Teaching NeuroImage: Vessel Wall MRI Features of Meningovascular Syphilis

A 67-year-old man presented with hemifacial weakness and maculopapular rash, treated as Bell palsy.Initial CT angiogram was normal.6 weeks later, he developed dizziness, diplopia, ataxia, and worsening rash.MRI revealed midbrain, pontine, and thalamic infarcts.An infectious vasculitis was suspected.Vessel wall MRI (VWMR) showed near-occlusion and concentric enhancement of the distal basilar and bilateral P1 PCAs (Figure 1), corroborated with a CT angiogram (Figure 2).His serum syphilis RPR was positive to 256 dilutions, and lumbar puncture revealed a positive CSF VDRL.A diagnosis of meningovascular syphilis (MVS) was made.He was treated with penicillin G 4M units IV every 4 hours for 14 days.Six-week followup angiogram was stable, and his deficits resolved.MVS is a rare cause of recurrent infarcts, with increasing incidence. 1Concentric, multifocal enhancement and VWMR patterns of vessel wall thickening can identify infectious and inflammatory vasculitides such as MVS. 2 VWMR is a useful adjunct to clarify the etiology of intracranial vasculopathies.