Stroke in HIV patients

Background

Etiologies

• Routine causes
  • Large artery atherosclerotic disease (11 to 42%)
  • Small-vessel disease (2 to 35%)
  • Cardioembolic (3 to 19%)
• Infectious (3 to 25%), including (from most to least common): VZV, infective endocarditis, tuberculosis, syphilis, meningitis not otherwise specified, cryptococcosis, toxoplasmosis, bacterial meningitis, mucormycosis, other opportunistic infection
• Other causes (2 to 27%), including (from most to least common): vasculitis, cocaine use, non-atherosclerotic vasculopathy, multiple etiologies, arterial dissection, medication use, sickle cell crisis, carcinomatous meningitis, carotid stump syndrome
• Cryptogenic (10 to 32%)

Investigations

• Assess for rash, manifestations of neurosyphilis, signs of infection
• Laboratory investigations
  • If indicated, lumbar puncture for cell count, protein, glucose, and other infectious workup
  • CBC, CD4, HIV viral load, ESR/CRP, ANA, ANCA, antiphospholipid antibodies, syphilis serology
  • Blood cultures
  • Toxoplasma IgG if not previously documented
  • As indicated, other infectious serologies
• Imaging and other procedures
  • Brain imaging including vasculature
  • Chest x-ray
  • Echocardiography
  • ECG
  • Cardiac rhythm monitoring

Management

• Check for drug-drug interactions
  • Antiplatelet therapy
    • Ritonavir and cobicistat interact with clopidogrel and ticagrelor; preference is for aspirin and/or prasugrel
  • Statins
    • Ritonavir and cobicistat increase levels of all statins; recommendation is atorvastatin or rosuvastatin at a maximum of 10 to 20 mg p.o. daily, with close monitoring for adverse effects (see HIV.gov guidelines)

Further Reading

• Stroke in HIV. Can J Cardiol. 2019 Mar;35(3):280-287. doi: 10.1016/j.cjca.2018.11.032. PMID: 30825950; PMCID: PMC6400325.