Advertisement

Acute Ischemic or Hemorrhagic Stroke Syndromes

  • Arsovska Anita
  • Arsovski Zoran
Chapter

Abstract

Acute stroke is a medical emergency; it is the leading cause of adult physical disability and second most common cause of death worldwide. The two main stroke types are ischemic stroke that occurs in 80–85% of the cases and hemorrhagic stroke that occurs in 15–20%. According to the World Health Organization, there are 15 million people in the world who suffer from stroke every year. The risk factors for stroke (modifiable and nonmodifiable) have already been established and are well known; however, the presence of certain infections may add a higher risk. Fungal infections may cause cerebral vasculitis and lead to ischemic and/or hemorrhagic stroke. Histoplasma capsulatum, Rhizopus spp., Cryptococcus neoformans, and Exserohilum rostratum have been related to the occurrence of ischemic stroke, while Mucormycetes and Rhizopus spp. have been related to hemorrhagic stroke. Aspergillus spp. and Coccidioides immitis have been associated with the occurrence of both types of stroke. Appropriate neuroimaging and laboratory testing and even brain biopsy are needed to quickly establish the diagnosis. Medicamentous treatment of fungal infections causing stroke includes antifungal medications, corticosteroids, and prophylactic antiplatelet therapy in ischemic stroke; however, there are no randomized clinical trials that have evaluated their efficacy and safety. The prognosis is extremely poor for patients with fungal infections of the central nervous system presenting with acute ischemic or hemorrhagic strokes.

Keywords

Fungal infections Central nervous system Acute ischemic stroke Acute hemorrhagic stroke Clinical syndromes Cerebral vasculitis 

Abbreviations

AIDS

Acquired immunodeficiency syndrome

CNS

Central nervous system

CSF

Cerebrospinal fluid

CT

Computed tomography

GI

Gastrointestinal

HIV

Human immunodeficiency virus

i.v

Intravenous

MCA

Middle cerebral artery

MR

Magnetic resonance

rtPA

Recombinant tissue plasminogen activator

WHO

World Health Organization

References

  1. Arsura EL, Johnson R, Penrose J, et al. Neuroimaging as a guide to predict outcomes for patients with coccidioidal meningitis. Clin Infect Dis. 2005;40(4):624–7.CrossRefGoogle Scholar
  2. Ashdown BC, Tien RD, Felsberg GJ. Aspergillosis of the brain and paranasal sinuses in immunocompromised patients: CT and MR imaging findings. Am J Roentgenol. 1994;162:155–9.CrossRefGoogle Scholar
  3. Bariola JR, Perry P, Pappas PG, et al. Blastomycosis of the central nervous system: a multicenter review of diagnosis and treatment in the modern era. Clin Infect Dis. 2010;50:797–804.CrossRefGoogle Scholar
  4. Bayer A, Scheld M. Endocarditis and intravascular infections. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell Douglas and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone; 2000. p. 857–902.Google Scholar
  5. Bell WR, Dalton JB, McCall CM, et al. Iatrogenic exserohilum infection of the central nervous system: mycological identification and histopathological findings. Mod Pathol. 2013;26:166–70.CrossRefGoogle Scholar
  6. Browne SK, Burbelo PD, Chetchotisakd P, et al. Adult-onset immunodeficiency in Thailand and Taiwan. N Engl J Med. 2012;367:725–34.CrossRefGoogle Scholar
  7. Bush JW, Wuerz T, Embil JM, et al. Outcomes of persons with blastomycosis involving the central nervous system. Diagn Microbiol Infect Dis. 2013;76:175–81.CrossRefGoogle Scholar
  8. Calli C, Savas R, Parildar M, Pekindil G, Alper H, Yunten N. Isolated pontine infarction due to rhinocerebral mucormycosis. Neuroradiology. 1999;41:179–81.CrossRefGoogle Scholar
  9. Challa S, Prayaga AK, Vemu L, Sadasivan J, Jagarlapudi MK, Digumarti R, et al. Fungal endocarditis: an autopsy study. Asian Cardiovasc Thorac Ann. 2004;12:95–8.CrossRefGoogle Scholar
  10. Chou SM, Chong YY, Kinkel R. A proposed pathogenetic process in the formation of Aspergillus mycotic aneurysm in the central nervous system. Ann Acad Med Singapore. 1993;22:518–25.PubMedGoogle Scholar
  11. Corvisier N, Gray F, Gherardi R, Lebras F, Blanc CM, Nguyen JP, et al. Aspergillosis of ethmoid sinus and optic nerve, with arteritis and rupture of the internal carotid artery. Surg Neurol. 1987;28:311–5.CrossRefGoogle Scholar
  12. Dayal Y, Weindling HK, Price DL. Cerebral infarction due to fungal embolus. A complication of Aspergillus infection on an aortic valve prosthesis. Neurology. 1974;24:76–9.CrossRefGoogle Scholar
  13. Elias J Jr, dos Santos AC, Carlotti CG Jr, et al. Central nervous system paracoccidioidomycosis: diagnosis and treatment. Surg Neurol. 2005;63:S13–2.CrossRefGoogle Scholar
  14. Endo T, Tominaga T, Konno H, Yoshimato T. Fatal subarachnoid hemorrhage, with brainstem and cerebellar infarction, caused by Aspergillus infection after cerebral aneurysm surgery: case report. Neurosurgery. 2002;50:1147–51.PubMedGoogle Scholar
  15. Ferro JM, Fonseca AC. Infective endocarditis. Handb Clin Neurol. 2014;119:75–91.CrossRefGoogle Scholar
  16. Fu K, Nguyena P, Sanossiana N. Basilar artery territory stroke secondary to invasive fungal sphenoid sinusitis: a case report and review of the literature. Case Rep Neurol. 2015;7:51–8.CrossRefGoogle Scholar
  17. Fugate JE, Lyons JL, Thakur KT, et al. Infectious causes of stroke. Lancet Infect Dis. 2014;14:869–80.CrossRefGoogle Scholar
  18. Goel D, Kalita J, Misra UK. Basilar artery occlusion in Cryptococcal meningitis. Neurol India. 1999;47:245–6.PubMedGoogle Scholar
  19. Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010;6:681–94.CrossRefGoogle Scholar
  20. Grouhi M, Dalal I, Nisbet-Brown E, Roifman CM. Cerebral vasculitis associated with chronic mucocutaneous candidiasis. J Pediatr. 1998;133:571–4.CrossRefGoogle Scholar
  21. Ho CL, Deruytter MJ. CNS aspergillosis with mycotic aneurysm, cerebral granuloma and infarction. Acta Neurochir (Wien). 2004;146:851–6.CrossRefGoogle Scholar
  22. Horten BC, Abbort GF, Porro RS. Fungal aneurysms of intracranial vessels. Arch Neurol. 1976;33:577–9.CrossRefGoogle Scholar
  23. Hurst RW, Judkins A, Bolger W, Chu A, Loevner LA. Mycotic aneurysm and cerebral infarction resulting from fungal sinusitis: imaging and pathologic correlation. AJNR Am J Neuroradiol. 2001;22:858–63.PubMedPubMedCentralGoogle Scholar
  24. Iihara K, Makita Y, Nabeshima S, Tei T, Keyaki A, Nioka H. Aspergillosis of the central nervous system causing subarachnoid hemorrhage from mycotic aneurysm of the basilar artery—case report. Neurol Med Chir. 1990;30:618–23.CrossRefGoogle Scholar
  25. Johnson MD, Perfect JR. Use of antifungal combination therapy: agents, order, and timing. Curr Fungal Infect Rep. 2010;4:87–95.CrossRefGoogle Scholar
  26. Kalita J, Bansal R, Ayagiri A, Misra UK. Midbrain infarction: a rare presentation of cryptococcal meningitis. Clin Neurol Neurosurg. 1999;101:23–5.CrossRefGoogle Scholar
  27. Kang D, Kim Y, Kim S, et al. Early surgery versus conventional treatment for infective endocarditis. N Eng J Med. 2012;366:2466–73.CrossRefGoogle Scholar
  28. Karchmer AM. Infection on prosthetic valves and intravascular devices. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell Douglas and Bennett’s principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone; 2000. p. 903–17.Google Scholar
  29. Kurino M, Kuratsu J, Yamaguchi T, Ushio Y. Mycotic aneurysm accompanied by aspergillotic granuloma: a case report. Surg Neurol. 1994;42:160–4.CrossRefGoogle Scholar
  30. Lan SH, Chang WN, Lu CH, Lui CC, Chang HW. Cerebral infarction in chronic meningitis: a comparison of tuberculous meningitis and cryptococcal meningitis. QJM. 2001;94:247–53.CrossRefGoogle Scholar
  31. Lau AH, Takeshita M, Ishii N. Mycotic (Aspergillus) arteritis resulting in fatal subarachnoid hemorrhage: a case report. Angiology. 1991;42:251–5.CrossRefGoogle Scholar
  32. Ludmerer SW, Wright DJ, Schimmel P. Purifi cation of glutamine tRNA synthetase from Saccharomyces cerevisiae. A monomeric aminoacyl-tRNA synthetase with a large and dispensable NH2-terminal domain. J Biol Chem. 1993;268:5519–23.PubMedGoogle Scholar
  33. Mateen FJ, Sweeney EM, Thakur KT, et al. IV-tissue plasminogen activator (IV-TPA) for acute ischemic stroke (AIS) in HIV+ adults (abstract S414). Ann Neurol. 2013;74(suppl):S17.Google Scholar
  34. McKee EE. Mycotic infection of the brain with arteritis and subarachnoid hemorrhage: report of case. Am J Clin Pathol. 1950;20:381–4.CrossRefGoogle Scholar
  35. Murray CJ, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197–223.CrossRefGoogle Scholar
  36. Murthy J. Fungal infections of the central nervous system: the clinical syndromes. Neurol India. 2007;55:221–5.CrossRefGoogle Scholar
  37. Murthy JM, Sundaram C, Prasad VS, Purohit AK, Rammurti S, Laxmi V. Aspergillosis of central nervous system: a study of 21 patients seen in a university hospital in south India. J Assoc Physicians India. 2000;48:677–81.Google Scholar
  38. Panackal AA, Williamson PR. Fungal infections of the Central Nervous System. Continuum (Minneap Minn). 2015;21(6 Neuroinfectious Disease):1662–78.Google Scholar
  39. Pierrotti LC, Baddour L. Fungal endocarditis, 1995-2000. Chest. 2002;122:302–10.CrossRefGoogle Scholar
  40. Piotrowski WP, Pilz P, Chuang IH. Subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping: case report. J Neurosurg. 1990;73:962–4.CrossRefGoogle Scholar
  41. Powers WJ, Rabinstein AA, Ackerson T, et al., on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46–e110.Google Scholar
  42. Radhakrishnana VV, Saraswathy A, Rout D, Mohan PK. Mycotic aneurysms of the intracranial vessels. Indian J Med Res. 1994;100:228–31.Google Scholar
  43. Rangel-Guerra RA, Martinez HR, Saenz C, Bosques-Padilla F, Estrada-Bellmann I. Rhinocerebral and systemic mucormycosis. Clinical experience with 36 cases. J Neurol Sci. 1996;143:19–30.CrossRefGoogle Scholar
  44. Rosario M, Song SX, McCullough LD. An unusual case of stroke. Neurologist. 2012;18:229–32.CrossRefGoogle Scholar
  45. Saccente M. Central nervous system histoplasmosis. Curr Treat Options Neurol. 2008;10:161–7.CrossRefGoogle Scholar
  46. Saul RF, Gallagher JG, Mateer JE. Sudden hemiparesis as the presenting sign in cryptococcal meningoencephalitis. Stroke. 1986;17:753–4.CrossRefGoogle Scholar
  47. Seton M, Pless M, Fishman JA, Caruso PA, Hedley-Whyte ET. Case records of the Massachusetts General Hospital. Case 18-2008. A 68-year-old man with headache and visual changes after liver transplantation. N Engl J Med. 2008;358:2619–28.CrossRefGoogle Scholar
  48. Sharma RR, Lad SD, Pawar SJ, Gurusinghe NT, Bhagwati SN, Mahapatra AK. Surgical management of fungal infections of the central nervous system. In: Schmidek HH, Roberts DW, editors. Schmidek Sweet’s operative neurosurgical techniques, indications, methods and results. 5th ed. Philadelphia, PA: Saunders Elsevier; 2006. p. 1633–71.Google Scholar
  49. Smith RM, Schaefer MK, Kainer MA, et al. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013;369:1598–609.CrossRefGoogle Scholar
  50. Suzuki K, Iwabuchi N, Kuramochi S, Nakanoma J, Suzuki Y, Serizawa H, et al. Aspergillus aneurysm of the middle cerebral artery causing a fatal subarachnoid hemorrhage. Intern Med. 1995;34:550–3.CrossRefGoogle Scholar
  51. Takeda S, Wakabayashi K, Yamazaki K, Miyakawa T, Arai H. Intracranial fungal aneurysm caused by Candida endocarditis. Clin Neuropathol. 1998;17:199–203.PubMedGoogle Scholar
  52. Takeshita M, Izawa M, Kubo O, Tanikawa T, Onda H, Wanifuchi H, et al. Aspergillotic aneurysm formation of cerebral artery following neurosurgical operation. Surg Neurol. 1992;38:146–51.CrossRefGoogle Scholar
  53. Taqui A, Koffman L, Hui F, et al. Intra-arterial vasodilator therapy for parainfectious cerebral vasospasm. J Neurol Sci. 2014;340:225–9.CrossRefGoogle Scholar
  54. Topcuoglu MA. Transcranial Doppler ultrasound in neurovascular diseases: diagnostic and therapeutic aspects. J Neurochem. 2012;123(suppl 2):39–51.CrossRefGoogle Scholar
  55. Tornos P, Almirante B, Mirabet S, et al. Infective endocarditis due to Staphylococcus aureus: deleterious effect of anticoagulant therapy. Arch Intern Med. 1999;159:473–5.CrossRefGoogle Scholar
  56. Wasserman AM, Sarantopoulos GP, Khanna D. Fungal leukocytoclastic vasculitis as a presentation of systemic vasculitis in a patient with systemic lupus erythematosus. J Clin Rheumatol. 2009;15:383–6.CrossRefGoogle Scholar
  57. Watson JC, Myseros JS, Bullock MR. True fungal mycotic aneurysm of the basilar artery: a clinical and surgical dilemma. Cerebrovasc Dis. 1999;9:50–3.CrossRefGoogle Scholar
  58. Williams PL, Johnson R, Pappagianis D, et al. Vasculitic and encephalitic complications associated with Coccidioides immitis infection of the central nervous system in humans: report of 10 cases and review. Clin Infect Dis. 1992;14:673–82.CrossRefGoogle Scholar
  59. Wolf PA, D’Agostino RB, Belanger AJ, Kannel WB. Probability of stroke: a risk profile from the Framingham study. Stroke. 1991;22:312–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Arsovska Anita
    • 1
  • Arsovski Zoran
    • 2
  1. 1.University Clinic of Neurology, Medical FacultyUniversity of Ss. Cyril and MethodiusSkopjeMacedonia
  2. 2.University Clinic of Pulmonology and Allergy, Medical FacultyUniversity of Ss. Cyril and MethodiusSkopjeMacedonia

Personalised recommendations