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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 2  |  Page : 580-582

Thrombolysis of acute ischemic stroke in a HIV-positive patient: Report and review of literature


1 Department of Neurology, Institute of Neuroscience, Medanta – The Medicity, Gurgaon, Haryana, India
2 Department of Neurointervention, Institute of Neuroscience, Medanta – The Medicity, Gurgaon, Haryana, India

Date of Web Publication13-May-2019

Correspondence Address:
Dr. Atma Ram Bansal
Institute of Neuroscience, Medanta – The Medicity, Sector 38, Gurgaon - 122 003, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.258007

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How to cite this article:
Sanariya K, Garg A, Das B, Bansal AR. Thrombolysis of acute ischemic stroke in a HIV-positive patient: Report and review of literature. Neurol India 2019;67:580-2

How to cite this URL:
Sanariya K, Garg A, Das B, Bansal AR. Thrombolysis of acute ischemic stroke in a HIV-positive patient: Report and review of literature. Neurol India [serial online] 2019 [cited 2019 Jul 16];67:580-2. Available from: http://www.neurologyindia.com/text.asp?2019/67/2/580/258007




Sir,

Since the emergence of acquired immune deficiency syndrome (AIDS) in 1981, significant advances in our understanding of AIDS have been achieved. The introduction of combined antiretroviral therapy (cART) since the 1990s has changed the course of human immunodeficiency virus (HIV) infection from a fatal disease to a chronic disease. Treatment with cART results in a longer life expectancy in a HIV-infected individual, which leads to concurrent diseases that are seen in the aging population like diabetes mellitus, hypertension, dyslipidemia, chronic kidney disease, and malignancies. This together with accelerated atherosclerosis due to the human immunodeficiency virus (HIV)-related chronic inflammation predisposes the patient to the risk of cardiovascular and cerebrovascular diseases. In different clinical studies, approximately up to 5% of patients with HIV infection develop stroke.[1] Clinicians managing patients with stroke who have HIV infection, should have knowledge regarding the effect of HIV on stroke, its clinical presentation, and its management. Moreover, stroke could be a presenting feature in patients with an unknown status of the HIV infection.

The index case was a 67-year old gentleman, who presented to the emergency department with complaints of sudden onset slurring of speech and facial asymmetry with right-sided weakness for a 125 min duration. He was a known diabetic and hypertensive on regular treatment. On examination, the patient was conscious and oriented, having a blood pressure of 146/88 mmHg and a pulse of 78/min, that was regular. His baseline National Institutes of Health Stroke Scale (NIHSS) scale score was 6. A clinical diagnosis of acute stroke was made and within the window period, the 'urgent code' brain rescue protocol was activated. The patient was shifted to the CT (computed tomography) suite. Noncontrast CT (NCCT) scan of the head showed no evidence of ischemic infarct and also ruled out a hemorrhage [Figure 1]a. The prethrombolysis basic investigation showed a random blood glucose of 136 mg% and a normal coagulogram (international normalized ratio, INR 1). His door to needle time was 31 min. He received intravenous alteplase over 1h (body weight – 68 kg, alteplase dose – 0.9 mg/kg, total dose – 61 mg, 6 mg given in a bolus for over 1 min and the remaining dose over 60 min). CT perfusion showed a small 'mismatch' area (penumbra) involving the left corona radiata, having preserved cerebral blood volume with decreased cerebral blood flow and increased mean transit time [Figure 1]b,[Figure 1]c,[Figure 1]d. The brain and neck vessel angiography did not reveal any major vascular occlusion [Figure 2]a. Thrombolysis was uneventful and the patient showed partial recovery within the first hour. His power in the right lower extremity improved to 4+/5 but no improvement was seen in the upper extremity strength or in his speech. The patient was shifted to the stroke neurocritical care unit for close observation. The workup also showed a normal cardiac function and no dyslipidemia. During re-evaluation, the patient revealed his HIV status and acknowledged taking antiretroviral therapy for 2 years. A repeat CT scan of the brain done at 24 h showed a small infarct in the left posterior corona radiata area without hemorrhagic transformation [Figure 2]b. He was discharged on aspirin and statin, and antiretroviral drugs were continued as advised by the immunology expert. On a 2-week follow-up, the patient significantly improved in power but persisted with a mild dexterity impairment (modified Rankin scale [mRS] = 2).
Figure 1: Noncontrast computed tomography of the head showed no acute infarct or hemorrhage (a). Computed tomography perfusion study (b-d) showed mismatch deficit (penumbra, red arrows) in the left corona radiata

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Figure 2: Cerebral angiography (a) showed no major vessel occlusion. Repeat (24 h) noncontrast computed tomography of the head (b) showed a small infract in the left posterior corona radiata

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Stroke mimics are common in patients with HIV infection. Neurocysticercosis, toxoplasmosis, tuberculoma, and brain tumor are the main causes of stroke mimics in HIV-infected patients. Limited literature is available regarding the management of acute stroke in HIV patients and the safety of thrombolysis.[2] Initial management of such patients remains the same as carried out in other cases of acute stroke. An urgent CT scan of the brain (based upon the acute stroke protocol) should be obtained to rule out the presence of an acute infarction or bleed. The role of intravenous thrombolysis is uncertain in the absence of randomized controlled studies on HIV-related stroke. Often, the HIV status of the patient is not known at the time of presentation of acute ischemic stroke or the patients may hide their HIV status and the decision for an intravenous thrombolysis must have to be taken in a short time period. Until there is sufficient data regarding the safety of intravenous thrombolysis in patients with HIV infection, the decision regarding thrombolysis in acute ischemic stroke should be based on clinical judgment of the clinician and the patient's choice. Naidoo et al., reported a female patient with retrovirus infection, who had massive pulmonary thromboembolism and acute stroke, was thrombolyzed with streptokinase and had significant improvement.[3]

A variety of causes have been mentioned that account for the development of acute cerebrovascular events in HIV patients, which can be due to the progression of the primary infection or sometimes be due drug-related sequele. HIV infection can lead to vasculopathy which increases the risk of stroke; or, it may predispose the patient to an opportunistic infection which may present as stroke. cART can cause either direct vessel wall injury, which may raise the concentration of endothelial dysfunction markers, or indirectly cause vascular injury by an alteration in the lipid metabolism.

HIV-induced atherosclerosis, vasculitis, cardiomyopathy, and hypercoagulable state are common causes of an ischemic event.[4] Indirect events like endocarditis or other intracranial opportunistic infection can also cause cerebrovascular events in AIDS patients. In our index case, no definite etiology could be found. Electrocardiography and 24 h Holter monitoring did not reveal any evidence of atrial fibrillation or ventricular tachyarrhythmia. Echocardiography showed a normal ejection fraction without any regional wall motion abnormality. No evidence of deep vein thrombosis or pulmonary embolism was noted. From the clinical examination and the available investigations, the probable cause for the ischemic insult was a thromboembolic phenomenon or the presence of a vasculopathy, rather than a cardioembolic phenomenon. Post-thrombolysis, at a 2-week follow-up visit, the patient had significant improvement in symptoms and he attained a modified Rankin scale (mRS) score of 2. In current practice, with proper selection of the patients utilizing an expert clinical judgment, intravenous thrombolysis should be offered in HIV-infected patients with ischemic stroke.

Only medical history and examination cannot identify patients infected with HIV. Hence, certain precautions should always be undertaken while handling the blood and body fluid of all the patients, especially of those having a high risk of acquiring an HIV infection. The Centre for Disease Control and Prevention has recommended “universal blood and body fluid precautions” or simply “universal precautions,”[5] which should be applied in taking care of such patients. Not every exposure to a potential HIV source requires a post-exposure prophylaxis. National AIDS Control Organization has divided such exposures into various categories depending upon the severity and risk of acquiring an HIV infection [Table 1].
Table 1: Different steps in case of post-exposure state

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The literature lacks specific guidelines and does not present with adequate measures to maintain the safety profile of intravenous thrombolysis in such patients. However, eligible patients should be offered thrombolytic therapy, as is done in non-HIV patients. Our case highlights the safety of the procedure and the expectation of a good outcome after intravenous recombinant tissue plasminogen activator (rtPA) therapy has been instituted in an AIDS patient. More studies are required in this regard, as the underlying cause and, therefore, outcome may vary considerably in different patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Benjamin LA, Bryer A, Emsley HC, Khoo S, Solomon T, Connor MD, et al. HIV infection and stroke: Current perspectives and future directions. Lancet Neurol 2012;11:878-90.  Back to cited text no. 1
    
2.
Sharma SR, Hussain M, Habung H. Neurological manifestations of HIV-AIDS at a tertiary care institute in north eastern India. Neurol India 2017;65:64-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Naidoo P, Hift R. Massive pulmonary thromboembolism and stroke. Case Rep Med 2011;2011:398571.  Back to cited text no. 3
    
4.
Khawcharoenporn T. HIV infection and stroke. J Thai Stroke Soc 2015;14: 135-45.  Back to cited text no. 4
    
5.
Centers for Disease Control (CDC). Recommendations for preventing transmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus during invasive procedures. MMWR Morb Mortal Wkly Rep 1986;35:221-3.  Back to cited text no. 5
    


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