Angiographic Findings in a Case of Brain Syphilis

Abstract

The clinical difficulties of differentiating neurosyphilis from other brain diseases have long been accepted. Indeed, many patients with this disease have been subjected to fruitless craniotomy in the mistaken belief that a tumor or some other disease lay at the basis of their symptoms (6). The fact that neurosyphilis may also be associated with angiographic abnormalities which can simulate brain tumor, however, is not generally recognized, though of growing importance with the increasing use of angiography. Since no reports of angiographic changes in paretic meningovascular neurosyphilis were found in angiographic texts (4, 8) or in the literature of the past twelve years, the following case is reported. Case Report B. D., a 46-year-old Negro factory worker, suffered an abrupt onset of aphasia and right-sided weakness and sensory loss a few hours prior to admission. Over the preceding months there had been a gradual personality change, loss of recent memory, wandering of speech, and increasingly short-tempered behavior. The patient was found to be confused and responded to questioning with incoherent mumbling phrases and perseveration. There was no papilledema and the pupils were normal, but the corneal reflexes were diminished and there was right hemiparesis and hemihypesthesia. The cerebrospinal fluid pressure was normal, but the fluid contained 10 lymphocytes per cubic millimeter as well as 190 red blood cells which were thought to be traumatic in origin. Protein was 104 mg. per cent. The electroencephalogram was grossly abnormal, indicating severe structural disturbance of the left hemisphere with some involvement of the right as well. Routine skull radiographs were normal. Left carotid angiography showed essentially normal internal carotid, middle cerebral, and anterior cerebral arteries, although the anterior cerebral artery was smaller than average and filled only transiently. In the late arterial and early venous phases of the examination a localized spherical “blush” 3 cm. in diameter with numerous fine vessels but without irregular pooling was demonstrated, high on the posterosuperior parietal convexity (Fig. 1). The large overlying superficial vein, possibly the vein of Trolard, filled and emptied slightly earlier than the other superficial veins and its branches appeared stretched and deformed over the area of blush. There was localized narrowing and irregularity of one of the large veins in the blush area. The angiographic findings were interpreted as favoring brain tumor, possibly a meningioma or glioma. Prior to surgery, complement fixation test of the blood and cerebrospinal fluid was noted to be positive (Hinton), and a first zone colloidal gold curve was found. These did not alter the angiographic evaluation because previous reports of similar angiographic findings in neurosyphilis were not available.