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| NEUROIMAGES |
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| Year : 2016 | Volume
: 64
| Issue : 7 | Page : 131-133 |
Bilateral vertebral artery and internal carotid artery dissecting aneurysms due to syphilis
Yunbo Chen
Department of Neurology, The Fourth People's Hospital, Zigong, Sichuan, China
| Date of Web Publication | 3-Mar-2016 |
Correspondence Address:
Yunbo Chen
Department of Neurology, The Fourth People's Hospital, Zigong, Sichuan
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.178060
How to cite this article:
Chen Y. Bilateral vertebral artery and internal carotid artery dissecting aneurysms due to syphilis. Neurol India 2016;64, Suppl S1:131-3 |
Multiple dissecting aneurysms in the cervical internal carotid and subclavian arteries as well as the intracranial vertebral artery (VA) are rare in clinical practice. These are mostly attributed to arterial diseases such as atherosclerosis, fibromuscular dysplasia, infective or noninfective arteritis, and trauma. We describe a patient with dissecting aneurysms of bilateral VAs associated with an internal carotid artery (ICA) dissecting aneurysm due to syphilitic arteritis.
A 50-year old male presented with sudden-onset vertigo, repeated episodes of vomiting, and impaired gait. His neurological examination revealed a right-sided cerebellar ataxia. The physical examination was unremarkable. He had a history of uncontrolled hypertension and smoking. He denied any possibility of a traumatic neck injury and had no manifestations of a coexisting autoimmune disease. There was no known hereditary disease in his family. In the past year, he was once referred to our neurological clinic with complaints of some nonspecific symptoms such as fatigue and dizziness. Nonenhanced computed tomography (NECT) scan was done at that time and the axial images revealed a hyperdense area within bilateral intracranial VA that also had a dilated lumen. This finding was interpreted as being a manifestation of atherosclerosis [Figure 1]a. | Figure 1: (a) Computed tomography (1 year before the onset of symptoms) shows dilated vertebral arteries, especially on the right side (white arrow). (b) The computed tomography image after the onset of symptoms showed a significantly dilated right vertebral artery (white arrow)
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His Treponema pallidum (TP) test, TP particle agglutination and serum fluorescent treponemal antibody absorption were all positive. The erythrocytic sedimentation rate was 18 mm in the first hour. The serological tests for detection of autoimmune diseases such as antinuclear antibody, extractable nuclear antigen, anti-double-stranded DNA, and anti-neutrophil cytoplasmic antibody, as well as his serological test for the human immunodeficiency virus (HIV) were all negative. The serum lipid burden and hemoglobin A1C were normal. The cerebrospinal fluid (CSF) analysis was normal.
Compared with the computed tomographic (CT) scan image taken 1 year ago, his axial image of nonenhanced computed tomography (NECT) at the onset of his present symptoms showed the significantly dilated bilateral VAs, especially on the right side [Figure 1]b. One day after the onset of the symptoms, his CT scan confirmed an infarction in the territory of right posterior inferior cerebellar artery (PICA) [Figure 2]. The CT angiography (CTA) showed the left VA and right ICA dissecting aneurysms [Figure 3]. Digital subtraction angiography (DSA) revealed the 'pearl and string' sign in the left VA with, aneurysms being present in the left VA and right ICA; it also showed an occlusion of the right VA at its V 3 segment proximal to the origin of PICA, thus confirming the findings seen on CTA [Figure 4]. The color Doppler ultrasound revealed a high-flow velocity in the left VA and a normal intimal-media thickness in both carotid arteries. | Figure 2: Computed tomography (1 day after the onset of symptoms) showed a hypodensity in the territory of right posterior inferior cerebellar artery
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 | Figure 3: Computed tomography angiography revealed a dissecting aneurysm in the right internal carotid artery (arrow) and and left vertebral artery (arrowhead) and non-filling of the the right vertebral artery
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 | Figure 4: Digital subtraction angiography revealed dissecting aneurysms in right internal carotid artery (a, arrow), left vertebral artery (b, arrow), and occlusion of the right vertebral artery at its V3 segment proximal to the origin of right posterior inferior cerebellar artery (c)
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The patient was treated with 100 mg aspirin/day and received benzathine penicillin G therapy (2 million units, intramuscular, weekly for 3 weeks). He did not receive any interventional or surgical treatment for the aneurysms. His symptoms resolved slightly during the following weeks. He was discharged 3 weeks later with his modified Rankin score being 3 and has been on regular follow-up visits.
Our patient presented with right-sided cerebellar ataxia and vertigo. The recent CT scan confirmed an infarcted area of the cerebellum in the territory of right PICA. It also revealed that the aneurysm at V 3 segment of the right VA had dilated significantly in the size as compared to the CT findings revealed in the scan done nearly an year ago. The most likely mechanism of infarction was the progressively dilating intramural hematoma in the dissecting aneurysm that involved the origin of PICA that had led to progressive occlusion of its lumen. The DSA indicated that there was no collateral flow from the contralateral VA that would compensate for the lack of flow in the right PICA.
The causes of dissecting aneurysms within intracerebral and cervical blood vessels are multiple. [1] A thorough physical examination, laboratory tests, radiological imaging, and angiography ruled out other potential causes such as fibromuscular dysplasia, atherosclerosis, trauma, cervical manipulation, polycystic kidney disease, Ehlers-Danlos syndrome More Details, HIV, and autoimmune diseases.
Our case was diagnosed as syphilis by serological tests. In general, syphilitic arteritis is believed to be associated with aortic aneurysms. [2] Meningovascular syphilis can also lead to cerebral ischemic stroke. [3] However, multiple dissecting aneurysms of bilateral VAs associated with an aneurysm in the ICA is not a common presentation in syphilitic arteritis. There are occasionally cases focusing on the probable association between syphilis and multiple intracerebral aneurysms [4] as well as aneurysms of the subclavian artery. [5] Given the negative results of the CSF analysis, it is assumed that syphilitic arteritis rather than neurosyphilis caused the aneurysmal formation.
The patient might have avoided the stroke and the progressive enlargement of aneurysms if the CT scan and his clinical condition had been correctly diagnosed a year ago. The instituted management has also been corroborated by a retrospective study. [6] Based on the findings of this case, tests for the detection of syphilis should also be included in the clinical work-up in cases detected to be having an ICA or VA dissecting aneurysm of an undetermined cause.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| » References | |  |
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| 3. | Cordato DJ, Djekic S, Taneja SR, Maley M, Beran RG, Cappelen-Smith C, et al. Prevalence of positive syphilis serology and meningovascular neurosyphilis in patients admitted with stroke and TIA from a culturally diverse population (2005-09). J Clin Neurosci 2013;20:943-7. |
| 4. | Opina AD, Tafur A. A night with Venus, a lifetime with Mercury: A case of multiple intracranial aneurysms. Am J Med Sci 2012;343:498-500. |
| 5. | Lin CM. Left subclavian artery aneurysm secondary to syphilitic arteritis presenting with a right ischemic cerebellar infarction. Neurol India 2009;57:344-6. [ PUBMED]  |
| 6. | Kai Y, Nishi T, Watanabe M, Morioka M, Hirano T, Yano S, et al. Strategy for treating unruptured vertebral artery dissecting aneurysms. Neurosurgery 2011;69:1085-91. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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