Neurosyphilis remains a “great imitator,” capable of presenting with diverse neurologic syndromes such as tabes dorsalis, general paresis, or the rarer meningovascular syphilis (MVS). MVS results from Treponema pallidum–induced endarteritis and meningitis, leading to arterial inflammation, thrombosis, and cerebral infarction. While most reported cases involve the MCA or posterior circulation, bilateral anterior cerebral artery (ACA) strokes from MVS have not been previously documented. We present the first known case of bilateral ACA infarctions secondary to meningovascular syphilis.

A 60-year-old man presented with sudden onset of lightheadedness, urinary incontinence, and difficulty walking following a “popping” sound in his head. In the emergency department, he exhibited bizarre behavior and mutism. Neurological examination showed profound bilateral lower-extremity weakness (right > left). Brain MRI revealed multifocal acute cortical infarcts in bilateral ACA territories, and CTA demonstrated right ACA A2 occlusion with left ACA stenosis. Serum Treponema pallidum antibody and RPR (1:64) were reactive; HIV testing was positive (viral load 125,000 copies/mL, CD4 = 453). CSF studies showed lymphocytic pleocytosis (182 cells/µL) and elevated protein (177 mg/dL). Cerebral angiography confirmed right ACA A2 occlusion and left ACA hypoplasia without evidence of vasculitis.