Imaging cns hiv Dr. Rahi Kiran.B Senior Resident, Neurology Govt Medical College, Kota

1. Radiology of Neurological
Manifestations of HIV
Dr. Rahi kiran.B
SR Neurology
GMC, KOTA

3. HIV Encephalitis
• 60% of AIDS patients develop neurologic disease
• HIV encephalitis (HIVE) and HIV leukoencephalopathy (HIVL)-
direct result of HIV infection of the brain.
• HIV-associated neurocognitive disorders (HANDs) - most frequent
neurologic manifestations of HIVE and HIVL.
• The term "acquired immunodeficiency dementia complex” refers
specifically to HIV-associated dementia.

4. HIV Encephalitis

5. HIV Encephalitis
Diffuse,confluent, bilaterally symmetric hyperintensity in the cerebral white matter with
sparing of the subcortical U-fibers, no parenchymal or meningeal enhancement, Axial DWI
shows no evidence of restricted diffusion

6. Toxoplasma
• most commonly involves the basal ganglia, thalami, CMJ and
cerebellum
• Multifocal lesions > solitary
• average SIZE 2-3 cm in diameter.

7. Toxoplasma
NECT – hypodense in left BG and frontal lobe with marked peripheral edema.T2WI- three
separate heterogeneous masses surrounded by marked edema, T1 C+ -eccentric "target" sign
lesion with a peripheral rim of enhancement

8. Cryptococcosis
Meningeal disease
• T1 C+ (Gd): can show
leptomeningeal enhancement
Cryptococcomas
• variable density masses on CT
• T1: low signal
• T2 / FLAIR: high signal
• T1 C+ (Gd): variable, ranging from
no enhancement to peripheral
nodular enhancement(depends on
immunity as capsule is non-
immunogenic)
• No DWI

9. • Immunocompetent - more likely to present with
cryptococcomas.
• Enhancement of these lesions might occur as a result of an
immunologic reaction by the host.
• Immediate and delayed imaging with a double dose of
contrast has been reported to reduce the false negative
studies by showing meningeal enhancement in
immunocompromised patients.

10. • Axial T1 post-gadolinium
image shows typical
cryptococcal meningitis
with ventricular wall
enhancement and subtle
frontal and occipital
leptomeningeal
enhancement.

11. Gelatinous pseudocysts
• Tend to give a "soap bubble"
appearance.
• low-density lesions on CT
• T1: low to intermediate (from mucin)
signal , no T1C+ (avascular)
• T2: hypointense ring surrounding a
hyperintense center
• FLAIR: low signal
• DWI - may or may not
• Hydrocephalus is the most common,
although nonspecific finding.

12. Progressive Multifocal
Leukoencephalopathy

13. c Progressive Multifocal
Leukoencephalopathy
clinically deteriorating 46y HIV-positive patient with a CD4 count < 10 cells/μL
confluent assymetric nonenhancing left occipital lesion that crosses the corpus
callosum

14. iPML
T1 & T2 -Characteristic involvement of both MCP, T1 C+ very faint rim enhancement, the right
MCP lesion restricts strongly

15. Cytomegalovirus
periventricular ependymal enhancement-
ventriculitis
periventricular restricted diffusion.

16. PCNSL
• 2-6% of HIV patients.
• 70% of all solitary brain parenchymal lesions in HIV/AIDS
patients.
• 90% are supratentorial - BG and deep white matter
• cross the corpus callosum
• highly specific - Linear enhancement at the margins of a
lesion, tracking along Virchow-Robin spaces

17. PCNSL
hypointense nodular
lesions on axial T2
Nodular enhancement
accompanied by linear
enhancement at the
margins of a lesion,
tracking along
perivascular spaces
restricted diffusion

18. PCNSL vs Toxoplasma
PCNSL
• single lesion
• subependymal spread
• solid enhancement
• no hemorrhage before
treatment
• thallium SPECT positive
• MRS: increased choline
• MR perfusion: increased
rCBV
Toxoplasma
• multiple lesions
• basal ganglia and CMJ
• ring or nodular enhancement
• hemorrhage occasionally occurs
mostly in the periphery
• thallium SPECT negative
• MRS: decreased choline
• MR perfusion: decreased rCBV

19. Tuberculosis
Hypointense center surrounded by hyperintense capsule that
enhances peripherally on contrast
meningeal enhancement in
the basal cisterns and
hydrocephalus

20. HIV-Associated Vacuolar
Myelopathy
• slowly progressive, painless spastic
paraparesis with sensory loss,
imbalance, and sphincter dysfunction.
Relapsing-remitting courses have been
described.
High-intensity lesion in the C2-C5
posterior spinal cord

22. Toxoplasma
T1 C+ -eccentric "target" sign
lesion with a peripheral rim of
enhancement
Large, heterogeneously hyperintense lesions but
numerous smaller foci scattered throughout the brain
in the cortex, BG and subcortical white matter
A 45-year-old male with CD4+ < count 100/mL, hemiparesis, and GTCS

23. Multiple gelatinous
pseudocysts and HIVE
Multiple pseudocysts and hyperintensity in the
cerebral white matter

24. PML-IRIS
Baseline MRI Repeat MRI 5 weeks after deterioration
Bifrontal hyperintense subcortical non-
enhancing white matter lesions
New lesions and enhancing
A 55-year-old female with, hemiparesis and GTCS-started on ART

25. Cytomegalovirus
periventricular ependymal enhancement-
ventriculitis
periventricular restricted diffusion.
A 35-year-old male with CD4+ < count 50/mL and GTCS

26. HIV Encephalitis
Diffuse,confluent, bilaterally symmetric hyperintensity in the cerebral white matter with
sparing of the subcortical U-fibers, no parenchymal or meningeal enhancement, Axial DWI
shows no evidence of restricted diffusion
A 32 yr female with cognitive, behavioral and motor dysfunction

27. PCNSL
hypointense nodular
lesions on axial T2
Nodular enhancement
accompanied by linear
enhancement at the
margins of a lesion,
tracking along
perivascular spaces
restricted diffusion
A 54-year-old male with left-sided weakness

28. toxoplasma abscess
"Eccentric target sign“, less prominent
choline peak and reduced NAA, large
lipid lactate peak
51-year-old male,
known HIV sero-
positive, initially
asymptomatic, came
with complaints of
generalized weakness
since 2 months
lymphoma vs
toxoplasma abscess

29. Tuberculosis
Hypointense center surrounded by hyperintense capsule that
enhances peripherally on contrast
meningeal enhancement in
the basal cisterns and
hydrocephalus
A 34-year-old male with seizures

30. THANK YOU