What is meningovascular syphilis?

Updated: Jul 17, 2018
  • Author: Richard P Knudsen, MD, FAAN, FAAP; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Answer

Answer

The pathology of meningovascular syphilis is endarteritis with perivascular inflammation (ie, Heubner arteritis in medium-sized vessels and Nissl-Alzheimer arteritis in small intracranial vessels). This causes fibroblastic proliferation of the intima, thinning of the media, and fibrous and inflammatory changes in the adventitia, with lymphocytic and plasma cell infiltration. Rarely, aneurysmal dilation results. Luminal narrowing predisposes to cerebrovascular thrombosis, ischemia, vessel occlusion, and infarction. Onset of the meningovascular stage occurs, on average, 7 years after the initial infection. [24]

The most common presentation of meningovascular syphilis is a stroke syndrome in a relatively young adult involving the middle cerebral artery (most common) or the branches of the basilar artery (second most common). A subacute encephalitic prodrome is present, with headaches, vertigo, insomnia, and psychological abnormalities (eg, personality change, emotional lability, insomnia, decreased memory), followed by a gradually progressive vascular syndrome.

Again, symptomatic neurosyphilis frequently involves the base of the brain and therefore may result in cranial nerve palsies.

Meningeal neurosyphilis usually manifests with the clinical features of acute meningitis, including hydrocephalus, cranial neuropathies, and the formation of leptomeningeal granulomas, called gummas. A gumma is a well-circumscribed mass of granulation tissue (avascular). It results from a cell-mediated immune response to T pallidum. Gummas usually are extra-axial lesions and dura based. The cortex is often involved secondary to invasion and direct extension. Seizures, due to the irritative focus, may develop. Early parenchymatous involvement is also reported. The presentation of mesial temporal encephalitis (limbic encephalitis) with status epilepticus and memory impairment is reported. The manifestations can be altered in the clinical setting of either concomitant HIV infection and/or previously partially treated syphilis. [25]


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