[A case of refractory meningovascular syphilis followed up by vessel wall imaging]

Meningovascular syphilis (MVS) is a rare but important cause of stroke. Vessel wall imaging (VWI) has emerged as a useful tool for evaluating cerebral vasculitis, but its correlation with clinical outcomes remains unclear. A 67-year-old man was admitted to our department with acute onset of left hemiparesis following headache and behavioral abnormalities. Brain MRI revealed subarachnoid hemorrhage in the right frontal lobe and acute infarctions in the right basal ganglia and parietal lobe. MRA demonstrated stenosis of the right middle cerebral artery. Serological and cerebrospinal fluid tests for syphilis were positive, and cerebrospinal fluid analysis showed pleocytosis, leading to a diagnosis of MVS. The patient was treated with intravenous penicillin G for 14 days. Although initial improvement was observed, the patient experienced recurrent subarachnoid hemorrhages and multiple cerebral infarctions, with progressive stenosis in multiple cerebral arteries. VWI revealed concentric wall thickening and homogeneous enhancement of both middle cerebral arteries. Treatment was escalated to include antiplatelet agents and immunosuppressive therapy with corticosteroids. While syphilis markers and VWI enhancement findings improved, clinical symptoms and arterial stenosis showed only limited recovery. This case highlights the utility of VWI in evaluating and monitoring cerebral vasculitis associated with MVS. However, VWI improvement did not correlate with clinical recovery, suggesting the need for further investigation into treatment strategies and prognostic indicators.