What is the role of imaging in the diagnosis of neurosyphilis?

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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Neuroradiologic findings in patients with neurosyphilis include ischemic lesions (typically lacunar or middle cerebral artery in distribution) in meningovascular syphilis, intracerebral gummata, and syphilitic myelitis. Cranial nerve involvement, particularly the optic and vestibulocochlear nerves, has been reported. With chorioretinitis, orbital MRI would likely show nerve sheath enlargement.

Patients with general paresis (parenchymatous neurosyphilis) have demonstrated frontocortical atrophy and disseminated frontal high-signal lesions. These patients have also been found to have cerebral atrophy (cortical thinning of the temporal and frontoparietal regions bilaterally, most prominent in the temporal regions); mesiotemporal (amygdalar) T2 hyperintensity; ventriculomegaly; and pathological T2 hypointensity of the globus pallidus, putamen, head of the caudate, and thalamus. In those with general paresis, MRI may be of prognostic value. [56] The iron (ie, ferritin) deposition and increased frontal atrophy correlate with the progression of neuropsychiatric disturbances, apparently independent of CSF changes.

Also reported is newly diffuse white-matter T2 hyperintensity, which was seen to be partially reversible after therapy and thus thought to be due to edema and gliosis. [57] It was not specific for neurosyphilis in that it has also been seen with Binswanger disease, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, progressive multifocal leukoencephalopathy, HIV encephalitides, and subacute sclerosing panencephalitis. Diffusion-weighted imaging (DWI) on MRI serves well to demonstrate cerebral syphilitic gumma, revealing findings that include juxtacortical lesional nodular enhancement, moderately restricted diffusion, and dural tail and surrounding vasogenic edema. [58, 59]

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