Stroke as the Initial Manifestation of the Human Immunodeficiency Virus

A 51-year-old man presented to the emergency department with acute onset of left-sided sensory loss and hemiparesis leading to a fall. The hemisensory loss had resolved at the time of presentation. He denied associated dysarthria, ataxia, visual field deficit, or aphasia. Furthermore, he had no current or history of headaches or seizures. The patient’s past medical history was significant for hypertension, anxiety, posttraumatic stress disorder and unilateral hearing loss after an explosion. Home medications included quetiapine, desvenlafaxine, amlodipine, benazepril/hydrochlorothiazide, and nebivolol, for which he was compliant. He did not smoke, drink alcohol, or use recreational drugs and was independent in activities of daily living. He denied unprotected sexual intercourse, intravenous drug abuse, and blood transfusions.He presented 1 hour 29 minutes after last seen normal with a blood pressure of 163/97 mm Hg and was in normal sinus rhythm. Neurological examination revealed left hemiparesis with motor strength of 0/5 in left upper and 4/5 in left lower extremity; sensory deficits and cortical findings were absent. National Institutes of Health Stroke Scale score was 5. Given the acuity of focal symptoms, stroke was the leading diagnosis. An emergent head computed tomography did not show any acute intracranial pathology. Intravenous tissue-type plasminogen activator was administered and the patient subsequently admitted to the neurointensive care unit. Magnetic resonance imaging brain demonstrated acute right frontoparietal infarcts, with a distribution suggestive of a watershed infarct between the anterior and middle cerebral artery territories, and a second acute infarct in the left pons (Figure [A]).Figure. Neuroimaging confirms multifocal acute infarctions and intracranial vasculopathy. A , Magnetic resonance imaging brain demonstrates acute infarcts in right frontoparietal lobe with distribution suggestive of a watershed infarct involving the right middle and anterior cerebral arteries; and left pontine paramedian perforator infarct …