Extracranial ectasia and embolic infarcts in HIV: two case reports and a clinical decision-making algorithm

HIV is known to increase the risk of both ischemic and hemorrhagic strokes. There are many postulated mechanisms for this elevated risk including an HIV-induced vasculopathy and/or coagulopathy, opportunistic infections, and cardioembolic etiologies, among others. Regarding vasculopathy, prior reports have described the various changes to the arterial vasculature that can occur in the setting of HIV, yet the appropriate workup and management of this condition remains poorly defined. Here we describe two cases of patients with HIV presenting with large vessel intracranial occlusions in the setting of ectatic extracranial vasculature accompanied by intraluminal thrombus formation. One patient underwent thrombectomy, while the other improved after receiving IV-tPA. Inferring on these cases and the existing literature, a standardized workup and treatment algorithm is proposed, emphasizing the key management decisions that should be considered on a case-by-case basis.