Cerebrovascular Disease in Children Perinatally Infected With Human Immunodeficiency Virus in Zambia.

BACKGROUND: High rates of cerebrovascular disease (CVD) have previously been described in pediatric human immunodeficiency virus (HIV). However, little is known about pediatric CVD in the era of antiretroviral therapy or about the contribution of CVD to HIV-associated neurocognitive disorders. METHODS: We completed a neuroimaging substudy of the HIV-Associated Neurocognitive Disorders in Zambia study, a prospective cohort study of neurocognitive complications of pediatric HIV. Brain magnetic resonance imaging (1.5 T) was acquired for 34 HIV+ children on antiretroviral therapy and 17 HIV-exposed uninfected children (aged eight to 17 years). Demographics, medical history, neurological examination, and neuropsychologic testing results were collected. Two neuroradiologists, unaware of HIV status and clinical course, read the scans. RESULTS: CVD was identified in seven of 34 children with HIV (HIV+ CVD+) and no HIV-exposed uninfected children (21% vs 0%, P = 0.05). Three participants had white matter changes suggestive of small vessel disease, four had infarcts, and two had evidence of intracranial artery stenosis. Age of antiretroviral therapy initiation and exposure to protease inhibitors or efavirenz was not significantly different between children with and without CVD. HIV+ CVD+ children had significantly worse scores on a summary measure of cognition than the HIV+ CVD- group (NPZ8 score -0.57 vs 0.33, P = 0.04). CONCLUSIONS: This study demonstrates high rates of CVD in children with HIV despite antiretroviral therapy, and worse cognitive performance in children with CVD. Longitudinal studies are necessary to determine the mechanisms and incidence of new-onset CVD in children with HIV.

Location, length, and enhancement: systematic approach to differentiating intramedullary spinal cord lesions.

PURPOSE: Intramedullary spinal cord abnormalities are often challenging to diagnose. Spinal cord biopsy is a high-risk procedure with the potential to cause permanent neurological injury. Magnetic resonance imaging is the modality of choice for diagnosis and preoperative assessment of patients with spinal cord abnormalities. The radiologist's ability to narrow the differential diagnosis of spinal cord abnormalities has the potential to save patients from invasive approaches for diagnosis and also guide appropriate management. APPROACH/METHODS: This article will provide a systematic approach to the evaluation of intramedullary spinal cord lesions-with emphasis on location, length and segment distribution, and enhancement pattern-to help narrow the differential diagnosis. In doing so, we will review various spinal cord pathologies, including demyelinating and metabolic conditions, neoplasms, and vascular lesions. Although intramedullary spinal cord abnormalities can be a challenge for the radiologist, a systematic approach to the differential diagnosis with a focus on lesion location, cord length and segment involvement, as well as enhancement pattern, can greatly help narrow the differential diagnosis, if not synch the diagnosis. This strategy will potentially obviate the need for an invasive approach to diagnosis and help guide treatment. TEACHING POINTS: • Imaging diagnosis of intramedullary spinal cord lesions could obviate cord biopsy. • Evaluation of cord lesions should focus on location, length, and enhancement pattern. • In demyelination, the degree of cross-sectional involvement is a distinguishing feature.