Introduction

Intracranial fusiform aneurysmal malformations in Human Immunodeficiency Virus (HIV), originally described in children, have been increasingly recognized in adults. We present 2 cases of this variant to highlight the spectrum of severity and outline long term course in one patient.

Cases:

 1

52 year old woman with 25 year history of HIV, antiretroviral therapy (ART) nonadherence, presented with PML, 18 years ago, at which time CT angiogram (CTA) revealed fusiform dilatation of the right internal carotid (ICA) and middle cerebral artery (MCA). At age 35, she presented with subacute right headache, vomiting, photophobia and alexia. Examination revealed inattention, left sided dysmetria. CT head revealed right frontal infarct. CTA demonstrated right distal ICA thrombosis. There was fusiform dilatation of the anterior communicating artery. She exhibited improvement in examination to baseline. Over 17 years neuroimaging demonstrated stability of aneurysmal dilatations and with development of right MCA territory Moyamoya vascularity. 

2

55 year old man with HIV, off ART for 4 years, presented with cerebral toxoplasmosis. He was restarted on ART and Bactrim, and developed encephalopathy, secondary to IRIS. After stabilization ART was restarted. CTA revealed left MCA fusiform dilation and left internal carotid artery aneurysm. Neurosurgery advised continued surveillance based on size and nature of these aneurysms, without other risk factors. Repeat CTA 9 months later revealed improvement in the fusiform dilatations. He remains neurologically stable and compliant.

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Discussion

The spectrum of HIV vasculopathy encompasses aneurysm, stenosis, small and large vessel occlusions and complications from superimposed opportunistic infections. Moyamoya in HIV vasculopathy is rare, with 3 prior reported cases in adults. The combination of fusiform abnormalities and moyamoya, has not previously been described. We discuss the successful empirical use of long-term anticoagulation in this case. In comparison our second case has interestingly already demonstrated improvement in vasculopathy with ART adherence.