Clinical Review & Education
Images in Neurology
Basilar Artery Aneurysm in a Woman With Syphilis Nathália Stela Visoná de Figueiredo, MD; Débora Bartzen Moraes Angst, MD; Lucas Silvestre Mendes, MD; Michel Ferreira Machado, MD; Maria Sheila Guimarães Rocha, MD, MSc; Sônia Maria Dozzi Brucki, MD, PhD
A woman in her 50s was evaluated in an outpatient memory clinic and was found to have had progressive cognitive impairment for at least 1 year, based on a Mini-Mental State Examination score of 20 out of 30 possible points, with a poor verbal fluency score of 4, and a reduced delayed recall (5 of 10 drawings). Her family observed that she developed a progressive commitment to the functional activities of daily living. During her life, she had arterial hypertension, but it was controlled. Laboratory and neuroimaging investigations were being scheduled at ambulatory care; however, she was admitted to the emergency department with a sudden neurologic deficit. The neurologic examination identified hemiparesis and tactile hypoesthesia on her left side.
The results of magnetic resonance imaging of her brain confirmed an ischemic stroke in the temporoparietal region on the right side of her brain (Figure, A) and revealed an image suggestive of a basilar aneurysm (Figure, B). These findings were confirmed by arteriography, which revealed another 2 aneurysms in the middle cerebral artery (Figure, C and D). Because of her history of progressive cognitive impairment and presenile-onset ischemic stroke, we obtained a sample of cerebrospinal fluid for testing, to rule out infectious or inflammatory disease.Thissampleshowedahighconcentrationoftotalprotein(0.35 g/dL [to convert to grams per liter, multiply by 10.0]) and 1 cell/mm3 as a positive VDRL test result (1:1). Moreover, her serum VDRL titer was 1:4, and her blood serum sample tested positive for Treponema
Figure. Magnetic Resonance Imaging Scans and Arteriograms of the Patient A
B
C
D
A magnetic resonance imaging fluid-attenuated inversion recovery sequence of the patient’s brain reveals acute ischemic stroke in the right frontotemporoparietal region (A) and an aneurismal formation on the basilar artery (B). Arteriography documented a saccular aneurysm at this topography (C), with another in the right middle cerebral artery trifurcation (arrowhead), and a possible aneurysm on the left side (which is not shown) (D). jamaneurology.com
(Reprinted) JAMA Neurology Published online April 27, 2015
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Clinical Review & Education Images in Neurology
pallidum hemagglutination. Then she received crystalline penicillin G intravenouslywithoutneurologicalorcognitiveimprovement,butwith severe impairment of her basic activities.
Discussion Treponema pallidum typically invades the central nervous system in secondary and later stages of syphilis infection. When spontaneous resolution does not happen, an individual can develop different symptomatic forms of syphilis. Although a broad spectrum of symptoms is possible, such as an aneurysm in the aorta, syphilis’ association with an intracranial aneurysm is a rare condition.1,2 Few
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cases are reported in the literature, with most occurring in the carotid artery, the middle cerebral artery, the anterior cerebral artery, and the anterior and posterior communicating arteries.1 To our knowledge, a basilar artery aneurysm in a person with neurosyphilis has not been previously described in the literature, although this finding could be coincidental. There is some uncertainty as to whether the development of inflammatory infiltration in the arterial wall could also predispose a person to developing intracranial aneurysms, which happens in cases of syphilitic aortitis. We suggest that serologic testing for syphilis must be performed in all cases of cognitive impairment.
ARTICLE INFORMATION
Accepted for Publication: February 6, 2015.
Author Affiliations: Department of Neurology, Hospital Santa Marcelina, São Paulo, Brazil.
Published Online: April 27, 2015. doi:10.1001/jamaneurol.2015.0154.
Corresponding Author: Nathália Stela Visoná de Figueiredo, MD, Department of Neurology, Hospital Santa Marcelina, Santa Marcelina St, No. 400, Vila Carmosina, São Paulo, Brazil 08270-070 (
[email protected]).
Conflict of Interest Disclosures: None reported. REFERENCES 1. Asdaghi N, Muayqil T, Scozzafava J, Jassal R, Saqqur M, Jeerakathil TJ. The re-emergence in
Canada of meningovascular syphilis: 2 patients with headache and stroke. CMAJ. 2007;176(12):1699-1700. 2. Cordato DJ, Djekic S, Taneja SR, et al. Prevalence of positive syphilis serology and meningovascular neurosyphilis in patients admitted with stroke and TIA from a culturally diverse population (2005-09). J Clin Neurosci. 2013;20(7):943-947.
JAMA Neurology Published online April 27, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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