CASE REPORT Carotid cavernous •aneurysm In an H IV-positive patient Abstract An intracavernous carotid aneurysm in an HIV-positive patient with tuberculous meningitis is presented. HIV- associated intracranial aneurysms are rarely detected in adults, unlike children. The aetiology is postulated. P Corr FRCR S Nadvi* FCS (SA) Depal1ments of Rad/%gy and Neurosurgery", University of Nata/ & Wentwol1h Hosp/ta/, Durban Introduction Cerebral aneurysms are increasingly being detected in children who are seropositive for the human immuno- deficiency virus (HIV).1,2There has, however, to the best of our knowledge, been only one report in the literature of six adult HN-positive patients who presented with subarachnoid haemor- rhage from berry aneurysms.' We present a caseof a woman who wasHN- positiveand developed an intracavemous carotid aneurysm while being treated for tuberculous meningitis. 4 SAJOURNAL OF RADIOLOGY. October 2000 Case report A 27-year-old woman presented with a five-day history of headache, neck pain and confusion. Clinical ex- amination detected a slightly confused patient with a Glasgow coma scale of 14 out of IS, with definite neck stiff- ness. Lumbar puncture detected 22 polymorphs, l82lymphocytes, 2 080 red blood cells, elevated protein level and slightly diminished glucose lev- els.The globulin levels were, however, elevated and the bacterial and crypto- coccal antigens were negative. A clinical diagnosis of tuberculous meningitis (TBM) was made and anti- tuberculous treatment was started. A CT scan was performed on admission to hospital, which demonstrated dila- tation of all the ventricles, with basal cistern enhancement consistent with tuberculous meningitis. The hydro- cephalus was treated with a ventriculoperitoneal shunt, with CSF pressures returning to normal the next day. The HIV test (ELISA) was posi- tive in a titre of one in 37. No organ- isms were grown from the cerebro- spinal fluid. On the 4th post-operative day, the patient developed a right 6th cranial nerve palsy. MR imaging performed on the 4th post-operative day demon- strated a right fusiform intracavernous carotid aneurysm on the T2 weighted axial image through the skull basel confirmed by the 3D time of flight sequences (Figures la, Ib and l c). This aneurysm was not identified on the admission CT scan study. The pa- tient's confused state remained un- changed and she suffered a cardio-res- piratory arrest and died on the 6th post-operative day. An autopsy was not performed. topage6 Carotid cavernous arie urvst n in an H IV-positive patient from page 4 cerebral arteries." This patient developed an aneurysm of the intracavernous portion of the right internal ca- rotid artery that was not identified on the first CT scan. As we do not have pathological proof of the aetiology of the aneurysm in this pa- tient, we can only pos- tulate that it could be due to HW infection or following tuberculous meningitis. Tuberculous meningitis can cause a vasculitis of small arterioles, resulting in vascular occlusion, al- though mycotic aneu- rysms of large arteries such as the internal ca- rotid artery are rare. HIV-associated fusi- form cerebral artery an- eurysms have been de- tected by imaging in two out of 250 HIV- positive children pre- senting for routine imaging," In both these patients the aneurysms were silent, despite pro- gressing to marked dila- tation. Fusiform dilata- tion of the arteries of the Circle of Willis has been described in three children." Pathologi- cally there is an inflammatory vasculopathy resulting in a panarteri- tis. The arteritis starts in the adventitia and involves the vasa vasorum, result- ing in ischaemia of the vessel wall.' The ischaemia causes destruction of the elastic lamina and subintimal fibrosis, Figure te: T2 weighted axial MR scan demonstrates hydrocephalus with a right ventricular peritoneal shunt in situ. Note the aneurysm of the internal carotid artery (arrow). Figures Ib and te: MRA time of flight sequence confirms the right inlracavemous carotid aneurysm in the axial and coronal planes (arrows). Discussion Vascular complications in patients who are infected with the HW virus include stroke from small vessel vascu- litis, cerebral haemorrhage from throm- bocytopenia and intratumoural bleeds, and granulomatous angiitis of the main 6 SA JOURNAL OF RADIOLOGY- October 2000 resulting in fusiform aneurysm forma- tien." Using the monoclonal antibody staining techniques to gp 41, which is the major glycoprotein of the HW vi- ral membrane, the aneurysm wall dem- onstrates positive staining of the intima but no staining of the media or adven- titia for the viral glycoprotein.' Aneurysms of medium and large arteries such as the common carotid, iliac and femoral arteries have also been recorded in Hlv-positive patients. 7 The pathology is identical to the cerebral aneurysms identified with acute and chronic panarteritis with occluded vasa vasora.' These aneurysms tend to be multiple. The natural history of cerebral an- eurysms in Hlv-positive patients is unknown apart from the one report suggesting rapid growth in size," Further research is required to de- termine the true incidence of cerebral aneurysms in Hlv-positive patients and to further investigate the aetiology of the pathological changes identified. References 1. Dubrovsky T, Curless R, Scott G, Chaneles M, Post MJ,Altman N, Petito CK, Start D, Wood C. Cerebral aneurysmal arteriopathy in childhood AIDS. Neurology 1998; 51: 560-565. 2. Fulmer BB, Dillard SC, Musulman EM, Palmer CA, Oakes J. Two cases of cerebral aneurysms in HlV+ children, Pediair Neurosurg 1998; 28: 31-34. 3. Maniker AH, Hunt CD, Cerebral aneurysm in the HIV patient: A report of six cases. Surg Neuro11996; 46: 49-54. 4, Shah SS, Zimmerman RA, Rorke LB,Vezina LG. Cerebrovascular complications of HIV in children.AJNR 1996; 17: 1913-1917. 5. Yankner BA, Skolnik PR, Shoukirnas GM, Gabuduzda DH, Sobel RA, Ho DD. Cerebral granulomatous angiitis associated with isolation of human T lyrnphtropic virus type III from the central nervous system. Ann Neuro11986; 20: 362-364. 6. Husson RN, Saini R, Lewis LL, Butler KM, Patron as N, Pizzo PA. Cerebral artery aneurysms in children infected with the human immunodeficiency virus. J Peduur 1992; 121: 927-930. 7. Nair R, Abdool Carrim A, Chetty R, Robbs 1. Arterial aneurysms in patients infected with human immunodeficiency virus: A distinct clinicopathology entity? ) Vase St/rg 1999; 29: 600-607.