Stroke in the Setting of Neurosyphilis: A Comprehensive Literature Review

Background: syphilis is globally recognized as a great imitator due to its multiple manifestations and multi-organ involvement. This holds especially true in the context of neurosyphilis (NS), where stroke and other cerebrovascular manifestations are frequently overlooked. With the global reemergence of syphilis, meningovascular syphilis (MVS) and other vascular syphilitic affectations are now important, yet underdiagnosed causes of ischemic stroke. Purpose: this literature review focuses on syphilis in the context of stroke, examining the condition through this specific perspective. The pathophysiological aspect focuses on immune-mediated endothelial injury and vascular inflammation as main mechanisms leading to stroke. Analysis: a broader approach to syphilis is initially described, showcasing the comprehensive medical workup necessary for accurate diagnosis of MVS and special treatment considerations. Diagnostic challenges of NS are initially exposed, with cerebrospinal fluid (CSF) analysis and neuroimaging playing critical roles. While CSF-VDRL remains the gold standard, although, its low sensitivity necessitates a multimodal diagnostic approach combining serological, clinical, and radiographic findings. MRI and angiographic studies often reveal concentric steno-occlusive arteriopathy, most commonly affecting the middle cerebral and basilar arteries. Early recognition is vital, as NS can mimic common neurovascular etiologies, particularly in the context of younger adults without traditional risk factors. Treatment involves intravenous penicillin G, corticosteroids and antiplatelet agents playing supportive roles. However, clinicians must weigh bleeding risks in specific cases, particularly in patients with syphilitic aneurysmal disease. Conclusions: timely diagnosis and treatment of NS and MVS are essential to prevent irreversible neurological damage and contribute to the reduction of global stroke burden.