What is the cerebrovascular involvement in syphilis (Sexually Transmitted Infection)?

From the Guidelines

Cerebrovascular involvement in syphilis, also known as neurosyphilis, is a serious complication that requires prompt diagnosis and treatment to prevent irreversible neurological damage. The recommended treatment for cerebrovascular syphilis is intravenous aqueous crystalline penicillin G at a dosage of 18-24 million units daily, administered as 3-4 million units every 4 hours for 10-14 days, as suggested by various guidelines 1.

Key Considerations

• Patients with late latent syphilis or syphilis of unknown duration and a normal CSF examination can be treated with benzathine penicillin G, at weekly doses of 2.4 million units for 3 weeks 1.
• Patients who have CSF consistent with neurosyphilis should be treated and managed as patients who have neurosyphilis, with a focus on preventing further neurological damage 1.
• All persons with syphilis, regardless of disease stage, should be evaluated for clinical evidence of CNS or ocular involvement, and those with neurologic or ocular symptoms or signs should undergo CSF examination to rule out neurosyphilis 1.

Treatment and Management

• Intravenous aqueous crystalline penicillin G is the preferred treatment for cerebrovascular syphilis, with alternative regimens available for penicillin-allergic patients, such as doxycycline 200 mg twice daily for 28 days or ceftriaxone 2 grams daily for 10-14 days.
• Patients should undergo cerebrospinal fluid examination before treatment to confirm the diagnosis, with findings typically showing elevated protein, pleocytosis, and positive VDRL test.
• Following treatment, clinical and serological follow-up at 3,6,12, and 24 months is essential to ensure treatment success and prevent further complications.

Clinical Presentation

• The cerebrovascular manifestations of syphilis result from endarteritis of small, medium, and large vessels, leading to vessel narrowing, thrombosis, and subsequent ischemic strokes.
• Patients may present with stroke-like symptoms, including hemiparesis, aphasia, or other focal neurological deficits, often accompanied by headache, altered mental status, or seizures.
• Early diagnosis and treatment are crucial as neurological damage may be irreversible despite successful eradication of the infection.

From the Research

Cerebrovascular Involvement in Syphilis

The cerebrovascular involvement in syphilis is a significant aspect of the disease, particularly in its tertiary stage. Some key points to consider include:

• Neurosyphilis, a complication of syphilis, can cause severe neurological symptoms, including cranial nerve dysfunction, acute or chronic altered mental status, and auditory abnormalities 2.
• Cerebrospinal fluid (CSF) examination is crucial in diagnosing neurosyphilis, especially in patients with serologic evidence of syphilis infection and neurologic symptoms 3.
• The treatment of neurosyphilis typically involves aqueous crystalline penicillin, although other antibiotic regimens can be used in cases of penicillin allergy 4.
• A study reported a case of confirmed neurosyphilis with no known modifiable stroke risk factors, who developed acute ischemic stroke and other constitutional symptoms consistent with Jarisch-Herxheimer reaction after IV penicillin 5.

Risk Factors and Treatment Outcomes

Some important factors to consider when evaluating cerebrovascular involvement in syphilis include:

• The risk of stroke and other cerebrovascular events may be increased in patients with neurosyphilis, particularly those with HIV infection 3.
• The effectiveness of antibiotic therapy in treating neurosyphilis and preventing cerebrovascular complications is still being studied, with some trials suggesting that ceftriaxone may be an effective alternative to penicillin G 4.
• However, the quality of evidence for these studies is often limited, and more research is needed to fully understand the cerebrovascular involvement in syphilis and the most effective treatment strategies 4.

Diagnosis and Prevention

Some key points to consider when diagnosing and preventing cerebrovascular involvement in syphilis include:

• Early diagnosis and treatment of syphilis are crucial in preventing the development of neurosyphilis and cerebrovascular complications 2, 6.
• CSF examination and serologic testing are essential in diagnosing neurosyphilis and monitoring treatment outcomes 3.
• Education and promotion of safe sex practices, such as condom use, are critical in preventing the spread of syphilis and reducing the risk of cerebrovascular complications 6.