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Chapter 18 : The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients

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Abstract:

As the HIV/AIDS epidemic approaches the 20th anniversary of the first mysterious reports of people with the syndrome, researchers and clinicians continue to grapple with the complexities of the virus. HIV has been detected in the brain as early as 15 days after accidental intravenous inoculation. However, the mechanism of HIV-related brain injury remains poorly understood. This review attempts to describe the imaging findings associated with brain disorders in HIV-seropositive patients and the rationales for integrating neuroradiological techniques, including radionuclide techniques. HIV has nine genes and belongs to the lentivirus genus of retroviruses. HIV-associated dementia (HAD) is now probably the most common cause of dementia worldwide among people aged 40 or less. The histopathological marker of the HIV-infected brain is the presence of multinucleated giant cells (MGC). Several authors have claimed that neuroimaging studies are relatively insensitive in the detection of early changes in the brain due to HIV infection. Future diffusion tensor imaging (DTI) studies comparing diffusion changes with MRS and virological and immunological parameters will be helpful in further understanding the alterations in the HIV-infected brain. Retinitis is one of the most common manifestations of cytomegalovirus (CMV) infection. In one study, MRS was used to distinguish HIV from CMV encephalitis. The findings suggest that a larger choline signal and a smaller N-acetylaspartate (NAA) signal could be inferred within the white-matter abnormalities due to HIV encephalitis/encephalopathy than in those due to CMV encephalitis.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18

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Figures

Image of FIGURE 1
FIGURE 1

HIV-leukoencephalopathy in an HIV-positive patient presenting with dementia. (A) Precontrast axial CT scan showing marked bilateral hypodensity of the white matter. (B) Axial FLAIR (TR/TE/TI, 10,000/130/2,100). The MRI image demonstrates bilateral high-signal-intensity changes of the white matter without mass effect. Enhancement was not present on postcontrast T1-weighted MRI images (not shown).

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 2
FIGURE 2

HIV-leukoencephalopathy in an HIV-positive female patient. (A) High-signal-intensity abnormality in the brainstem on axial FLAIR MRI image (TR/TE/TI, 10,000/130/2,100). The brainstem is not enlarged. (B and C) Axial FLAIR (TR/TE/TI, 10,000/130/2,100) and coronal T2-weighted MRI images showing high-signal-intensity abnormalities without mass effect in the white matter bilaterally. Note sparing of the subcortical fibers and dilatation of the ventricles, indicating associated atrophy. The lesions are iso- or hypointense on T1-weighted MRI images and show no enhancement on postcontrast images (not shown). In addition, bilateral subdural effusions are present.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 3
FIGURE 3

MRS in a symptomatic HIV-positive patient. A proton spectrum (TE, 23 ms; TR, 6,365 ms) from the voxel outlined from the frontal white matter shows slightly decreased NAA and increased MI, findings consistent with the early stage of HIV encephalitis.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 4
FIGURE 4

Patient with HIV encephalitis being treated with HAART. (A) Axial FLAIR-TSE (TR/TE/TI, 7,385/130/2,100) MRI image showing bilateral, symmetric, high-signal-intensity abnormalities in the periventricular white matter and white matter of the centrum semiovale. Additional widening of the sulci and ventricle is present. The patient had a high viral-load level in plasma and in the CSF and a low CD4 T-lymphocyte count. The results of the neuropsychological examination were consistent with subcortical dementia. The diagnosis of HIV leukoencephalopathy was made, and combination antiretroviral therapy was started. (B) Nine months after the initiation of therapy, a follow-up FLAIR-TSE (TR/TE/TI, 7,385/130/2,100) MRI image shows progression of the white-matter SI abnormalities. (C) At 18 months after the initiation of HAART, a follow-up MRI scan shows interval decrease of the white-matter signal intensity abnormalities. (D) At 26 months after the initiation of the therapy, follow-up MRI scans show regression of the white-matter disease (not shown) and stabilization after 33 months.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 5
FIGURE 5

PML in an AIDS patient who presented at the emergency department with impaired consciousness. (A) Postcontrast CT scan of the brain showing a scalloped, nonenhancing, hypodense lesion in the left temporal lobe. (B to D) Axial and coronal FLAIR (TR/TE/TI, 6,000/100/2,000) MRI images showing a scalloped high-signal-intensity lesion located in the left temporal white matter with extension through the external capsule to the left frontal white matter. There is an additional lesion in the right temporal periventricular white matter. The subcortical fibers and cortex are also involved. There is no mass effect. (E and F) On postcontrast T1-weighted TFE (TR/TE/flip degree, 20/2.1/35°) MRI images, no enhancement is observed.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 6
FIGURE 6

PML in an HIV-positive patient who responded well to HAART. (A) Scalloped high-signal-intensity lesions are demonstrated on an axial FLAIR (TR/TE/TI, 6,000/100/2,000) MRI image in the left frontal and parietal lobes. (B) The lesions have low signal on a T1-weighted TFE (TR/TE/flip degree, 20/2.1/35°) MRI image. (C) Faint peripheral enhancement is seen on a post-contrast T1-weighted TFE (TR/TE/flip degree, 20/2.1/35°) MRI image (unusual imaging feature in PML).

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 7
FIGURE 7

PML in an AIDS patient under HAART. (A) Initial FLAIR-TSE (TR/TE/TI, 7,373/130/2,100) MRI image showing a high-signal-intensity lesion in the right centrum semiovale. There is no mass effect. (B) The lesion has low signal on a T1-weighted TFE (TR/TE/flip degree, 10/3.5/10°) MRI image. Analysis of the CSF revealed positive PCR for JC virus, and HAART, including protease inhibitors, was initiated. (C and D) Two months after initiation of therapy, follow-up MRI images show progression of the disease with hyperintense white-matter abnormalities (C) extending to the entire white matter of the right side. Note the moderate mass effect with compression of the right lateral ventricle. (D) Postcontrast T1-weighted TFE (TR/TE/flip degree, 10/3.5/10°) MRI image showing low signal of the lesion but no enhancement. (E and F) Seven months later, subsequent MRI examination shows leukomalacia and atrophy of the right hemisphere and vacuo widening of the right lateral ventricle (E), indicating a burn-out process.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 8
FIGURE 8

VZV encephalitis. (A) Axial FLAIR (TR/TE/TI, 7,383/130/2,100) MRI image showing high-signal-intensity abnormality of the cortex on the right side. (B) On a T1-weighted (TR/TE/flip degree, 8.4/2.8/10°) MRI image, swollen hypointense cortex can be observed. (C) Postcontrast T1-weighted SE (TR/TE, 500/15) MRI with MTC image demonstrating marked enhancement of the affected cortex.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 9
FIGURE 9

HIV-positive patient with meningovascular neurosyphilis. (A and B) Axial FLAIR-TSE (TR/TE/TI, 11,000/80/2,800) MRI images showing multiple hyperintense lesions in the left cerebellum and bilaterally in the brainstem. (C) Three-dimensional time-of-flight TFE MRA (TR/TE/flip degree, 22/2.9/20°) nicely demonstrating high-grade stenosis of the basilar artery. The combination of MRI findings of vascular lesions in the posterior fossa, narrowing of the basilar artery, and laboratory findings suggests vascular neurosyphilis.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 10
FIGURE 10

Tuberculous CNS infection in an AIDS patient. (A) Axial FLAIR-TSE (TR/TE/TI, 11,000/120/2800) MRI image showing low-signal abnormality in the right cerebellopontine angle region. (B) Axial FLAIR-TSE (TR/TE/TI, 11,000/120/2800) MRI image at a higher level demonstrating marked enlargement of the ventricular system, indicating hydrocephalus. (C and D) Contrast-enhanced T1-weighted TFE (TR/TE/flip degree, 20/1.9/35°) MRI images showing marked meningeal enhancement (tuberculous meningitis), homogeneous enhancement of the lesion in the right cerebellopontine angle (large tuberculoma), and ring-like enhancement of the lesion in the right midbrain (small tuberculoma).

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 11
FIGURE 11

Tuberculous CNS infection with infarctions in a 50-year-old female patient. (A) Contrast-enhanced T1-weighted TFE (TR/TE/flip degree, 20/4.6/25°) MRI image in the axial plane showing extensive meningeal enhancement and enlargement of the ventricles, suggesting tuberculous meningitis with obstructive hydrocephalus. (B) On DWI (TR/TE/b value, 2,282/156/1,000 mm), high-signal-intensity abnormalities are demonstrated in the basal-ganglion region bilateral and in the right occipital cortex. On an apparent diffusion coefficient (ADC) map (not shown), low values were measured. The lesions were consistent with cytotoxic edema and infarctions. CSF analysis was consistent with tuberculosis.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 12
FIGURE 12

Multiple CNS tuberculomas with obstructive hydrocephalus. (A) Axial FLAIR-FSE (TR/TE/TI, 7000/150/2100) MRI image showing multiple low-signal-intensity lesions in the cerebellum bilateral. (B) On a nonenhanced T1-weighted TSE (TR/TE/flip degree, 20/4.6/25°) MRI image, the lesions have slightly higher signal than brain parenchyma. (C) Enhanced T1-weighted TSE (TR/TE/flip degree, 20/4.6/25°) MRI image demonstrating ring-like enhancement of the lesions. (D) Obstructive hydrocephalus with dilatation of the ventricular system is shown on a coronal T2-weighted MRI image. Note the marked low signal of tuberculomas. Brain biopsy revealed a diagnosis of tuberculous granuloma.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 13
FIGURE 13

HIV-positive patient with a biopsy-proven abscess. (A) Axial FLAIR-TSE (TR/TE/TI, 7,383/130/2,100) MRI image showing a lesion of intermediate signal intensity in the right parietal region. (B and C) High signal is present on trace DWI (TR/TE/b value, 2,286/83/1,000) (B) and low signal on an ADC map (C), indicating restricted diffusion in a bacterial abscess formation. Stereotactic biopsy confirmed the diagnosis of a abscess of the brain.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 14
FIGURE 14

Dilated Virchow-Robin spaces in cerebral cryptococcosis (autopsy proven). Axial T1-weighted SE (TR/TE, 700/19) (A) and coronal T2-weighted MRI (TR/TE, 2,500/90) (B) images demonstrating small, cyst-like lesions bilaterally in the basal ganglia, representing dilated perivascular spaces filled with fungi. On an enhanced T1-weighted MRI image, no enhancement was observed (not shown).

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 15
FIGURE 15

Cerebral aspergillosis in a patient after bone marrow transplantation. (A) Axial FLAIR-TSE (TR/TE/TI, 7,383/130/2,100) MRI image showing multiple hyperintense lesions in the basal-ganglion region and subcortical and cortical regions on both sides. (B) T2-weighted MRI image in the coronal plane demonstrating central low signal intensity of the lesions. (C) High signal intensities seen on T1-weighted (TR/TE/flip degree, 20/4.6/25°) image representing subacute hemorrhage. (D) No enhancement was observed on postcontrast T1-weighted (TR/TE/flip degree, 20/4.6/25°) MRI images. Necrotizing, hemorrhagic encephalitis due to the aspergillosis was found at the autopsy.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 16
FIGURE 16

Cerebral toxoplasmosis in an HIV-positive individual. (A) Low-signal-intensity lesion with high-signal-intensity edema located in the left basal-ganglion region is shown on an axial FLAIR-TSE (TR/TE/TI, 11,000/140/2,800) MRI image. (B) The lesion shows ring enhancement after gadolinium injection on a T1-weighted TFE (TR/TE/flip degree, 20/1.8/35°) MRI image. (C) Low signal intensity of the lesion shown on a coronal T2-weighted MRI image. (D and E) On trace DWI, the lesion shows low signal (D), with mixed intensity on an ADC map (E). (F) Proton MRI spectrum acquired from a lesion demonstrating a large lipid/lactate peak and no NAA or choline peaks. The imaging findings on conventional MRI and MRI spectrum and the results of the FDG-PET (not shown) were consistent with toxoplasmosis. Ten days after the initiation of treatment, a follow-up MRI showed a decrease in size and enhancement of the lesion (not shown).

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 17
FIGURE 17

Cerebral toxoplasmosis in an HIV-positive patient. (A) Nonenhanced CT scan of the brain demonstrating bilateral hypodensity in the frontal lobes. (B) Postcontrast scan showing peripherally enhancing lesions with associated edema. (C) The lesions have low signal on an axial FLAIR MRI image (TR/TE/TI, 10,000/150/2,600). (D and E) Postcontrast T1-weighted TFE (TR/TE/flip degree, 10/3.4/10°) MRI images in the axial (D) and the coronal (E) planes demonstrating peripheral enhancement of the necrotic lesion surrounded by edema.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 18
FIGURE 18

Cerebral toxoplasmosis in a 30-year-old female patient with AIDS. (A) Low-signal-intensity lesions with high-signal-intensity edema located in the right and left frontal lobes are shown on an axial FLAIR-TSE (TR/TE/TI, 11,000/140/2,800) MRI image. (B and C) On a trace DWI (B), the lesion located in the right frontal lobe has high signal intensity with a low ADC value (C), indicating restricted diffusion. (D) Coronal postcontrast T1-weighted TFE (TR/TE/flip degree, 10/3.4/10°) MRI image showing peripheral enhancement of the necrotic toxoplasma lesions.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 19
FIGURE 19

Non-Hodgkin’s lymphoma in an HIV-positive patient. (A) Nonenhanced CT scan of the brain showing a hypodense lesion in the left occipital periventricular cortex. (B) Centrally low-signal-intensity lesion with high-signal-intensity edema on an axial FLAIR-TSE (TR/TE/TI, 11,000/140/2,800) MRI image. (C) A ring-like enhancing lesion on an axial postcontrast T1-weighted TFE (TR/TE/flip degree, 10/3.4/10°) MRI image. Two other lesions were also present (not shown). At the autopsy, lymphoma was confirmed.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 20
FIGURE 20

Multifocal CNS lymphoma in an HIV-positive patient. (A) Multiple hypointense lesions located in both hemispheres of the brain are shown on an axial FLAIR-TSE (TR/TE/TI, 11,000/140/2,800) MRI image. (B and C) On a trace DWI MRI image (B), the lesions have intermediate signal with low ADC values (C), indicating restricted diffusion due to the high cellularity of lymphoma lesions. (D and E) Peripherally enhancing lesions are demonstrated on axial (D) and coronal (E) postcontrast T1-weighted TFE (TR/TE/flip degree, 10/3.4/10°) MRI images.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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Image of FIGURE 21
FIGURE 21

Periventricular lymphoma in a 30-year-old AIDS patient. (A) Axial FLAIR MRI image (TR/TE/TI, 10,000/150/2,600) showing hyperintense abnormality in the periventricular frontal white matter. (B) Postcontrast T1-weighted SE MRI image (TR/TE, 550/20) showing periventricular enhancement.

Citation: Thurnher M, Post M. 2009. The Uses of Structural Neuroimaging in the Brain in HIV-1-Infected Patients, p 247-272. In Goodkin K, Shapshak P, Verma A (ed), The Spectrum of Neuro-AIDS Disorders. ASM Press, Washington, DC. doi: 10.1128/9781555815691.ch18
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