.002) were more common in PLWH. Clinical presentation, ischemic stroke type, and in-hospital outcomes did not differ between the groups.

DISCUSSION

Stroke patients with HIV were younger, had less traditional cardiovascular risk factors, and more concurrent infections than patients without HIV, especially those with a lower CD4 count. Recent ART initiation or reinitiation rates were high. Significant differences in CT brain imaging findings were seen. Understanding the multifactorial mechanisms underlying increased stroke risk, including associated infections and potential ART-associated immune reconstitution, is crucial and needs further study.

Risk of subarachnoid haemorrhages and aneurysms in Danish People Living With HIV, a nationwide cohort study

OBJECTIVE

It remains unclear whether people with HIV (PWH) have increased risk of aneurysms. We aimed to investigate if the risk of subarachnoid haemorrhage, cerebral aneurysm, aortic aneurysm and other arterial aneurysms and dissections is increased in PWH compared with the general population.

DESIGN

We performed a nationwide population-based matched cohort study.

METHODS

We compared PWH with age-matched and sex-matched comparison cohort members to calculate incidence rate ratios (IRR) of subarachnoid haemorrhage, cerebral aneurysm, aortic aneurysm and other arterial aneurysms and dissections as well as surgery for these conditions.

RESULTS

We included all PWH, who were Danish residents and treated at a HIV healthcare centre between January 1995 and February 2018 (n = 6935) and an age-matched and sex-matched comparison cohort (n = 55 480). PWH had increased risk of subarachnoid haemorrhage (IRR 1.7, 95% CI, 1.1-2.6), but no increased risk of surgery for this condition. PWH had no increased risk of cerebral aneurysm or aortic aneurysm or surgery for these conditions. The risk of other arterial aneurysms and dissections was increased in PWH (IRR 2.0, 95% CI, 1.4-2.9), but this only applied for PWH who reported intravenous substance use as route of HIV transmission (IRR 18.4, 95% CI, 9.3-36.6), and not for PWH without reported injection drug use (IRR 1.2, 95% CI, 0.73-1.7).

CONCLUSION

PWH were not at an increased risk of cerebral, aortic or other arterial aneurysms and dissections. Although PWH were at an increased risk of subarachnoid haemorrhage, subarachnoid haemorrhages were rare among PWH.

Trends and Clinical Characteristics of HIV and Cerebrovascular Disease in Low- and Middle-Income Countries (LMICs) Between 1990 and 2021

PURPOSE OF THE REVIEW

To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding.

RECENT FINDINGS

In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.

Infectious Agents and Stroke: A Systematic Review

Introduction:

A major cause of injury and the second cause of death worldwide is stroke. Among several infectious agents considered as the risk factor of stroke, some pathogens demonstrated stronger robust associations with stroke. Proposing an accurate correlation between infectious microorganisms and stroke provides valuable information for early intervention and control of the infections.

Methods:

In this study, we searched the literature using the Web of Science, PMC/Medline via PubMed, and Scopus databases up to July 2018 without time and language restrictions. After quality assessment, 16 articles were included in the study. The whole data extraction process was independently conducted by two reviewers.

Results:

Based on the results of the studies, viruses, such as Hepatitis C virus (HCV), Hepatitis B virus (HBV), Human Immunodeficiency Virus (HIV), Herpes Simplex Virus Type-1, 2 (HSV-1, 2), Varicella-Zoster Virus (VZV or Chickenpox), and West Nile virus (WNV) seem to be common causes of ischemic stroke. Moreover, the association of other microbial categories, such as Streptococcus mutans (in bacteria), Toxocara spp. and Toxoplasma gondii (in parasites), and Rhizopus sp. (in fungi) with stroke was reported.

Conclusion:

Considering the adverse role of the above-mentioned microorganisms, it is necessary to implement some preventive measures for stroke treatment.

Risk Factors for Stroke in HIV-Positive and-Negative Patients in Pretoria, South Africa

OBJECTIVES

Low- to middle-income countries experience a marked rise in cardiovascular diseases, and have the highest incidence of HIV infection. Stroke data in HIV-positive patients is still scarce. This study compares risk factors and types of stroke between HIV-positive and -negative patients in South Africa.

MATERIALS AND METHODS

We conducted a cross-sectional study at Kalafong Provincial Tertiary Hospital in Pretoria over a 10-month period. All adult patients presenting with an acute stroke were included.

RESULTS

One hundred and forty consecutive patients with stroke were included, 23% were HIV-positive. The average age in the HIV-positive group was 41 years, compared to 61 years in the HIV-negative group (p < 0.01). Ischemic infarcts occurred in 80.7 and 19.3% were hemorrhagic, with no significant difference between the HIV-positive and -negative group (ischemic: 81% vs 80%; hemorrhagic: 19% vs 20%; p = 0.55). Small vessel infarcts occurred more frequently in HIV-positive patients (25% vs 9.3%; p < 0.02). While 78% of HIV-positive patients presented with concomitant infections, these were found in only 23% of HIV-negative patients (P < 0.001). Hypertension (81% vs 37.5%; p = 0.01) and dyslipidemia (62% vs 38%; p = 0.01) were more prevalent in the HIV-negative patients. Confounding variables were gender and age. Although more than half of the HIV-positive patients were on antiretroviral therapy, the majority (62.5%) showed virological non-suppression.

CONCLUSIONS

HIV infection occurred in almost one-quarter of stroke patients and was seen more in the younger age group. Small vessel ischemic infarcts and underlying infections were more common in HIV-positive patients. The high number of HIV-positive patients with virological non-suppression is concerning and needs to be addressed.

Role of Brain Arterial Remodeling in HIV-Associated Cerebrovascular Outcomes

As the life expectancy of people living with HIV (PLWH) on combination antiretroviral therapy (cART) increases, so does morbidity from cerebrovascular disease and neurocognitive disorders. Brain arterial remodeling stands out as a novel investigational target to understand the role of HIV in cerebrovascular and neurocognitive outcomes. We therefore conducted a review of publications in PubMed, EMBASE, Web of Science and Wiley Online Library, from inception to April 2021. We included search terms such as HIV, cART, brain, neuroimmunity, arterial remodeling, cerebrovascular disease, and neurocognitive disorders. The literature shows that, in the post-cART era, PLWH continue to experience an increased risk of stroke and neurocognitive disorders (albeit milder forms) compared to uninfected populations. PLWH who are immunosuppressed have a higher proportion of hemorrhagic strokes and strokes caused by opportunistic infection and HIV vasculopathy, while PLWH on long-term cART have higher rates of ischemic strokes, compared to HIV-seronegative controls. Brain large artery atherosclerosis in PLWH is associated with lower CD4 nadir and higher CD4 count during the stroke event. HIV vasculopathy, a form of non-atherosclerotic outward remodeling, on the other hand, is associated with protracted immunosuppression. HIV vasculopathy was also linked to a thinner media layer and increased adventitial macrophages, suggestive of non-atherosclerotic degeneration of the brain arterial wall in the setting of chronic central nervous system inflammation. Cerebrovascular architecture seems to be differentially affected by HIV infection in successfully treated versus immunosuppressed PLWH. Brain large artery atherosclerosis is prevalent even with long-term immune reconstitution post-cART. HIV-associated changes in brain arterial walls may also relate to higher rates of HIV-associated neurocognitive disorders, although milder forms are more prevalent in the post-cART era. The underlying mechanisms of HIV-associated pathological arterial remodeling remain poorly understood, but a role has been proposed for chronic HIV-associated inflammation with increased burden on the vasculature. Neuroimaging may come to play a role in assessing brain arterial remodeling and stratifying cerebrovascular risk, but the data remains inconclusive. An improved understanding of the different phenotypes of brain arterial remodeling associated with HIV may reveal opportunities to reduce rates of cerebrovascular disease in the aging population of PLWH on cART.

HIV sero-positivity and risk factors for ischaemic and haemorrhagic stroke in hospitalised patients in Uganda: A prospective-case-control study

Objectives

We examined HIV sero-positivity and risk factors in patients admitted with ischaemic stroke (IS) and haemorrhagic stroke (HS) in Kampala, Uganda.

Study design

We conducted a matched case-control study between December 2016 and December 2018 ​at ​St Francis Hospital, Nsambya.

Methods

The study population comprised of stroke cases (adults aged ≥18 years with IS or HS confirmed by neuroimaging) and controls (age- and sex-matched stroke-free adults aged ≥18 years who were recruited from the same hospital as the cases). A comprehensive assessment for sociodemographic, lifestyle and clinical factors was performed using the World Health Organization (WHO) STEP-wise approach to Surveillance (STEPS) for stroke risk factor surveillance. We used conditional logistic regression to identify risk factors associated with IS or HS.

Results

We enrolled 137 matched case-control pairs; 48 (35%) were men, and the mean ages were 62.4 years (SD ​± ​14.8) for cases and 61.1 years (SD ​± ​14.1) for controls. Of stroke patients, 86 (63%) had IS and 51 (37%) had HS. Overall, HIV sero-positivity was 10% among stroke cases versus 7% among controls. HIV sero-positivity was not significantly associated with stroke (unadjusted odds ratio [uOR] ​= ​1.49, 95% confidence interval [CI] 0.59-3.78). A self-reported family history of diabetes mellitus was associated with an increased risk of all stroke (adjusted odds ratio [aOR] ​= ​4.41, 95% CI 1.47-13.2), as well as for IS and HS separately (aOR ​= ​3.66, 95% CI 1.09-12.4 and aOR ​= ​4.99, 95% CI 1.02-24.4, respectively). High blood pressure (≥140/90 ​mmHg) was associated with an increased risk of all stroke (aOR ​= ​12.3, 95% CI 42-44.1), and this was also true for IS and HS individually (aOR ​= ​6.48, 95% CI 1.15-36.7 and aOR ​= ​5.63, 95% CI 1.74-18.2, respectively).

Conclusions

No association was found between HIV sero-positivity and stroke occurrence among Ugandan stroke patients. Hypertension and a self-reported family history of diabetes mellitus were significant risk factors for both IS and HS. Interventions to reduce hypertension and diabetes mellitus in the Ugandan population are urgently required. Much larger studies are required to demonstrate if any association exists between HIV and stroke.

Stroke and HIV-associated neurological complications: A retrospective nationwide study

There is an increased risk of stroke and other neurological complications in human immunodeficiency virus (HIV) infected patients with no large population-based studies in the literature. We aim to evaluate the prevalence of stroke, HIV-associated neurological complications, and identify risk factors associated with poor outcomes of stroke among HIV admissions in the United States. In the nationwide inpatient sample with adult HIV hospitalizations, patients with primary cerebrovascular disease (CeVDs) and HIV-associated neurological complications were identified by ICD-9-CM codes. We performed a retrospective study with weighted analysis to evaluate the prevalence of stroke and neurological complications and outcomes of stroke among HIV patients. We included 1,559,351 HIV admissions from 2003 to 2014, of which 22470 (1.4%) patients had CeVDs (transient ischemic attack [TIA]: 3240 [0.2%], acute ischemic stroke [AIS]: 14895 [0.93%], and hemorrhagic stroke [HS]: 4334 [0.27%]), 7781 (0.49%) had neurosyphilis, 29,925 (1.87%) meningitis, 39,190 (2.45%) cytomegalovirus encephalitis, 4699 (0.29%) toxoplasmosis, 9964 (0.62%) progressive multifocal leukoencephalopathy, and 142,910 (8.94%) epilepsy. There is increased overall prevalence trend for CeVDs (TIA: 0.17%-0.24%; AIS: 0.62%-1.29%; HS: 0.26%-0.31%; pTrend < .0001) from 2003 to 2014. Among HIV admissions, variables associated with AIS were neurosyphilis (odds ratio: 4.38; 95% confidence interval: 3.21-5.97), meningitis (4.87 [4.10-5.79]), and central nervous system tuberculosis (6.72 [3.85-11.71]). Toxoplasmosis [4.27 [2.34-7.76]), meningitis (2.91 [2.09-4.06)], and cytomegalovirus encephalitis (1.62 [1.11-2.37]) were associated with higher odds of HS compared to patients without HS. There was an increasing trend of CeVDs over time among HIV hospitalizations. HIV-associated neurological complications were associated with the risk of stroke, together with increased mortality, morbidity, disability, and discharge to long-term care facilities. Further research would clarify stroke risk factors in HIV patients to mitigate adverse outcomes.

Acute stroke in the emergency department: A chart review at KwaZulu-Natal hospital

Background

Stroke is the second leading cause of death worldwide. There is limited literature detailing the clinical profile of stroke in developing countries’ emergency departments (EDs). The aim of this study is to describe the demographics and risk factors of patients presenting with stroke to an ED in South Africa.

Methods

This study was a retrospective chart review of all patients with a clinical diagnosis of stroke presenting to an ED of a regional hospital in rural KwaZulu-Natal from November 2018 to November 2019.

Results

A total of 362 patient charts were screened, and 136 of the charts met the inclusion criteria for the study. Seventy per cent of the patients had pre-existing hypertension, only one patient was not on treatment and two patients were not on secondary prevention. In human immunodeficiency virus–positive patients (20.5%; n = 28), 17 patients were under 50 years old. The most common finding on computer tomography was ischemic strokes (74%, n = 100). Thrombolysis was given to five patients included in the study. The overall in-hospital mortality rate was 4.06%.

Conclusion

This study adds to the limited data about stroke in South Africa. Our population represents a unique blend of infectious and lifestyle disease. More research in this setting is recommended to develop local guidelines on emergency stroke care.

Ischemic stroke in human immunodeficiency virus-positive patients: An increasingly age-related comorbidity?

Introduction

The global incidence of ischemic stroke among patients with human immunodeficiency virus is increasing. The aim of this controlled case analysis was to study patient characteristics, stroke etiologies, and risk factors in human immunodeficiency virus-positive patients in a medical system with easy access to antiretroviral therapies.

Patients and methods

We conducted a retrospective, observational study of human immunodeficiency virus-positive patients treated in our stroke unit and outpatient clinic in Germany between 2012 and 2018. A control group of all patients treated for acute ischemic stroke in 2018 was used to elicit possible differences in stroke localization, etiology, and distribution of risk factors.

Results

Out of 3615 patients with an acute ischemic stroke, 24 (0.7%) were newly or previously diagnosed as human immunodeficiency virus-positive. Strokes in this cohort were caused by large-vessel disease (37.5%), small-vessel disease (20.8%), cryptogenic-embolism (20.8%), vasculitis (16.7%), and cardio-embolism (4.2%). Large-vessel disease-related strokes were more often located in the posterior circulation (77.8%). Compared to the control group, cardio-embolic strokes were less and vasculitis and large-vessel disease more frequent. Human immunodeficiency virus-positive patients were younger at stroke onset (53.7 ± 12.8 vs. 70.2 ± 14.6 years, p = 0.05).

Discussion

Although the prevalence of human immunodeficiency virus-infection among patients treated for acute ischemic strokes appears low, this collective merits special attention due to a high burden of potentially modifiable risk factors and vasculitis.

Conclusion

Compared to previous studies, age at stroke onset was one of the highest, supporting the hypothesis that as antiretroviral therapy increases the life expectancy of people living with HIV/AIDS, they will be increasingly affected by cardiovascular disease. Human immunodeficiency virus-related cerebral vasculitis was associated with high mortality (75%).

Frequency of Human Immunodeficiency Virus in Patients Admitted with Acute Stroke

Introduction Stroke is a leading cause of chronic disability and death in both developing and developed countries. A significant proportion of stroke patients are human immunodeficiency virus (HIV) positive. About half of the HIV patients experience some sort of neurological deficit in their lifetimes. The exact reason for the occurrence of stroke in HIV infected patients is poorly understood. The purpose of our study is to determine the frequency of HIV among patients admitted with acute stroke. Materials and methods This cross-sectional study is conducted at a major metropolitan hospital in Karachi for six months. A total of 130 patients of stroke between the ages of 30 and 70 years of either gender were included in this study. A complete history was taken and a physical examination was performed. Each patient underwent a battery of tests that included HIV serology, lipid profile, electrocardiography (ECG), chest X-ray (posteroanterior (PA) view), and computed tomography (CT) scan of the brain. Carotid Doppler ultrasonography to assess carotid artery stenosis was also ordered. The means and standard deviations of age and cluster of differentiation 4 (CD4) cell count were calculated. The frequencies and proportions of gender, diabetes mellitus (DM), hypertension (HTN), smoking, obesity, dyslipidemia, carotid artery stenosis, and HIV status were calculated. Stratification was done by applying the chi-square test and assuming p-value ≤0.05 as significant. This helped analyze the association of age, gender, DM, HTN, smoking, obesity, dyslipidemia, and carotid artery stenosis to the frequency of HIV. Results The mean age of the study population was 55.54 ± 11.166 years. There were 39 (30%) patients <50 years of age while 91 (70%) patients were ≥50 years of age. Gender distribution showed that 86 (66.15%) patients were male, and 44 (33.85%) patients were female. Furthermore, 71 (54.62%) patients were hypertensive, 53 (40.77%) were diabetic, 62 (47.69%) were smokers, 49 (37.69%) were obese, 52 (40%) had dyslipidemia, and 77 (59.23%) had carotid artery stenosis. The frequency of HIV was noted at 24 (18.46%). The mean CD4 count was estimated at 241 ± 103.295 cells/mm³. Stratification showed a significant relationship between the frequency of HIV with only gender (p=0.01) and dyslipidemia (p=0.037). Conclusion HIV infection in patients with stroke is not uncommon. Patients who are male, younger in age, have dyslipidemia, belong to a low socioeconomic class, or have a bad sexual history are more likely to have HIV as an underlying cause of stroke. The exact pathogenesis of such a stroke and the role of antiretroviral therapy in the prevention and treatment of this group of stroke are not completely understood and need further analysis.

Functional outcome of stroke inpatients according to human immunodeficiency virus status: A feasibility study

Background

Stroke in human immunodeficiency virus positive (HIV+) individuals is becoming an increasing concern. Being significantly younger than typical stroke patients, the impact of functional challenges on quality of life and burden on society becomes more eminent.

Objectives

This feasibility study aims to determine the requirements for a large descriptive cohort, to adequately describe the functional outcome of stroke patients with varying HIV status.

Method

All stroke patients meeting the inclusion criteria were recruited over a 6-month period at a South African inpatient rehabilitation centre. Data were collected on admission and discharge using outcome measures including the Barthel Index (BI), Berg Balance Scale (BBS) and the use of assistive devices used to describe independence with activities of daily living (ADL), mobility and safety post-stroke. Statistical analysis was performed using Stata version 14.2.

Results

The feasibility study identified appropriate procedures and barriers to a successful study in addition to describing preliminary data on participant demographics, relevant medical history and functional outcomes post-stroke. Limitations that affected feasibility included minimal recruitment sites, length of data collection period, timely communication of participant discharge plans and dates, and confirmation of participant HIV status. An appropriate comparison between sub-groups could not be made because of disproportionate group sizes, median age differences and no assessor blinding.

Conclusion

To increase generalisability and the understanding of the unique HIV+ stroke profile, multiple recruitment sites, longer data collection periods, assessor blinding and age-matched groups with HIV status confirmation are recommended.

HIV-related cardiovascular diseases: the search for a unifying hypothesis

Although the extensive rollout of antiretroviral (ARV) therapy resulted in a longer life expectancy for people living with human immunodeficiency virus (PLHIV), such individuals display a relatively increased occurrence of cardiovascular diseases (CVD). This health challenge stimulated significant research interests in the field, leading to an improved understanding of both lifestyle-related risk factors and the underlying mechanisms of CVD onset in PLHIV. However, despite such progress, the precise role of various risk factors and mechanisms underlying the development of HIV-mediated CVD still remains relatively poorly understood. Therefore, we review CVD onset in PLHIV and focus on 1) the spectrum of cardiovascular complications that typically manifest in such persons and 2) underlying mechanisms that are implicated in this process. Here, the contributions of such factors and modulators and underlying mechanisms are considered in a holistic and integrative manner to generate a unifying hypothesis that includes identification of the core pathways mediating CVD onset. The review focuses on the sub-Saharan African context, as there are relatively high numbers of PLHIV residing within this region, indicating that the greater CVD risk will increasingly threaten the well-being and health of its citizens. It is our opinion that such an approach helps point the way for future research efforts to improve treatment strategies and/or lifestyle-related modifications for PLHIV.

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

INTRODUCTION

An 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.

METHODS

Data 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.

RESULTS

Of 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.

CONCLUSIONS

From 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.

Carotid Artery Aneurysm in HIV: A Review of Case Reports in Literature

BACKGROUND

HIV infection may affect the cardiovascular system through different physiopathological patterns. Rarely reported in HIV negative patients, aneurysms involving the carotid artery have been described for the first time in seropositive patients in 1989.

AIMS

In our study, we have focused on aneurysm pathology affecting carotid arteries in HIV patients, analyzing clinical and surgical presentation, management, and outcome, through a review of cases published in the literature.

METHODS

The MEDLINE (www.ncbi.nlm.nih.gov/pubmed) database was reviewed for "carotid artery aneurysm AND HIV OR AIDS OR immunodeficiency."

RESULTS

Nineteen articles including a total of 46 cases were included in our report. The mean age of patients was 30.6 ± 14.2 years; 30 patients (65.2%) were male. Aneurysms were localized in the intracranial carotid (41.3%) or extracranial artery (58%). Presenting features included symptoms due to compression of neck structures; positivity for neurological symptoms occurred in 36.9%. Patients were managed surgically in 58.7% of cases; surgical morbidity and mortality were of 22.2% and 7.4% respectively, higher for endovascular procedures. The overall mortality in treated and untreated cases was 26.1%.

CONCLUSIONS

Aneurysms may occur in both the extracranial and intracranial carotid artery in patients with HIV at younger age than in non-HIV patients and are linked to a high morbidity and mortality. Seropositivity must be ruled out whenever this rare vascular condition may occur in the absence of a more likely aetiology and must also be suspected in HIV patients presenting with compressive symptoms of the neck, neurological impairment or stroke.

HIV vasculopathy versus VZV vasculitis in an HIV patient with multiple brain ischaemic infarcts

We report the case of a 56-year-old man who presented to the emergency department with a 3-day onset of left limb weakness and feeling intoxicated with poor balance. Stroke hospitalisations in the USA decreased from 2000 to 2010, however the number of hospitalised patients with ischaemic stroke and HIV infection has increased significantly. Herein, we discuss the management of this unique case to highlight the importance of a broad differential diagnosis when approaching HIV/AIDS patients presenting with acute or subacute neurological focalisation. Given that HIV vasculopathy is a diagnosis of exclusion, it requires a thoughtful elimination of all possible aetiologies.

Neurological disorders in HIV in Africa: a review

BACKGROUND

Neurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa.

METHODS

Seminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. "Nervous System Diseases" "HIV Infections" and "Africa South of the Sahara" and "Seizures" or "Spinal Cord Diseases" or "Peripheral Nervous System Diseases" or "AIDS Dementia Complex" or "Opportunistic Infections" or "Immune Reconstitution Inflammatory Syndrome" or "Stroke". Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders.

RESULTS

Neurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6-9-month mortality rate of 60-70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%.

CONCLUSION

Neurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.

Incidence of stroke in patients with HIV infection: A population-based study in Taiwan

Background

Few studies have evaluated whether people infected with human immunodeficiency virus (HIV) are at an increased risk of stroke in an Asian population. We investigated the association between HIV infection and the risk of developing stroke by age, calendar year of HIV diagnosis, and follow-up duration in Taiwan.

Methods

Using the claims data of a universal health insurance program, we identified 5,961 patients with HIV and 23,844 matched non-HIV subjects without previous stroke from 1998 to 2005 and followed them up until the end of 2011 to measure the incidence of stroke. Cox proportional hazards models adjusted for potential confounders were used to estimate hazard ratios (HR) and 95% confidence intervals (CI), with the non-HIV group as reference.

Results

During a median follow-up of 8 years, the incidence rates for total, ischemic, and hemorrhagic stroke per 1000 person-years were 2.12, 1.22, and 0.60, respectively, in patients with HIV infection, and 1.98, 1.14, and 0.54, respectively, in the comparison group. HIV infection was associated with an elevated risk of developing total stroke (adjusted HR [95% CI], 1.57 [1.15–2.14]) and ischemic stroke (1.91 [1.25–2.91]) in patients aged less than 45 years, but no association was observed in other age groups (P for interaction with age, p = 0.048 and 0.024, respectively). Patients diagnosed with HIV infection in 1998–1999 had a greater HR for total stroke and ischemic stroke than those diagnosed in 2000–2002 and 2003–2005 (P for interaction, for total stroke p = 0.034, for ischemic stroke p = 0.056). The HRs did not differ by follow-up duration.

Conclusions

HIV infection among a young age group is associated with increased risk of developing overall and ischemic stroke. The findings highlight the importance of screening and correcting risk factors for young stroke prevention immediately and aggressively.

Global HIV neurology: a comprehensive review

: Neurological conditions associated with HIV remain major contributors to morbidity and mortality and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence shows that the central nervous system (CNS) may serve as a reservoir for viral replication, which has major implications for HIV eradication strategies. Although there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of neurological conditions associated with HIV infection, significant scientific gaps remain. In many resource-limited settings, antiretrovirals considered second or third line in the United States, which carry substantial neurotoxicity, remain mainstays of treatment, and patients continue to present with severe immunosuppression and CNS opportunistic infections. Despite this, increased global access to cART has coincided with an aging HIV-positive population with cognitive sequelae, cerebrovascular disease, and peripheral neuropathy. Further neurological research in low-income and middle-income countries (LMICs) is needed to address the burden of neurological complications in HIV-positive patients, particularly regarding CNS viral reservoirs and their effects on eradication.

Risk factors for stroke occurrence in a low HIV endemic West African country: A case-control study

BACKGROUND

HIV infection is an emerging vascular risk factor associated with stroke occurrence. The weight of evidence from sub-Saharan Africa in support of this has accrued from countries with high HIV prevalence. Our objective was to assess the contribution of HIV sero-positivity to the occurrence and outcomes of stroke in a West African country with low HIV prevalence.

METHODS

A case-control study design conducted at a tertiary medical center in Ghana involved in the Stroke Investigative Research & Educational Networks (SIREN) epidemiological study. Stroke cases were adults (aged ≥18 years) with CT or MRI confirmed stroke and stroke-free controls were age-matched and recruited from communities in the catchment areas of cases. Standard instruments were used to assess vascular and lifestyle factors and serological screening for HIV antibodies was conducted for all study participants. Stroke patients were followed for in-patient mortality outcomes. Associations between HIV, demographic and vascular risk factors and stroke occurrence and outcomes were assessed using logistic regression analysis.

RESULTS

We enrolled 540 stroke cases and 540 control subjects with a mean (± SD) age of 60.8 ± 15.5 years (cases) and 60.0 ± 15.5 (controls). Among stroke cases, the frequency of HIV was 12/540 (2.2%, 95% CI: 1.3% - 3.6%) versus 15/540 (2.8%, 95% CI: 1.7% - 4.6%) among stroke-free controls, p = .70. However, the median (IQR) age of Persons Living with HIV (PLWH) with stroke was significantly lower at 46.5 (40-65.3) years versus 61.0 (50-74) years, p = .03 among HIV- stroke patients. Stroke among PLWHA was predominantly hemorrhagic in 7 out of 12 cases and ischemic in 5 of 12 with notable clustering of established factors such as hypertension, (100%), dyslipidemia, 83.3%, central obesity, 50.0%, diabetes mellitus, 33.3%, cardiac diseases, 8.3% in this group. None of the PLWH with stroke were receiving antiretroviral therapy.

CONCLUSION

We found no associations between HIV infection and stroke occurrence among Ghanaians. However a clustering of cardio-metabolic factors in the context of HIV may promote stroke occurrence in younger individuals.

Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke

There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.

Association of HIV infection with age and symptomatic carotid atherosclerotic disease at the time of carotid intervention in the United States

The primary objectives of this work were: (1) to describe trends in HIV prevalence among those undergoing carotid intervention (carotid endarterectomy or carotid artery stenting) in the United States; and (2) to determine if HIV infection is independently associated with symptomatic carotid atherosclerotic disease or age at the time of carotid intervention. In a nationally representative inpatient database from 2004 to 2014, HIV infection was associated with younger age at the time of carotid intervention (59 years [SE 0.2] vs 71 years [SE 0.01], p < 0.001), male sex (83% vs 58%, p < 0.001), black race (21% vs 4%, p < 0.001), and symptomatic carotid atherosclerotic disease (18.8% vs 11.0%, p < 0.001). Among those undergoing carotid intervention, there was a significant increase in the prevalence of HIV from 0.08% in 2004 to 0.17% in 2014 ( p < 0.001). After adjustment for patient demographics, comorbidities and other covariates, HIV infection remained significantly associated with younger age (-8.9 years; 95% CI: -9.7 to -8.1; p < 0.001) at the time of carotid intervention, but HIV infection was not independently associated with symptomatic carotid atherosclerotic disease.

Stroke in Human Immunodeficiency Virus-infected Individuals in Sub-Saharan Africa (SSA): A Systematic Review

BACKGROUND

Human immunodeficiency virus (HIV) infection is associated with worse outcomes after stroke, but this association is less well-described in sub-Saharan Africa (SSA). We reviewed literature on stroke among people living with HIV (PLWH) in SSA.

METHODS

We systematically reviewed published literature for original clinical stroke studies conducted in SSA that included PLWH. We included studies that reported data on presenting characteristics, risk factors, and/or outcomes after stroke.

RESULTS

Seventeen studies (N = 478) met inclusion criteria. At the time of stroke presentation, PLWH had a median age ranging from 32 to 43 years. Subjects had low CD4 counts (median CD4, 108-225 cells/µl), and most were antiretroviral therapy-naïve. Fever, seizures, and concurrent opportunistic infections were common at presentation. Ischemic stroke accounted for up to 96% of strokes, which were mostly located in the anterior circulation territory. In studies comparing PLWH with HIV-uninfected individuals, PLWH had more frequent coagulopathy, greater stroke severity, (72% versus 36% National Institutes of Health Stroke Scale >13, P = .02), longer hospital length of stay (30.5 versus <10 days), and a higher 30-day mortality rate (23% versus 10.5%, P = .007).

CONCLUSION

Stroke in PLWH in SSA occurs at a young age, in those with advanced disease, and is associated with worse outcomes than in HIV-uninfected comparators. Stroke in young individuals in the region should prompt HIV testing, and ongoing efforts to promote early antiretroviral therapy initiation might also help decrease stroke incidence, morbidity, and mortality in the region.

Six hours of task-oriented training optimizes walking competency post stroke: a randomized controlled trial in the public health-care system of South Africa

OBJECTIVE

To evaluate a minimal dose intervention of six 1-hour sessions of task-oriented circuit gait training including a caregiver over a 12-week period to persons post stroke in the South African public health sector.

DESIGN

Stratified, single blinded, randomized controlled trial with three intervention groups.

PARTICIPANTS

Persons post stroke ( n = 144, mean age 50 years, 72 women), mean 9.5 weeks post stroke.

INTERVENTIONS

Task group ( n = 51)-accompanied by a caregiver; task-oriented circuit gait training (to improve strength, balance, and task performance while standing and walking). Strength group ( n = 45); strength training of lower extremities while sitting and lying. Control group ( n = 48); one 90-minute educational session on stroke management.

MEASURES

The six-minute walk test (6MinWT) was the primary outcome; the secondary outcomes included comfortable and fast gait speeds, Berg Balance Scale (BBS), and Timed Up and Go (TUG). Particpants evaluated at baseline, post intervention (12 weeks), and at follow-up 12 weeks later. Change scores were compared using generalized repeated measures analysis of variance (ANOVA).

RESULTS

Task group change scores for all outcomes post intervention and at follow-up were improved compared to the other groups ( P-values between 0.000005 and 0.04). The change scores (mean, 1SD) between baseline and follow-up for the Task, Strength, and Control groups, respectively, were as follows: 6MinWT:119.52 m (81.92), 81.05 m (79.53), and 60.99 m (68.38); comfortable speed 0.35 m/s (0.23), 0.24 m/s (0.22), and 0.19 m/s (0.21); BBS: 9.94 (7.72), 6.93 (6.01), and 5.19 (4.80); and TUG: -14.24 seconds (16.86), -6.49 seconds (9.88), and -5.65 seconds (8.10).

CONCLUSION

Results support the efficacy of a minimal dose task-oriented circuit training program with caregiver help to enhance locomotor recovery and walking competency in these persons with stroke.

Ischemic Stroke in an HIV Positive Patient: An Initial Presentation of Neurosyphilis

Ischemic stroke occurring in patients with human immunodeficiency virus (HIV) needs to be approached with a vast differential diagnosis in mind. We report a case of middle-aged male patient with immune reconstituted HIV on therapy without known cardiovascular risk factors who had a right middle cerebral artery territory infarct. After a thorough evaluation, he received a final diagnosis of neurosyphilis-associated vasculitis leading to stroke. He recovered without any neurological deficits following treatment with intravenous benzylpenicillin. Neurosyphilis is an easily diagnosed and treatable cause of a stroke that can be an initial presentation of neurosyphilis but requires a high index of suspicion.

HIV infection and stroke

The landscape of human immunodeficiency virus (HIV) infection is changing with the increasing coverage of antiretroviral therapy (ART). Patients are living longer but continually exposed to a virologically suppressed HIV infection. This has resulted in a decrease in acquired immune deficiency syndrome (AIDS)-related complications such as opportunistic infections, and an increase in non-AIDS complications such as stroke. In this era, stroke is perhaps the most important neurologic complication of HIV infection. Furthermore, stroke is more of a heterogeneous disease in people living with HIV infection and therefore needs to be approached systematically. Many of the etiologies are treatable. HIV-associated vasculopathy is perhaps the most common etiology in this population and our understanding of this is still evolving. Moreover, the treatment of HIV infection may contribute to an excess risk of stroke and interact with stroke therapies.

Global developments in HIV neurology

Neurologic conditions associated with HIV remain major contributors to morbidity and mortality, and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence suggests that the central nervous system (CNS) serves as a reservoir for viral replication with major implications for human immunodeficiency virus (HIV) eradication strategies. Though there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of HIV-associated neurologic conditions, significant scientific gaps remain. In many low-income settings, second- and third-line cART regimens that carry substantial neurotoxicity remain treatment mainstays. Further, patients continue to present severely immunosuppressed with CNS opportunistic infections. Public health efforts should emphasize improvements in access and optimizing treatment of HIV-positive patients, specifically in resource-limited settings, to reduce the risk of neurologic sequelae.

The association between HIV and atherosclerotic cardiovascular disease in sub-Saharan Africa: a systematic review

Background

Sub-Saharan Africa (SSA) has confronted decades of the HIV epidemic with substantial improvements in access to life-saving antiretroviral therapy (ART). Now, with improved survival, people living with HIV (PLWH) are at increased risk for non-communicable diseases (NCDs), including atherosclerotic cardiovascular disease (CVD). We assessed the existing literature regarding the association of CVD outcomes and HIV in SSA.

Methods

We used the PRISMA guidelines to perform a systematic review of the published literature regarding the association of CVD and HIV in SSA with a focus on CVD surrogate and clinical outcomes in PLWH.

Results

From January 2000 until March 2017, 31 articles were published regarding CVD outcomes among PLWH in SSA. Data from surrogate CVD outcomes (n = 13) suggest an increased risk of CVD events among PLWH in SSA. Although acute coronary syndrome is reported infrequently in SSA among PLWH, limited data from five studies suggest extensive thrombus and hypercoagulability as contributing factors. Additional studies suggest an increased risk of stroke among PLWH (n = 13); however, most data are from immunosuppressed ART-naïve PLWH and thus are potentially confounded by the possibility of central nervous system infections.

Conclusions

Given ongoing gaps in our current understanding of CVD and other NCDs in PLWH in SSA, it is imperative to ascertain the burden of CVD outcomes, and to examine strategies for intervention and best practices to enhance the health of this vulnerable population.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4940-1) contains supplementary material, which is available to authorized users.

Disparities in Management of Cardiovascular Disease in Rural South Africa: Data From the HAALSI Study (Health and Aging in Africa: Longitudinal Studies of International Network for the Demographic Evaluation of Populations and Their Health Communities)

BACKGROUND

Optimal secondary prevention is critical for the reduction of repeated cardiovascular events, and the control of cardiovascular risk factors in this context is essential. Data on secondary prevention of cardiovascular disease (CVD) in sub-Saharan Africa are needed to inform intervention strategies with a particular focus on local disparities. The aim of this study was to assess CVD management in a rural community in northeast South Africa.

METHODS AND RESULTS

We recruited adults aged ≥40 years residing in the Agincourt subdistrict of Mpumalanga province. Data collection included socioeconomic and clinical data, anthropometric measures, blood pressure, human immunodeficiency virus status, and point-of-care glucose and lipid levels. CVD was defined as self-report of myocardial infarction and stroke or angina diagnosed by Rose Criteria. A linear regression model was built to identify variables independently associated with the number of cardiovascular risk factors controlled. Of 5059 subjects, 592 (11.7%) met CVD diagnostic criteria. Angina was reported in 77.0% of these subjects, stroke in 25.2%, and myocardial infarction in 3.7%. Percent controlled of the 5 individual risk factors assessed were as follows: tobacco 92.9%; blood pressure 51.2%; body mass index 33.8%; low-density lipoprotein 31.4%; and waist-to-hip ratio 29.7%. Only 4.4% had all 5 risk factors controlled and 42.4% had ≥3 risk factors controlled. Male sex (β coefficient=0.44; 95% confidence interval, 0.25-0.63; P<0.001), absence of physical disability (β coefficient=0.40; 95% confidence interval, 0.16-0.65; P=0.001), and socioeconomic status (β coefficient=0.10; 95% confidence interval, 0.01-0.19; P=0.035) were directly associated with the number of risk factors controlled.

CONCLUSIONS

Currently, CVD is not being optimally managed in this rural area of South Africa. There are significant disparities in control of CVD risk factors by sex, socioeconomic status, and level of disability. Efforts to improve secondary prevention in this population should be focused on females, subjects from lower socioeconomic status, and those with physical disabilities.

The Role of Human Immunodeficiency Virus-Associated Vasculopathy in the Etiology of Stroke

Background

Human immunodeficiency virus (HIV) infection is a recognized risk factor for stroke among young populations, but the exact mechanisms are poorly understood. We studied the clinical, radiologic, and histologic features of HIV-related ischemic stroke to gain insight into the disease mechanisms.

Methods

We conducted a prospective, in-depth analysis of adult ischemic stroke patients presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi, in 2011.

Results

We recruited 64 HIV-infected and 107 HIV-uninfected patients. Those with HIV were significantly younger (P < .001) and less likely to have established vascular risk factors. Patients with HIV were more likely to have large artery disease (21% vs 10%; P < .001). The commonest etiology was HIV-associated vasculopathy (24 [38%]), followed by opportunistic infections (16 [25%]). Sixteen of 64 (25%) had a stroke soon after starting antiretroviral therapy (ART), suggesting an immune reconstitution-like syndrome. In this group, CD4+ T-lymphocyte count was low, despite a significantly lower HIV viral load in those recently started on treatment (P < .001).

Conclusions

HIV-associated vasculopathy and opportunistic infections are common causes of HIV-related ischemic stroke. Furthermore, subtypes of HIV-associated vasculopathy may manifest as a result of an immune reconstitution-like syndrome after starting ART. A better understanding of this mechanism may point toward new treatments.

HIV Infection and Risk of Cardiovascular Diseases Beyond Coronary Artery Disease

PURPOSE OF REVIEW

Cardiovascular disease (CVD) increasingly afflicts people living with HIV (PLWH) in the contemporary era of antiretroviral therapy (ART). Coronary artery disease (CAD) is the most widely studied cardiovascular problem in PLWH; however, less is known about other clinically relevant subtypes of CVD such as heart failure (HF), cerebrovascular disease, sudden cardiac death, pericardial diseases, and pulmonary hypertension. This paper reviews evidence of other subtypes of CVD as emerging issues in the post-ART era.

RECENT FINDINGS

Recent studies have shown that PLWH have higher risk of HF as well as subclinical impairment of left ventricular (LV) mechanics (systolic and diastolic dysfunction) and myocardial abnormalities (fibrosis and steatosis). The underlying mechanisms, however, are not well-understood. A few studies have also shown higher rates of atrial fibrillation and sudden cardiac death in PLWH. Ischemic stroke is the most common stroke type in the post-ART era, with underlying mechanisms like those identified in CAD: chronic inflammation and associated vasculopathy. Studies of great vessels (carotid artery and aorta) and peripheral arterial disease show heterogeneous results. Small subclinical pericardial effusions are common in PLWH in post-ART era. Pulmonary hypertension continues to be an underdiagnosed and potentially fatal complication of HIV infection. PLWH remain at higher risk for all types of CVD including heart failure, stroke, and arrhythmias in the post-ART era. Chronic inflammation may play an important role in this increased risk. More studies are needed to further elucidate the extent of non-coronary CVD in PLWH and the underlying mechanisms for them.

HIV infection, hypercoagulability and ischaemic stroke in adults at the University Teaching Hospital in Zambia: a case control study

BACKGROUND

In Zambia, 14.2% of adults have HIV/AIDS. There has been a substantial and significant increase in patients hospitalized for ischaemic stroke with co-existing HIV infection. However, little is known about the mechanism of stroke in these HIV + ve patients let alone studied in our region. The aim of this pilot study was to explore the association of hypercoagulability state in HIV + ve patients with ischaemic stroke. This was achieved by comparing hypercoagulability state markers between HIV + ve ischaemic stroke patients with HIV-ve and HIV + ve patients with and without ischaemic stroke respectively.

METHODS

A matched case control study in which a total of 52 HIV + ve patients with ischaemic stroke were prospectively compared with control groups for the presence of protein S, protein C deficiencies and hyperhomocysteinaemia. The control groups comprised an equal number of consecutively matched for age and sex HIV-ve and HIV + ve patients with and without ischaemic stroke respectively. Data was analysed in contingency tables using Paired t- test, Chi square and conditional logistic regression.

RESULTS

Ischaemic stroke of undetermined aetiology occurred more frequently in HIV + ve compared to HIV-ve patients (p < 0.001). In addition, protein S deficiency and Hyperhomocysteinaemia were more prominent in HIV + ve than HIV-ve ischaemic stroke patients (P = 0.011). There was no difference in the presence of hyperhomocysteinaemia or protein S deficiency in HIV + ve patients with or without ischaemic stroke. Protein C deficiency was not noted to be significantly different between the cases and the two control arms.

CONCLUSION

Protein S deficiency and hyperhomocysteinaemia were associated with HIV infection, but not stroke in our study population. However, this is an area that requires extensive research and one that we cannot afford to ignore as it is an important bridge to all cardiovascular and cerebrovascular diseases.

Considerations on the Relevance of Cerebral Fusiform Aneurysms Observed During HIV Infection

Human immunodeficiency virus (HIV)-associated ectatic cerebral vasculitis (HIV-AECV) is a rare form of vasculitis with diffuse fusiform aneurysms. Its pathophysiology remains poorly understood. Although extensively described in children, it is still incompletely studied in adults. Our objective was to present five adult cases with emphasis on imaging findings and long-term evolution. From 2006 to 2014, we included 5 HIV-infected patients presenting with fusiform cerebral aneurysms. Vessels abnormalities were assessed with brain computed tomography (CT) angiography, magnetic resonance angiography (MRA) and/or digital subtraction angiography (DSA). All patients had MR assessment of the brain. Clinical and biological data were analyzed. Fusiform aneurysms of carotid terminations extending to middle and anterior cerebral arteries were bilateral in three patients and unilateral in one. More distal fusiform aneurysms were observed in four patients and saccular aneurysms in two patients, two patients suffered from ischemic lesions while none experienced hemorrhage. Unlike recent reviews, our study underlines the low hemorrhagic potential of HIV-AECV and long-term follow-up suggests a monophasic evolution under antiretroviral medication.

Epidemiology of Acquired Immune Deficiency Syndrome and Cerebrovascular Disease in a Post Antiretroviral Era

BACKGROUND

People with acquired immune deficiency syndrome (AIDS) develop ischemic stroke through distinct mechanisms. These include infections such as syphilis, tuberculosis, varicella, and other conditions such as cocaine abuse, endocarditis, and hypercoagulability. The effect of improved awareness, detection, and treatment with highly active antiretroviral therapy (HAART) on the incidence and outcome of AIDS patients with stroke is unknown.

METHODS

Data from the Nationwide Inpatient Sample from 1995 to 2010 were analyzed. Patients with ischemic stroke and AIDS were identified using ICD-9 (International Classification of Diseases) codes. Time trends for demographics, survival, and frequency of AIDS-associated conditions were analyzed.

RESULTS

Proportion of AIDS among stroke patients increased significantly during the study. Median age of all strokes decreased from 75 years in 1995 to 72 years in 2010. Conversely, median age for men with stroke and AIDS increased from 43 years to 53 years; and for women with stroke and AIDS, from 41 years to 51 years. Death rates from stroke in the AIDS patients declined. In recent years, the death rates from stroke are similar to patients without HIV/AIDS. Stroke patients with AIDS had increased odds of syphilis (odds ratio [OR]: 33.50), varicella (OR: 48.34), tuberculosis (OR: 137.48), endocarditis (OR: 5.19), cocaine abuse (OR: 26.05), and hypercoagulability (OR: 4.82).

CONCLUSIONS

In the HAART era, the median age of incident stroke in AIDS has increased and the mortality from stroke has improved. Research should focus on optimal management of dyslipidemia while on HAART. Whether HAART can reduce the incidence and improve survival of stroke needs to be explored.

Impact of HIV on inpatient mortality and complications in stroke in Thailand: a National Database Study

The co-existence of stroke and HIV has increased in recent years, but the impact of HIV on post-stroke outcomes is poorly understood. We examined the impact of HIV on inpatient mortality, length of acute hospital stay and complications (pneumonia, respiratory failure, sepsis and convulsions), in hospitalized strokes in Thailand. All hospitalized strokes between 1 October 2004 and 31 January 2013 were included. Data were obtained from a National Insurance Database. Characteristics and outcomes for non-HIV and HIV patients were compared and multivariate logistic and linear regression models were constructed to assess the above outcomes. Of 610 688 patients (mean age 63·4 years, 45·4% female), 0·14% (866) had HIV infection. HIV patients were younger, a higher proportion were male and had higher prevalence of anaemia (P < 0·001) compared to non-HIV patients. Traditional cardiovascular risk factors, hypertension and diabetes, were more common in the non-HIV group (P < 0·001). After adjusting for age, sex, stroke type and co-morbidities, HIV infection was significantly associated with higher odds of sepsis [odds ratio (OR) 1·75, 95% confidence interval (CI) 1·29-2·4], and inpatient mortality (OR 2·15, 95% CI 1·8-2·56) compared to patients without HIV infection. The latter did not attenuate after controlling for complications (OR 2·20, 95% CI 1·83-2·64). HIV infection is associated with increased odds of sepsis and inpatient mortality after acute stroke.

Central nervous system vasculitis in adults: An update

Primary central nervous system vasculitis (PCNSV) is a challenging diagnosis due to broad clinical manifestations and variable specificity and sensitivity of laboratory and imaging diagnostic tools. Differential diagnosis includes reversible cerebral vasoconstriction syndrome (RCVS), secondary vasculitis of the CNS and other noninflammatory vasculopathies. Brain biopsy is essential for definitive diagnosis and to exclude mimickers. Recent data show that data large-vessel PCNSV present worse prognosis when compared to small-vessel PCNSV. Herein we review diagnosis and management of PCNSV, secondary vasculitis of CNS and RCVS.

Computed tomography stroke findings and population demographics at Pelonomi Hospital, Bloemfontein

Background: Stroke remains the highest cause of death in patients more than 50 years old in South Africa, and the fourth highest cause of death overall. There is a paucity of information regarding this disease in the Free State Province.Objectives: To assess the stroke profile of patients referred for computed tomography (CT) imaging to our institution along with evaluating factors that could improve stroke management.Method: The demographic information, stroke risk factors, stroke types and time to imaging were evaluated for all patients who presented for CT stroke imaging from July 2014 until July 2015. Information was gathered prospectively from the hospital and radiology information systems.Results: The study included 174 patients (53.5% female, 46.5% male). Their mean age was 59 years (standard deviation (SD) 14.6). The most prevalent risk factors were hypertension (83.7%), smoking (20.5%) and diabetes (15.0%). The population group consisted of 67.8% ischaemic (n = 118) and 32.2% (n = 56) haemorrhagic strokes. The majority of patients with a known time of symptom onset (n = 102) presented after 8 hours (82.4%). The median order to report time (ORT) was 61 min (range 18 min–1361 min). The median arrival to report time (ART) was 32 min (range 4 min–893 min).Conclusion: Our stroke population did not differ significantly from others in South Africa and Africa overall. Pre- and in-hospital delays significantly influenced patient numbers qualifying for thrombolysis.

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

OBJECTIVE

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.

DESIGN AND SETTING

Studies including HIV-infected patients developing a cerebral ischemic event were systematically searched for in MEDLINE/PubMed.

PATIENTS AND MAIN OUTCOME MEASURES

Baseline, treatment and outcome data were appraised and pooled with random-effects methods computing summary estimates (95% confidence intervals).

RESULTS

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.

CONCLUSION

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.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Arterial ischemic stroke in HIV: Defining and classifying etiology for research studies

HIV infection, and potentially its treatment, increases the risk of an arterial ischemic stroke. Multiple etiologies and lack of clear case definitions inhibit progress in this field. Several etiologies, many treatable, are relevant to HIV-related stroke. To fully understand the mechanisms and the terminology used, a robust classification algorithm to help ascribe the various etiologies is needed. This consensus paper considers the strengths and limitations of current case definitions in the context of HIV infection. The case definitions for the major etiologies in HIV-related strokes were refined (e.g., varicella zoster vasculopathy and antiphospholipid syndrome) and in some instances new case definitions were described (e.g., HIV-associated vasculopathy). These case definitions provided a framework for an algorithm to help assign a final diagnosis, and help classify the subtypes of HIV etiology in ischemic stroke.

Incidence and predictors of hypertension in adults with HIV-initiating antiretroviral therapy in south-western Uganda

OBJECTIVE

The successful scale-up of antiretroviral therapy (ART) in sub-Saharan Africa has led to increasing life expectancy, and thus increased risk of hypertension. We aimed to describe the incidence and predictors of hypertension in HIV patients receiving ART at a publicly funded clinic in rural Uganda.

METHODS

We abstracted data from medical records of adult patients who initiated ART at an HIV clinic in south-western Uganda during 2010-2012. We defined hypertension as at least two consecutive clinical visits, with a SBP at least 140 mmHg and/or SBP of at least 90 mmHg, or prescription for an antihypertensive medication. We calculated the incidence of hypertension and fit multivariable Cox proportional-hazards models to identify predictors of hypertension.

RESULTS

A total of 3389 patients initiated ART without a prior diagnosis of hypertension during the observation period. Over 3990 person-years of follow-up, 445 patients developed hypertension, for a crude incidence of 111.5/1000 (95% confidence interval 101.9-121.7) person-years. Rates were highest among men aged at least 40 years (158.8 per/1000 person-years) and lowest in women aged 30-39 years (80/1000 person-years). Lower CD4 cell count at ART initiation, as well as traditional risk factors including male sex, increasing age, and obesity, were independently associated with hypertension.

CONCLUSION

We observed a high incidence of hypertension in HIV-infected persons on ART in rural Uganda, and increased risk with lower nadir CD4 cell counts. Our findings call for increased attention to screening of and treatment for hypertension, along with continued prioritization of early ART initiation.

[Incidence of strokes in HIV-positive patients treated with long term antiretroviral treatment]

INTRODUCTION

With the introduction of triple therapy regimen in 1996, the morbidity and mortality associated with HIV infection decreased significantly. Concomitantly with this clinical success, several metabolic changes including diabetes, arterial hypertension, dyslipidemia and lipodystrophy were observed, being associated with the risk of stroke. This study aims to determine the incidence of strokes in HIV-positive patients treated with long term antiretroviral treatment.

METHODS

This was a retrospective cohort study of HIV-positive adult patients receiving long term antiretroviral treatment for at least 12 months. It was conducted at the Approved Treatment Centres of Douala General Hospital (HGD); data collection spanned a 10-year period from May 2001 to April 2010. Patients were treated according to Cameroon national treatment guidelines. The Kaplan-Meyer method was used to determine the time of stroke onset. The Khi-2 test was used to investigate the association between two qualitative variables. The statistical significance level was set at 0.05.

RESULTS

407 patients were included in the study, 62.4% were female, the average age was 40.1 ± 9.9 years. The incidence of strokes was 1.7% over 72 months follow up with no significant difference between women and men (P = 0.76). The incidence rate was calculated to be 0.3 per 100 person years. 85.7% of cases had an ischemic stroke. The mean time from stroke onset was 33.4 months. Factors associated with stroke occurrence were: patients who underwent treatment at WHO Clinical Stage III and IV and with CD4 count> 100/mm3at the start of antiretroviral therapy.

CONCLUSION

The incidence of stroke in HIV-positive patients treated with long term antiretroviral therapy is similar to that previously reported but these strokes occur at an early age and justify increased clinical monitoring. A prospective study involving a control population is needed.