Progressive Stroke Caused by Neurosyphilis With Concentric Enhancement in the Internal Cerebral Artery on High-Resolution Magnetic Resonance Imaging: A Case Report

Abstract

Background: Neurosyphilis can initially present as a stroke. However, the general management strategy for stroke may not be effective for this condition. Intracranial vessel wall imaging indicating arteritis can help differentiate neurosyphilis from other causes of stroke.Case presentation: A 59-year-old Chinese woman presented with an acute infarct in the left basal ganglia and multiple stenoses in the bilateral middle cerebral arteries, anterior cerebral artery, and basilar artery, which aggravated twice, despite antiplatelet treatment. High-resolution magnetic resonance imaging (HR-MRI) suggested concentric enhancement in the left middle cerebral artery. Treponema pallidum test results were positive, suggesting neurosyphilis.Conclusions: HR-MRI provides valuable information regarding arteritis, which is helpful in differentiating neurosyphilis from other causes of stroke. Antiplatelet medication should be used judiciously for neurosyphilis-related stroke.

Cerebral infarction as initial manifestation of meningovascular neurosyphilis in an immunocompetent patient – A case report with long term follow‐up

“…Our patient was not homosexual and not HIV positive, which is also one of the risk factors for syphilis 9 . Vasculitis in patients with neurosyphilis occurs in two main forms: Heubner's arteritis, which affects medium and large blood vessels, and Nissl‐Alzheimer's arteritis, which affects the small blood vessels of the brain 10,11 . The mentioned forms are based on a chronic infection that leads to inflammation and fibrous changes in the vascular adventitia, leading to mural thrombi formation and ultimately blood vessel occlusion with consequent stroke.…”

“…9 Vasculitis in patients with neurosyphilis occurs in two main forms: Heubner's arteritis, which affects medium and large blood vessels, and Nissl-Alzheimer's arteritis, which affects the small blood vessels of the brain. 10,11 The mentioned forms are based on a chronic infection that leads to inflammation and fibrous changes in the vascular adventitia, leading to mural thrombi formation and ultimately blood vessel occlusion with consequent stroke. The most common localization is the middle cerebral artery and afterward the basilar artery, as in the case of this patient.…”

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

“…Beside PACNS, VW-MRI can depict inflammatory changes in a wide range of secondary vasculitis, including radiation-induced and those associated with infectious disease as the human immunodeficiency virus (HIV), syphilis and VZV [ 51 , 52 , 53 ]. Preliminary findings obtained with VW-MRI also suggested a possible inflammatory mechanism underlying a percentage of cryptogenic stroke in Coronavirus disease 2019 (COVID-19) patients [ 54 , 55 ].…”

Vessel wall MR imaging in neuroradiology

“…VW-MRI can depict inflammatory changes in a wide range of secondary vasculitis, including radiation-induced and those associated with infectious disease such as the human immunodeficiency virus (HIV), syphilis [ 110 ], herpes [ 111 ], and varicella zoster (Fig. 7 ).…”