Case report and literature review.

33 year old male  presented with right hemiparesis, encephalopathy, and weight loss.  NIHSS was 8. CT head showed left internal capsule(IC) hypodensity. MRI brain confirmed ischemic stroke in left IC and lenticocapsular area, MRA revealed steno-occlusive disease involving vertebro-basilar junction, bilateral ICA terminus, M1 and A1 segments.  HIV test returned positive, viral load of 6,970 copies and CD4 counts of 229.  RPR was positive at 1:1256 titers.  Lumbar puncture revealed lymphocytic pleocytosis, high protein, low glucose and VDRL positive (1:16).  MRA of vessel wall showed multifocal enhancement and severe stenosis of bilateral supraclinoid ICA, right ACA and proximal basilar artery consistent with vasculitis.

Additional serologies were notable for ANA titers 1:640, elevated cardiolipin antibody and beta 2-glycoprotein. Echocardiogram showed positive bubble test.

He was started on IV Penicillin, bictegravir, IV Solumedrol and ASA.

Patient was discharged to rehab.

His neurological status worsened, with aphasia and left gaze preference.  Serial MRI brain showed new areas of acute infarcts in bilateral basal ganglia, right thalamus and corpus callosum and subsequently new infarcts in bilateral frontal lobes, left occipital lobe and extension of the corpus callosum.

Clinical status deteriorated and he eventually passed away.

Our patient was diagnosed with recurrent ischemic strokes due to MVS with vasculitis and HIV.  Vasculitis was confirmed by cerebral angiogram and MRA with vessel wall study.  Unfortunately, clinical course was malignant.

MVS vasculitis is rare condition, should be considered in young patients presenting with stroke.  MRA with vessel wall images allows to confirm cerebral vasculitis.