Li Wenyang, Sguigna Peter, Rupareliya Chintan, Subramanian Suriya, Salahuddin Hisham, Husari Khalil S, Moore William, Johnson Mark, Magadan Alejandro, Grose Charles, Nijhawan Ank E, Shang Ty
Department of Neurology Peter O'Donnell Jr. Brain Institute, University of Texas Southwestern Medical Center Dallas TX USA.
Department of Pediatric Neurology University of Texas Southwestern Medical Center Dallas TX USA.
J Am Heart Assoc. 2025 Jul;14(13):e039489. doi: 10.1161/JAHA.124.039489. Epub 2025 Jun 18.
Epidemiological data suggest that the risk of ischemic stroke increases after varicella-zoster virus (VZV) reactivation. The frequency of VZV reactivation in acute ischemic stroke (AIS) is unknown. The risk of recurrent stroke and the antiviral treatment effect, particularly in patients with HIV infection, have yet to be defined. Here, we investigate the proportion of VZV reactivation in the cerebrospinal fluid (CSF) of patients who presented with AIS or transient ischemic attack and underwent VZV testing, along with relevant follow-up information.
We retrospectively reviewed medical records of patients who presented with AIS or transient ischemic attack and underwent VZV polymerase chain reaction and anti-VZV IgG testing in CSF during their workup from January 1, 2014, to December 31, 2021. VZV reactivation was confirmed by a positive VZV polymerase chain reaction result or increased intrathecal anti-VZV IgG synthesis in CSF. The cause of AIS and transient ischemic attack was classified using the SSS-TOAST (Stop Stroke Study-Trial of ORG 10172 in Acute Stroke Treatment) criteria. The occurrence of recurrent ischemic stroke during follow-up was compared between patients who received antiviral treatment and those who did not, as well as between patients with and without HIV.
Among the 177 patients included, VZV reactivation in CSF was found in 23.2%. VZV reactivation was more common in strokes involving intracranial arteries compared with those that did not (28% versus 3%, =0.01). Seven (17%) patients with VZV reactivation had recurrent ischemic stroke within 1 year from positive test results. There was no significant difference in recurrent ischemic stroke between patients who received short-term antiviral therapy and those who did not (14.8% versus 21%, =0.593). Patients with AIS and HIV had a significantly higher risk of VZV reactivation (57% versus 20%, =0.002) and recurrent ischemic stroke despite antiviral treatment (42.8% versus 5.0%, =0.02) compared with patients without HIV.
Among individuals who underwent VZV testing in CSF, VZV reactivation was present in 1 of 5 patients with AIS/transient ischemic attack. Patients with HIV were at particularly high risk of VZV reactivation and recurrent ischemic stroke.
流行病学数据表明，水痘-带状疱疹病毒（VZV）再激活后缺血性卒中风险增加。急性缺血性卒中（AIS）中VZV再激活的频率尚不清楚。复发性卒中的风险以及抗病毒治疗效果，尤其是在HIV感染患者中，尚未明确。在此，我们调查了出现AIS或短暂性脑缺血发作并接受VZV检测的患者脑脊液（CSF）中VZV再激活的比例以及相关随访信息。
我们回顾性分析了2014年1月1日至2021年12月31日期间出现AIS或短暂性脑缺血发作并在检查期间接受CSF中VZV聚合酶链反应和抗VZV IgG检测的患者的病历。VZV再激活通过CSF中VZV聚合酶链反应结果阳性或鞘内抗VZV IgG合成增加来确认。使用SSS-TOAST（急性卒中治疗中停止卒中研究-ORG 10172试验）标准对AIS和短暂性脑缺血发作的病因进行分类。比较接受抗病毒治疗和未接受抗病毒治疗的患者以及有和没有HIV的患者在随访期间复发性缺血性卒中的发生情况。
在纳入的177例患者中，CSF中发现VZV再激活的比例为23.2%。与未累及颅内动脉的卒中相比，累及颅内动脉的卒中中VZV再激活更常见（28%对3%，P=0.01）。7例（17%）VZV再激活患者在检测结果阳性后的1年内发生了复发性缺血性卒中。接受短期抗病毒治疗和未接受抗病毒治疗的患者之间复发性缺血性卒中无显著差异（14.8%对21%，P=0.593）。与没有HIV的患者相比，AIS合并HIV的患者VZV再激活风险显著更高（57%对20%，P=0.002），且尽管接受了抗病毒治疗，复发性缺血性卒中风险也更高（42.8%对5.0%，P=0.02）。
在接受CSF中VZV检测的个体中，5例AIS/短暂性脑缺血发作患者中有1例存在VZV再激活。HIV患者VZV再激活和复发性缺血性卒中的风险特别高。
