Report

Clinical and imaging findings in patients with neurosyphilis:
a study of a cohort and review of the literature
Ziad Khamaysi1, MD, Reuven Bergman1, MD, Gregory Telman2, MD, and
Dorith Goldsher3, MD

1
Department of Dermatology, Rambam
Health Care Campus and the Ruth & Bruce
Rappaport Faculty of Medicine, Haifa,
Israel, 2Department of Neurology, Rambam
Health Care Campus and the Ruth & Bruce
Rappaport Faculty of Medicine, Haifa,
Israel, and 3Department of Radiology,
Rambam Health Care Campus and the
Ruth & Bruce Rappaport Faculty of
Medicine, Haifa, Israel

Correspondence
Dr. Z. Khamaysi
Department of Dermatology
Rambam Health Care Campus
POB 9602
Haifa 31096, Israel
E-mail: z_khamaysi@rambam.health.gov.il

Abstract
Background Most patients with neurosyphilis are considered asymptomatic. The diagnosis
is challenging and the role of neuroimaging is not yet well established. The present study
was conducted to focus on the clinical findings and further characterize the imaging
features of the disease, along with a review of the pertinent literature.
Methods Six male patients with neurosyphilis based on abnormal cerebrospinal fluid
findings, five of whom were asymptomatic at presentation, underwent cranial computerized
tomography (CT) and magnetic resonance imaging (MRI). They also underwent a complete
physical, neurological, and ophthalmological examination, with special attention paid to
atherosclerotic vascular risk factors. In addition, all were examined for cardiac involvement
using electrocardiography and cardiac ultrasound.
Results The meticulous neurological and ophthalmological

examination

revealed

abnormalities in five patients, most commonly cranial nerve involvement (three patients)
and hemiparesis (two patients). The CT and MRI studies revealed abnormalities in five of
the six patients, and in all six patients, respectively. The most common findings were brain
infarcts, which were demonstrated in four of the six patients. MRI was found to be more

Conflicts of interest: None.

sensitive than CT in detecting these brain infarcts, as expected.
Conclusions Vascular insult was the most common neuroimaging finding in our patients
with neurosyphilis, probably due to meningovascular endarteritis. Neurosyphilis should
always be considered in young patients with unexplained brain infarcts.

812

The use of penicillin therapy has significantly reduced
the incidence of syphilis over time.1,2 However, the
emergence of acquired immunodeficiency syndrome
(AIDS) has dramatically increased the incidence of syphilis throughout the Western world during the last decade.1–4 A high rate of syphilis coinfection has been
reported in HIV-positive patients residing in northern
Israel.5 Similarly, a syphilis outbreak among men who
have sex with men has been reported in Tel-Aviv, Israel,
during 2008–2009.6
Invasion of the central nervous system by spirochetes
may occur in up to 40% of untreated patients.7,8 The
central nervous system may be involved in four major
syndrome forms: syphilitic meningitis, meningovascular
syphilis, parenchymatous neurosyphilis, and gummatous
neurosyphilis. Syphilitic meningitis appears mostly within
two years following acquisition of the disease. Acute basilar syphilitic meningitis is characterized primarily by the
presence of cranial nerve involvement, most commonly
the 8th (42%), 7th (41%), 2nd (27%), and 3rd (24%)
International Journal of Dermatology 2014, 53, 812–819

cranial nerves.9 General paresis and tabes dorsalis are
usually progressive and largely irreversible.
The diagnosis of neurosyphilis relies on clinical and
serological findings, as well as on the examination of
cerebrospinal fluid (CSF). There are still only limited
data available on the diagnostic value of neuroimaging
in neurosyphilis.9–12 The present study was conducted
to explore further the role of neuroimaging in the diagnosis of this disease, as well as a review of the pertinent
literature.
Patients and Methods
All patients referred to our clinic in northern Israel with a
positive serology for syphilis, but without a known date of
previous infection and/or proper therapy, undergo CSF analysis.
The cohort for this study consisted of six consecutive patients
who were diagnosed between 2003 and 2010 with
neurosyphilis, based on abnormal CSF findings. All were men,
ranging in age from 33 to 49 years old (mean 39).
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Report

Of the six patients in our cohort, five were asymptomatic at
presentation. All six patients underwent cranial computerized

1 : 64. He underwent a repeated CSF examination, which
showed normal protein levels and lymphocyte counts, a positive

tomography (CT) and magnetic resonance imaging (MRI).

VDRL test with a titer of 1 : 2, and a positive TPHA test with a

Detailed histories were taken, atherosclerotic vascular disease

titer of 1 : 2560. A repeated neurological examination revealed

risk factors were investigated, and each patient underwent a

a decreased vibratory sense and absence of the Achilles reflex

physical examination with a thorough neurological assessment,

response.

including an ophthalmological examination. Baseline routine

Electromyographic test results were normal, and the brain CT

blood counts and chemistries were also performed. In addition,

disclosed mild generalized atrophy above and below the

all six patients were examined for cardiac involvement,
including electrocardiography and cardiac ultrasound (US), as

tentorium (mild dilatation of the third and fourth ventricles). The
left lateral ventricle was found to be somewhat wider than the

part of the work-up for tertiary syphilis.

right one. A mild to moderate dilatation of the frontal and

The Venereal Disease Research Laboratory (VDRL) test or

temporal sulci and prominent dilatation of the sylvian fissures

the Rapid Plasma Reagin (RPR) test and the Treponema

were noted. Mild dilatation of the cerebellar and parietal sulci

Pallidum Hemagglutination (TPHA) test were performed on the

was also observed.

sera. (In 2007, our medical center’s laboratory switched from

MRI demonstrated the same atrophic changes and revealed

VDRL to RPR serological testing.) Each patient underwent

two small lesions not seen on the CT. A small ill-defined left

lumbar puncture for CSF analysis that included protein
concentrations, glucose levels, and cell counts. Cerebrospinal

parietal lesion of high intensity on both T2WI and fluid
attenuated inversion recovery was found adjacent to the roof of

fluid, VDRL or RPR, and TPHA tests were performed in all six

the left ventricle. The other lesion abutted the lower lateral wall

cases. HIV serology was performed in all six patients using

of the fourth ventricle, compatible with an old infarct.

enzyme-linked immunosorbent assay test. The CSF findings

The patient was again treated with IV crystalline penicillin, 24

were considered compatible with neurosyphilis according to the

million units/day, for 14 days. Unfortunately, he did not return

criteria currently recommended by the Centers for Disease

for his follow-up examination and died two years later from an

Control (www.cdc.gov).

unknown cause.

The six patients diagnosed with neurosyphilis were treated with
intravenous (IV) penicillin and scheduled six months later for a
repeat CSF examination to evaluate the response to treatment.
They all had a cranial CT performed with a 16 or 64 multidetector
row CT (MX 8000 IDT & Brilliance, Philips, Netherlands), with or
without contrast, and by a 1.5T MRI system (Signa HDX14, GE
Healthcare, Milwaukee, WI, USA). The MRI studies included T1weighted spin echo or fast spin echo sequences, T2-weighted
imaging (fast spin echo), T2 fluid attenuated inversion recovery,
and diffusion weighted imaging sequences in different planes
before and after IV injection of contrast material, which was
gadolinium based.

Case 1
A 40-year-old man underwent serological screening for syphilis
during withdrawal therapy from alcoholism. The blood work-up
indicated a positive VDRL test with a titer of 1 : 16 and a positive
TPHA test. The patient did not report any clinical history of
syphilis or neurological complaints. The neurological examination
was normal, and HIV serology results were negative.
To rule out asymptomatic neurosyphilis, the patient underwent
lumbar puncture. The CSF examination demonstrated normal
protein levels; lymphocytic pleocytosis (17/mm3); neutrophils
2/mm3; a positive VDRL test with a titer of 1 : 2; and a negative
TPHA test. Consequently, the patient was diagnosed with
asymptomatic neurosyphilis and was treated with IV crystalline
penicillin, 24 million units/day, for 14 days.
Six months later, a persistent positive serum VDRL test was
found on two consecutive occasions, with titers of 1 : 32 and
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Case 2
A 40-year-old man with positive HIV (CD4 count 190/ll) and
hepatitis C virus (HCV) serologies underwent routine serological
screening for syphilis. The work-up indicated a positive RPR
test with a titer of 1 : 128 and a positive TPHA test. Three
months later, he was hospitalized because of seizures, loss of
consciousness, and fever. The repeated serological RPR test
was positive with a titer of 1 : 64.
The CSF examination revealed normal protein levels; slight
lymphocytic pleocytosis (5 cells/mm3); a positive VDRL test
with a titer of 1 : 8; and a positive TPHA test. The patient did
not report any clinical history of syphilis or neurological
complaints. The neurological examination was normal. The
brain CT disclosed mild general cerebral atrophy, more
prominent in the frontal lobes, and somewhat dilated superior
ophthalmic veins on both sides. MRI demonstrated the same
findings and showed mild atrophy of the parietal convexity
as well.
Based on the CSF findings, the patient was diagnosed with
neurosyphilis and was treated with IV crystalline penicillin, 24
million units/day, for 14 days. He did not return for his follow-up
examination and died four years later from an unknown cause.
Case 3
A 33-year-old patient with a history of drug abuse and positive
HCV serology underwent serological screening for syphilis. The
work-up indicated a positive RPR test with a titer of 1 : 2 and a
positive TPHA test. The patient did not report any clinical
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MRI in neurosyphilis

history of syphilis or neurological complaints. The HIV serology
results were negative.
The CSF examination demonstrated normal protein and

Khamaysi et al.

frontoparietal infarct, affecting both white matter and gray
matter in the convexity of the left hemisphere (Fig. 1); and
another old left upper paramedian parietal infarct. There was a

glucose levels without pleocytosis. The VDRL test was positive

tiny vascular insult noted within the body of the left caudate

with a titer of 1 : 2, and the TPHA test was negative. The

nucleus, adjacent to the ventricular wall. Multiple small and tiny

neurological examination revealed anisocoria and bilateral

lesions of high intensity were observed on T2-weighted

Adie’s tonic pupil syndrome. The brain CT and MRI findings

sequences in the periventricular and deep white matter,

were normal except for mild atrophy in the convexity of the

compatible with ischemic lesions and lacunar infarcts due to

cerebral hemispheres.
The patient was diagnosed with neurosyphilis and treated

small vessel disease. In addition, numerous prominent Virchow–
Robin spaces were depicted. Carotid Doppler ultrasound (US)

with IV crystalline penicillin, 24 million units/day, for 14 days.

demonstrated normal hemodynamics without pathological

He did not return for further follow-up examination.

changes in the carotid arteries on both sides.

Case 4
A 49-year-old healthy man, who came to Israel from an
endemic region for syphilis, underwent routine serological
testing for syphilis. The work-up indicated a positive VDRL test
with a titer of 1 : 2 and a positive TPHA test. The HIV serology
results were negative. The patient recalled noticing a small
ulcer on his penis 1.5 years earlier, which had healed
spontaneously without leaving a scar and without ensuing skin
eruptions. Five years earlier, he had also been treated with
antibiotics for gonorrhea.
The CSF examination demonstrated: elevated protein levels
(55 mg/dL); normal glucose levels; lymphocytosis (20 cells/
mm3); a positive VDRL test with a titer of 1 : 8; and a positive
TPHA test with a titer of 1 : 160. The neurological examination
revealed right hemiparesis, increased muscular tonus,
hyperreflexia, and tongue deviation. In addition, an Argyle
Robertson pupil was found. Concerning atherosclerotic vascular
risk factors, the patient had both hypertension and
hyperlipidemia.
The brain CT disclosed an old left cerebellar infarct. The MRI
demonstrated mild to moderate cerebral atrophy, mainly in the
parietal lobes; the same old left infarct in the anterior inferior
cerebellar artery territory; an old partially hemorrhagic left

million units/day, for 14 days. Six months later, the patient

The patient was treated with IV crystalline penicillin, 24
underwent a repeated CSF examination, which revealed close
to normal protein levels (42 mg/dL); normal glucose levels; mild
lymphocytosis (6 cells/mm3); a positive VDRL test with a titer of
1 : 4; and a positive TPHA test with a titer of 1 : 80. There was
no change in the results of the neurological examination. A
repeated brain MRI showed all of the lesions detected in the
previous MRI, with no new findings.

Case 5
A 33-year-old patient was admitted to the neurology department
because of vision disturbances in his right eye. The
neurological examination revealed left abducens paresis. The
right eye visus was 6/6. As part of the routine laboratory workup, the patient underwent a serological examination for syphilis,
which indicated a positive VDRL test and a positive TPHA test.
The HIV serology results were negative. The CSF examination
showed elevated protein and glucose levels, lymphocytosis (12
cells/mm3), and negative VDRL and TPHA tests. The patient
reported no clinical history of syphilis.
The brain CT disclosed a hypodense lesion within the genu
of the corpus callosum, representing an old encephalomalacic
focus. An MRI performed two days later (Fig. 2) revealed two

Figure 1 Case 4. Partially hemorrhagic (small arrows) chronic encephalopathy surrounded with gliosis (long arrows), possibly
due to an old vascular event. Note the small high-intensity white matter lesion in the right frontal lobe (arrowhead)
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MRI in neurosyphilis

A

B

C

D

Report

Figure 2 Case 5. A tiny acute infarct in the pons, adjacent to the anterior wall of the 4th ventricle. Demonstrated as a bright
spot on T2 and FLAIR sequences and proved by restricted diffusion, as shown with high intensity on DWI and a black tiny
spot on ADC maps. ADC, apparent diffusion coefficient; DWI, diffusion weighted imaging; FLAIR, fluid attenuated inversion
recovery; FSE, fast spin echo

more lesions in the genu of the corpus callosum, with isotropic

demonstrated resolution of the tiny pontine infarction noted in

diffusion and intensity equal to that of CSF, raising the

the first one, with a new acute, more extensive infarct

possibility of cysts, lacunae, or Virchow–Robin spaces. A tiny
acute infarct with restricted diffusion was depicted in the

appearing in the mesencephalon with restricted diffusion
weighted imaging. There were no other significant changes

posterior aspect of the pons adjacent to the anterior wall of the

when compared to the previous MRI study. A third MRI (Fig. 4)

fourth ventricle. In addition, a small lacunar infarct was

performed 14 months later again showed the left

observed anterior to the right temporal horn. Carotid Doppler

mesencephalic infarct, which was now chronic, with newly

US demonstrated normal hemodynamics without pathological

appearing subacute ischemic lesions/infarcts in the medulla

changes in the carotid arteries on both sides. Electrocardiogram

oblongata that were more prominent on the left side. Three

and cardiac US results were also normal, with no indication of

years later, the patient’s neurological condition remained

any changes due to ischemic events.
As neurosyphilis was the likely diagnosis, the patient was

unchanged.

treated with IV crystalline penicillin, 24 million units/day, for

Case 6
A 40-year-old patient with a positive serology for HCV
underwent routine serological testing for syphilis, which
indicated a positive RPR test with a titer of 1 : 64 and a
positive TPHA test. The HIV serology results were negative.
The patient recalled a small ulcer on his penis that had
appeared seven years earlier and had healed spontaneously
without leaving a scar. He did not report any history of
eruptions or neurological complaints.

10 days. His condition improved within several days after
initiation of therapy, with fading of his neurological complaints.
Eighteen months later, he was hospitalized again because of
diplopia and weakness of his right extremities. The neurological
examination revealed left abducens paresis and mild weakness of
his right arm and leg. He declined a repeated CSF examination.
A repeated cranial CT did not point to any changes when
compared with the previous one (Fig. 3). A second MRI
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MRI in neurosyphilis

Khamaysi et al.

A

B

C

D

E

F

Figure 3 Case 5. Axial computed tomography and magnetic resonance imaging (T1) showing an encephalomalacic small lesion
in the genu of the corpus callosum. T2 (fast spin echo) and T1 sagittal images and two axial images on different planes
depicting two different lesions

The CSF examination demonstrated: elevated protein levels;
normal glucose levels; lymphocytosis (10 cells/mm3);
neutrophils 37/mm3; a positive VDRL test with a titer of 1 : 2;
and a positive TPHA test. The neurological examination and
brain CT were interpreted to be normal. The MRI showed
multiple old lacunar infarcts in the basal ganglia on both sides,
including the internal and external capsules. The patient did not
have atherosclerotic vascular risk factors except for untreated
mild hypertension. He was treated with IV crystalline penicillin,
24 million units/day, for 14 days. The patient did not return for
further follow-up examination.

Results
The clinical, laboratory, and neuroimaging data are summarized in Table 1. Five asymptomatic, mostly high-risk
patients were diagnosed following routine serological testing for syphilis, and the sixth patient was diagnosed
because of neurological complaints. Of the six patients,
only one tested positive for HIV but without clinical signs
of AIDS. Two patients recalled untreated penile lesions in
the past, which healed spontaneously.
The neurological examination revealed abnormalities in
five of the six patients. The most common neurological
findings were cranial nerve involvement, observed in three
International Journal of Dermatology 2014, 53, 812–819

of the six (50%) patients. Hemiparesis was the second
most common finding, occurring in two of the six (33%)
patients. The other neurological findings, which were
found in one patient each, included seizures, loss of vibration, hyperreflexion, increased muscular tone, and tongue
deviation.
The CSF findings (Table 1) included lymphocytic pleocytosis in five patients, positive VDRL test in five
patients, and positive TPHA test in three. Two patients
had atherosclerotic vascular risk factors, namely, hypertension and hyperlipidemia in one patient (case 4) and
mild untreated hypertension in a second patient (case 6).
The former patient had a Doppler US examination of his
carotid arteries, which showed normal hemodynamics.
All six patients had normal results on cardiac US examination.
The brain CT indicated abnormal findings in five of the
six patients, whereas the MRI demonstrated pathological
findings in all six patients. The MRI detected cerebral
infarcts in four of the six patients and was more sensitive
than the CT, which detected infarcts in only one case.
All six patients underwent IV therapy with crystalline
penicillin, 24 million units/day, for 14 consecutive days,
as recommended by the Centers for Disease Control. Of
the three patients who were followed up, only one
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Figure 4 Case 5. 14 months later – an appearance of a new acute infarct, as demonstrated in the left lower aspect of the
mesencephalon as a bright lesion on both T2 (FSE) and FLAIR sequences, with restricted diffusion on DWI and ADC maps
(red arrows). ADC, apparent diffusion coefficient; DWI, diffusion weighted imaging; FLAIR, fluid attenuated inversion
recovery; FSE, fast spin echo

improved neurologically. The two patients who
underwent a repeated CSF examination following therapy demonstrated improvement in some of the CSF
parameters.
Discussion
Neurosyphilis is often asymptomatic. Most of our
patients were diagnosed by routine serological tests in
asymptomatic high-risk patients. Although the majority
of our patients, with the exception of one, had no initial
neurological complaints, the neurological examination
revealed abnormal findings in three patients. Upon meticulous history taking, two patients admitted having
untreated penile ulcers in the past. These findings underscore the value of serological testing for syphilis in
asymptomatic high-risk patients.
There have been only a few reports of neuroradiological findings in a relatively small series of patients with
neurosyphilis.10–12 Peng et al.11 described 14 patients
ª 2013 The International Society of Dermatology

with neurosyphilis whose CT results were similar to their
MRI findings, though MRI seemed to be more useful in
the diagnosis of general paresis. Using CT and MRI with
14 HIV-negative neurosyphilis patients, Peng et al.11
demonstrated cerebral infarction in six cases, arteritis in
four, nonspecific white matter lesions in three, acute
syphilitic meningitis in one, and normal neuroimaging in
one. In addition, four of their patients had general paresis
supported by the MRI findings.11
In our cohort, the MRI was more sensitive than the CT
in detecting brain infarcts, as expected due to its superiority in detecting small infratentorial lesions. The most
common MRI findings were brain lacunar infarcts
detected in four of the six patients. In two of these
patients, there were risk factors for atherosclerotic vascular disease, namely hyperlipidemia and/or hypertension.
In one of them (case 4) with both hyperlipidemia
and hypertension, the carotid Doppler US was normal,
and the patient was found to have an Argyle Robertson
pupil. In another patient (case 6) with mild untreated
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International Journal of Dermatology 2014, 53, 812–819
Generalized atrophy above and
below the tentorium. Mild dilatation
of 3rd and 4th ventricles
Mild general atrophy. Slightly dilated
superior ophthalmic veins, bilaterally

Mild atrophy in the convexity of
the cerebral hemisphere
Old left cerebellar infarct

1st and 2nd: hypodense lesion within
the ingenue of the corpus
callosum = old
encephalomalacic focus

Two small infarcts adjacent
to left ventricle and 4th ventricle

Mild enlargement of the
cerebral sulci

Mild atrophy in the convexity of
the cerebral hemisphere

Several infarcts in the cerebellum, frontoparietal region, caudate nucleus,
periventricular and deep white matter

1st: lesions in the genu of the corpus
callosum + infarcts in the pons and
temporal horn
2nd: resolution of the pontine infarction
+ new infarct in the mesencephalon
3rd: new infarct in the medulla oblongata
Multiple lacunar infarcts in the basal ganglia
on both sides
Normal

1st: vision disturbances.
Right visus 6/60
Left abducens
2nd: left abducens paresis. Mild
weakness of right arm and leg

Right hemiparesis, increased tonus,
hyperreflexia, tongue deviation,
Argyle Robertson pupil

Anisocoria,
bilateral Adie’s tonic pupils

Seizures, loss of consciousness, fever,
neurological examination – normal

1st: none
2nd: diminished vibratory
sense. Achilles tendon reflex: –ve

Neurological complaints
and findings

Proteins: 128 mg/dL
Lymph: 10/mm3
Neutrophils: 37/mm3
VDRL: 1 : 2
TPHA: +ve

Proteins: 55 mg/dL
Lymph: 20/mm3
VDRL: 1:8
TPHA: 1 : 160
Proteins: 67 mg/dL
Lymph: 12/mm3
VDRL: –ve
TPHA: –ve

VDRL: 1 : 2
TPHA: –ve

1st: lymph: 17/mm9
VDRL: 1 : 2
2nd: VDRL: 1 : 2
TPHA: 1 : 2560
Lymph: 5/mm3
VDRL: 1 : 8TPHA: +ve

CSF findings

RPR: 1 : 64
TPHA: +ve
HCV: +ve

VDRL: 1 : 2
TPHA: +ve

1st: VDRL: 1 : 16
TPHA: +ve
2nd: VDRL: 1 : 64
TPHA 1 : 2560
RPR: 1:128
TPHA: +ve
HIV: +ve
HCV: +ve
RPR: 1 : 2
TPHA: +ve
HCV: +ve
VDRL: 1 : 2
TPHA: +ve

Abnormal serological
findings

6/M/40

5/M/33

4/M/49

3/M/33

2/M/40

1/M/40

Patient no./
sex/age (years)

CSF, cerebrospinal fluid; CT, computerized tomography; HCV, hepatic C virus; HIV, human immunodeficiency virus; Lymph, lymphocytes; M, male; MRI, magnetic
resonance imaging; N, normal; –ve, negative; +ve, positive; RPR, Rapid Plasma Regain; TPHA, Treponema Pallidum Hemagglutination; VDRL, Veneral Disease
Research Laboratory.

Normal

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Cranial MRI

Table 1 Summary of major findings

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Khamaysi et al.

hypertension, the relatively young age (40 years old)
and serological and CSF findings of active untreated syphilis made asymptomatic atherosclerotic vascular disease
unlikely as the cause of his brain infarcts. Furthermore,
all six patients had normal cardiac US, which ruled out
patent foramen ovale as a possible conduit for emboli.
Clotting disorders were not a likely cause because of the
involvement of small blood vessels in the brain without
any evidence of thrombotic episodes elsewhere.
Gurses et al.10 found some incongruency with the clinical findings, as two of their eight patients with neurosyphilis had normal MRI studies, though both had
abnormal neurological findings. The cranial nerve neuropathy in three of our six cases was compatible with the
sequelae of syphilitic meningitis. This may explain the
absence of specific parallel MRI findings. Cranial nerve
abnormalities are seen in 45% of patients with syphilitic
meningitis.8 Meningovascular lesions are common in
patients with neurosyphilis, and many manifest neuroradiologically as small infarcts in the basal ganglia or brain
stem, as in our patients. These may result from insult to
perforating arteries by endarteritis, causing cortical and
subcortical infarcts, leptomeningeal enhancement, meningitis, and arteritis.7,13 Neurosyphilis resulting in cerebral
infarctions was found to be common in our study, as in
previous research.7,11,14
The presentation of neurosyphilis has changed over the
last 40 years.15 Patients now tend to present atypically
with seizures, ophthalmic symptoms such as poor vision,
stroke, confusion, or personality changes.15 The present
study has demonstrated that routine serological testing
for syphilis, followed by CSF examination of the positive
cases, may detect asymptomatic neurosyphilis. Subsequent
meticulous neurological examination may detect abnormal findings even in patients who initially present without
complaints. Moreover, cranial neuroimaging may detect
abnormal findings not always suspected during neurological examination. Vascular lesions were the most common
neuroimaging finding in our patients with neurosyphilis,
probably due to meningovascular endarteritis, and MRI
was found to be more sensitive than CT in detecting such
lesions. In conclusion, neurosyphilis should always be
considered in young patients with idiopathic brain
infarcts.

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