Comment authors: Kateriine Orav, Department of Neurology, North Estonia Medical Center, Estonia and Diana Aguiar de Sousa, Department of Neurology, Hospital de Santa Maria, Universityof Lisbon, Portugal

Original Article: Schaefer JH, Stephan C, Foerch C, Pfeilschifter W, 2020. Ischemic stroke in human immunodeficiency virus -positive patients: An increasingly age-related comorbidity? DOI: 10.1177/2396987320927672

The advances of antiretroviral therapy have significantly improved life expectancy for people living with HIV/AIDS. However, this has led to an increased prevalence of age-related diseases such as stroke and has caused a measurable shift towards morbidity from non-AIDS complications. Chronic infection as well as antiretroviral drugs may play a role in stroke pathophysiology, although the mechanisms remain largely unknown.

In the current issue of ESJ, Schaefer and colleagues described patient characteristics, stroke etiologies and risk factors in a German cohort of HIV-positive patients

In this retrospective observational study the authors identified 24 HIV-positive patients among 3651 stroke patients treated in the stroke unit at University Hospital Frankfurt between 2012 and 2018. All ischemic strokes treated in 2018 served as a control group.

The estimated prevalence of HIV-positive patients among all stroke patients was 0.66%, which is almost 7 times higher than the general prevalence of HIV-infection in Germany. Importantly, more than 80% of patients were taking antiretroviral therapy and had non-detectable HIV-RNA levels. The mean age of stroke onset was substantially younger for HIV patients (54 years). Stroke etiology differed significantly in HIV-positive patients with a higher rate of large-vessel disease (38%), small-vessel disease (21%) and vasculitis (17%) but lower rate of cardio-embolism (4%). There was a predilection for ischemic strokes of the posterior circulation in HIV patients, which has also been observed in other inflammatory diseases. A positive HIV status did not worsen outcome in comparison to the control group except for cases with confirmed vasculitis. As for risk factors, HIV patients were more frequently smokers and had significantly higher cholesterol and triglyceride levels.

This study adds to the sparse literature on stroke in HIV infected patients and, as the authors point out, describes one of the oldest cohorts so far. It highlights large-vessel occlusion as a common cause of stroke among HIV-positive patients receiving antiretroviral therapy. Nonetheless, a more extensive diagnostic work-up can be warranted in these patients, as the prevalence of vasculitis is significantly higher. Due to an increased risk of stroke, HIV-positive patients should receive special attention regarding modifiable risk factors, especially with increasing age.

The original article “Ischemic stroke in human immunodeficiency virus -positive patients: An increasingly age-related comorbidity?” is available in the Online First section of the European Stroke Journal.