Cerebellar Tonsillar Herniation Following Acute Ischemic Stroke in Meningovascular Neurosyphilis: A Case Report

Cerebellar Tonsillar Herniation Following Acute Ischemic Stroke in Meningovascular Neurosyphilis: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cerebellar Tonsillar Herniation Following Acute Ischemic Stroke in Meningovascular Neurosyphilis: A Case Report Prakash Gupta, Linh Nguyen, Raman Goit, Prateeti Bekoju, Manoj Argariya, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8567222/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 13 You are reading this latest preprint version Abstract Introduction: Meningovascular neurosyphilis (MVNS) represents an uncommon manifestation of Treponema pallidum infection, potentially leading to stroke, cerebral edema, and elevated intracranial pressure. Cerebellar tonsillar herniation represents a rare yet critical complication with potentially life-threatening consequences. Timely diagnosis and intervention are critical to avert lethal consequences. Case Presentation: A 20-year-old female presented with headache, dizziness, and altered sensorium, which were preceded by a self-limiting genital lesion eight weeks prior. She exhibited disorientation without any focal neurological deficits. The MRI indicated a left thalamic infarct, while cerebrospinal fluid analysis validated the presence of meningovascular neurosyphilis. Intravenous ceftriaxone and corticosteroids were administered for her treatment. On the 14th day of hospitalization, the patient experienced a generalized seizure accompanied by a rapid deterioration in consciousness. Subsequent imaging revealed widespread cerebral edema and herniation of the cerebellar tonsils. Despite receiving supportive care, she ultimately died due to complications arising from brainstem compression and increased intracranial pressure. Conclusion: This case illustrates the significant consequences of MVNS resulting in infarction, cerebral edema, and tonsillar herniation in a young woman without a previous STD diagnosis. Early neuroimaging, cerebrospinal fluid analysis, and timely antimicrobial therapy are essential. The provision of IV penicillin and prompt surgical decompression are essential, particularly in resource-limited settings. Key Clinical Message: This case shows how a thalamic stroke caused by meningovascular neurosyphilis can quickly lead to cerebral edema and a tonsillar herniation. Neurological problems need to be diagnosed, treated, and decompressed surgically as soon as possible to avoid permanent damage. Meningovascular neurosyphilis ischemic stroke cerebellar tonsillar herniation Figures Figure 1 Figure 2 Figure 3 1. Introduction Syphilis, caused by Treponema pallidum, can progress to neurosyphilis at any stage. It is more prevalent in high-risk groups, including men who have sex with men and individuals with human immunodeficiency virus (HIV) 1 . Early neurosyphilis may involve the meninges, cerebrospinal fluid (CSF), and vasculature 2 ; syphilitic meningitis and meningovascular forms are more common, and timely treatment along with earlier diagnosis can help prevent late progression to conditions such as tabes dorsalis 3 . While most cases resolve spontaneously and remain asymptomatic, approximately 5% progress to meningitis, which may present with seizures, aphasia, hemiplegia, or confusion. Meningovascular neurosyphilis (MVNS), a sub-type, typically occurs as early as six months to seven years after primary infection 4 . It causes vascular inflammation, ischemic infarction, cerebral edema, and increased intracranial pressure (ICP) 5 . Cerebellar tonsillar herniation, an exceptionally rare but life-threatening consequence of elevated ICP, can result in brainstem compression, hydrocephalus, and fetal cardio-respiratory failure 6 . Timely recognition and neurosurgical decompression are essential to prevent irreversible injuries 7 . We present a rare case of a 20-year-old female with neuro-psychiatric symptoms and altered sensorium, ultimately diagnosed with MVNS complicated by thalamic infarction, which progressed to diffuse cerebral edema and ultimately cerebellar tonsillar herniation. This case underscores the critical importance of early neuroimaging, CSF analysis, and prompt decompression to prevent life-threatening complications. 2. Case History and Examination A 20-year-old female presented to our hospital with a sudden onset of a dull headache localized to the parietal region. The patient reported dizziness, nausea, vomiting, and orbital pain. The patient presented with a history of multiple episodes of watery vomiting, devoid of bile or blood. The patient reported no fever, visual disturbances, or prior history of trauma, diabetes, or hypertension. The patient's mother reported that eight months ago, the patient developed a painless, itchy lesion on her genitalia, which resolved spontaneously after two months without treatment. Two weeks ago, she had visited the emergency room with similar symptoms, which painkillers alleviated. The patient exhibited altered sensorium characterized by confusion, disorientation, amnesia, nervousness, personality changes, hostility, aggressive behaviors, hallucinations, and illusions. The patient's temperature measured 98.9°F, with a pulse rate of 100 beats per minute, a respiratory rate of 20 breaths per minute, blood pressure recorded at 110/90 mm Hg, and oxygen saturation at 94% in room air. On physical examination, pupils were equal, measuring 4 mm in diameter, and exhibited reactivity to light. She experienced disorientation regarding time, place, and person. Motor examinations reveal that muscle bulk, tone, and power in both upper and lower limbs are within normal limits. The plantar reflex, along with other reflexes, was intact. We did not conduct the sensory examination. Aside from the neurological examination, the examination of other systems revealed no significant findings. 3. Differential Diagnosis At this point, given the patient’s presentation with altered mental status, headache, visual hallucinations, and a prior painless genital lesion, the most probable differential diagnoses included viral encephalitis, bacterial or tubercular meningoencephalitis, autoimmune encephalitis and cerebral vasculitis. 4. Diagnosis, Investigation, and Treatment Routine labs (CBC, RFT, LFT, BMP) were normal. TSH was elevated (16.28 mU/L), and Vitamin B12 was low (143 ng/L). Serology for HBsAg, HCV, and HIV was negative. RPR and TPHA tests confirmed syphilis. CSF analysis revealed 79 cells/μL (100% lymphocytes), high protein levels, low glucose levels, and numerous pus cells. Gram stain and culture results were negative; the CSF VDRL test was positive. AFB stain and HSV-1/2 PCR were negative. Findings are summarized in [ Table 1] . An MRI of the brain revealed diffusion restriction in the postero-lateral region of the left thalamus, suggestive of an acute infarct [ Figure 1 ]. The patient was admitted to the intensive care unit (ICU) with a provisional diagnosis of acute ischemic stroke with possible meningoencephalitis. Empirical antimicrobial therapy was initiated on the day of admission, including intravenous ceftriaxone, vancomycin, and acyclovir. On the following day, ampicillin was added to broaden coverage. In light of the ischemic infarct, she was started on aspirin and atorvastatin. Concurrently, levothyroxine 75 mcg daily was administered for hypothyroidism, and intramuscular methylcobalamin 1000 mcg was given to correct her vitamin B12 deficiency. Following the cerebrospinal fluid (CSF) analysis results, acyclovir, vancomycin, and ampicillin were discontinued, and ceftriaxone was continued as monotherapy. Given the patient’s young age and ischemic stroke, further investigations were conducted to rule out autoimmune and hypercoagulable states, including rheumatoid factor, antinuclear antibodies (ANA), serologies for HIV, hepatitis B, and C, as well as tests for natural anticoagulant levels and vasculitis markers. Based on positive VDRL and TPHA findings in both serum and CSF, the patient was diagnosed with neurosyphilis, specifically the meningovascular form. Despite our best efforts, intravenous crystalline penicillin could not be administered due to its unavailability. The patient initially showed mild clinical improvement with ceftriaxone and corticosteroid therapy. However, on the 14th day of hospitalization, her condition deteriorated abruptly. She developed a generalized tonic-clonic seizure, after which her Glasgow Coma Scale (GCS) score declined to E2V3M2. The seizure was managed with intravenous midazolam, and she was immediately intubated and placed on supportive care. A repeat MRI could not be performed on the same day of clinical deterioration. However, an MRI brain with MRA done the following day revealed significant findings, including tonsillar herniation, diffuse cerebral edema, and effacement of the visualized sulci and cisterns [ Figure 2 ]. Neurological examination showed bilateral pupillary dilation to 4.5 mm and a positive Babinski sign, indicating severe brainstem involvement and raised ICP. Unfortunately, her neurological status continued to decline despite ongoing management, ultimately leading to her demise. 5. Conclusion and Results Meningovascular neurosyphilis (MVNS), particularly in its early and aggressive form, may result in severe complications including ischemic infarction, diffuse cerebral edema, and cerebellar tonsillar herniation if not diagnosed and treated promptly. This case emphasizes the need to consider neurosyphilis and perform early interventions among young patients who present with altered sensorium and a history of genital lesions. Prompt CSF analysis and neuroimaging are crucial for assessing CNS involvement. Early intervention with appropriate antimicrobial therapy and management of complications, such as cerebellar herniation, often requires decompression surgery and is vital, involving a multidisciplinary approach. This approach can significantly improve outcomes, especially in resource-limited settings. The patient initially showed mild improvement but later developed seizures and a drop in GCS. Follow-up MRI revealed diffuse cerebral edema and cerebellar tonsillar herniation, leading to her death. 6. Discussion Our case highlights a rare and severe complication post-neurosyphilis, a cerebellar tonsillar herniation secondary to diffuse cerebral edema and ICP, following an ischemic stroke in a young female with no prior diagnosis of a sexually transmitted infection (STD). Syphilis is an important but often overlooked cause of ischemic stroke, especially in young patients. According to a nationwide retrospective cohort study by Chang et al. (2022), it showed a 35% increased risk of stroke in patients with syphilis compared to matched controls. This supports the association between syphilis and cerebrovascular events 8 . Similarly, a Brazilian tertiary center found 13% of stroke patients had positive syphilis serology, and 4.7% met criteria for neurosyphilis, despite most having negative CSF-VDRL 9 . Ischemic strokes are increasingly affecting individuals under the age of 50. Rare disorders collectively account for 22% of cases¹³ [Table 2]. MVNS, which affects 15% to 30% of neurosyphilis cases and usually manifests 7 years after infection, can cause ischemic stroke 10 . Treponema pallidum penetrates the central nervous system (CNS) hematogenously shortly after inoculation and stays latent 11 . Later, it results in inflammation of small vessels (Nissl endarteritis) and medium to large arteries (Heubner endarteritis), which primarily affects the anterior circulation. The natural development of untreated neurosyphilis over time, including its different neurological symptoms like meningitis, MVNS, general paresis, and tabes dorsalis, is shown in [Figure 3] , just like in our patient who did not get treatment on time. Prodromal symptoms like headache and malaise often precede onset 12 . Prior to making the diagnosis, serologic treponemal tests such as the fluorescence treponemal antibody test, absorption test, or EIA are used to confirm the existence of a syphilis infection. The RPR and TPHA tests that were conducted on our patient produced positive findings. The next step should be to undergo a lumbar puncture. Neurosyphilis is consistent with pleocytosis, elevated protein content (>45 mg/dL), or a positive CSF VDRL test 12 , as conducted in our patient. The vascular involvement may have been exacerbated by a prolonged, undetected infection. Although cerebellar tonsillar herniation due to stroke is a well-documented phenomenon, secondary to stroke caused by MVNS, it has been rarely reported. Tonsillar herniation is a severe outcome of elevated intracranial pressure, typically arising from traumatic brain injury (TBI), which impacts around 69 million people worldwide annually 14 . Additional causes encompass intracerebral and subarachnoid hemorrhages. The precise incidence of tonsillar herniation remains undetermined, as it serves as a physiological endpoint for multiple underlying diseases. The Monroe-Kellie concept posits that the cranial cavity contains fixed amounts of brain tissue (1400 mL), cerebrospinal fluid (150 mL), and blood (150 mL) 15 . As one component rises, others must diminish to preserve equilibrium. Initially, cerebrospinal fluid and venous blood are displaced for compensation. Once these processes are depleted—termed loss of intracranial compliance—cerebral tissue may herniate through the foramen magnum. This results in medullary compression, which may lead to respiratory arrest, cardiac failure, coma, and death 16 . Therefore, herniation occurs when the cerebellar tonsils shift down through the foramen magnum, putting pressure on the medulla against the clivus or odontoid. This “coning” effect triggers Cushing’s reflex and can rapidly progress to death 17 . This could be a possible cause of death of our patient. Tonsillar herniation generally represents a final phase of significant intracranial pressure, particularly with brainstem compression and respiratory failure 16 . Nonetheless, prompt identification and timely surgical decompression may enhance results and avert mortality, as described by Cushing 7 . Our patient, a young woman with no traditional risk factors, was diagnosed with MVNS based on CSF findings, resulting in thalamic infarct ultimately progressing to diffuse cerebral edema and tonsillar herniation. The tragic outcome of the patient's condition highlights the critical nature of timely intervention in cases of escalating intracranial pressure. The shift from a thalamic infarct to widespread brain swelling and then to tonsillar herniation shows the serious dangers and difficulties associated with MVNS. This case serves as a reminder that prompt identification and surgical decompression are not merely procedural steps but vital actions that can significantly alter the course of patient outcomes. The unfortunate demise due to cerebellar tonsillar herniation illustrates the urgent need for awareness and swift response in managing neurological emergencies, emphasizing that every moment counts in preserving life when faced with such severe complications. Declarations Consent :During admission, the patient and her father gave consent for all the procedures and data collection. The authors have obtained written informed consent from the patient’s legal guardian for publication. Conflict of Interest: No Disclosure: A preliminary version of this case was previously published in Dhulikhel Medical Update, concentrating on the diagnosis of meningovascular neurosyphilis. This report, submitted to Wiley Clinical Case Reports, offers a novel and essential perspective on cerebellar tonsillar herniation as a rare, life-threatening complication that was not addressed in the previous publication. Funding: None Author Contribution 1-Prakash Gupta: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing2-Linh Nguyen: Conceptualization, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing3-Raman Goit: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Writing – original draft4-Prateeti Bekoju: Conceptualization, Formal analysis, Investigation, Supervision, Validation, Writing – original draft5-Manoj Argariya: Writing – original draft6-Karan Rana: Writing – original draft7-Srivatsa Srirama Reddy: Writing – original draft, 8-Parikshit Prasai: Writing – original draft9-Daniel Nguyen: Writing – original draft Acknowledgement The authors thank the patient for providing consent to publish this case report, including the use of anonymized clinical details and related images. No additional acknowledgments are declared. References Zhou J, Zhang H, Tang K, Liu R, Li J. An Updated Review of Recent Advances in Neurosyphilis. Front Med (Lausanne) . 2022;9. doi:10.3389/fmed.2022.800383 Xiang L, Zhang T, Zhang B, Zhang C, Hou S, Yue W. The associations of increased cerebral small vessel disease with cognitive impairment in neurosyphilis presenting with ischemic stroke. Brain Behav . 2021;11(6). doi:10.1002/brb3.2187 Flood JM, Weinstock HS, Guroy ME, Bayne L, Simon RP, Bolan G. Neurosyphilis during the AIDS Epidemic, San Francisco, 1985-1992. Journal of Infectious Diseases . 1998;177(4):931-940. doi:10.1086/515245 Berger JR, Dean D. Neurosyphilis. In: ; 2014:1461-1472. doi:10.1016/B978-0-7020-4088-7.00098-5 Bäuerle J, Zitzmann A, Egger K, Meckel S, Weiller C, Harloff A. The Great Imitator—Still Today! A Case of Meningovascular Syphilis Affecting the Posterior Circulation. Journal of Stroke and Cerebrovascular Diseases . 2015;24(1):e1-e3. doi:10.1016/j.jstrokecerebrovasdis.2014.07.046 Tadevosyan A, Kornbluth J. Brain Herniation and Intracranial Hypertension. Neurol Clin . 2021;39(2):293-318. doi:10.1016/j.ncl.2021.02.005 Meyer GA, Winter DL. Spinal cord participation in the Cushing reflex in the dog. J Neurosurg . 1970;33(6):662-675. doi:10.3171/jns.1970.33.6.0662 Chang SH, Kao CH, Hung CH, et al. Syphilis and ischemic stroke: Old question revisited by a nationwide cohort study. International Journal of Stroke . 2022;17(9):997-1005. doi:10.1177/17474930221079163 Targa Martins R, Castilhos RM, Silva da Silva P, Costa LS. Frequency of Screening and Prevalence of Neurosyphilis in Stroke Population. Cerebrovascular Diseases . 2020;49(3):301-306. doi:10.1159/000508491 Shulman JG, Cervantes-Arslanian AM. Infectious Etiologies of Stroke. Semin Neurol . 2019;39(04):482-494. doi:10.1055/s-0039-1687915 Carod Artal FJ. Clinical management of infectious cerebral vasculitides. Expert Rev Neurother . 2016;16(2):205-221. doi:10.1586/14737175.2015.1134321 Chow F, Marra C, Cho T. Cerebrovascular Disease in Central Nervous System Infections. Semin Neurol . 2011;31(03):286-306. doi:10.1055/s-0031-1287658 Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Neurosyphilis in a clinical cohort of HIV-1-infected patients. AIDS . 2008;22(10):1145-1151. doi:10.1097/QAD.0b013e32830184df Dewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg . 2019;130(4):1080-1097. doi:10.3171/2017.10.JNS17352 Mokri B. The Monro–Kellie hypothesis. Neurology . 2001;56(12):1746-1748. doi:10.1212/WNL.56.12.1746 Plum F, Posner JB. The diagnosis of stupor and coma. Contemp Neurol Ser . 1972;10:1-286. Weinberg JS, Rhines LD, Cohen ZR, Langford L, Levin VA. Posterior Fossa Decompression for Life-threatening Tonsillar Herniation in Patients with Gliomatosis Cerebri: Report of Three Cases. Neurosurgery . 2003;52(1):216-223. doi:10.1097/00006123-200301000-00028 Tables Table 1 : Comprehensive Cerebrospinal Fluid (CSF) Analysis, WBC: White Blood Cell, ADA: Adenosine Deaminase, AFB: Acid Fast Bacilli, VDRL: Venereal Disease Research Laboratory, HSV: Herpes Simplex Virus, DNA: Deoxyribonucleic Acid, PCR: Polymerase Chain Reaction Parameter Result Reference Range Volume 1 ml Color Watery Transparency Clear Total WBC Count 76 cells/ µL 0-5 cells/µL (normal) Differential Count Neutrophils 0% 0–6% Lymphocytes 100% 40–80% Monocytes 0% 15–45% Eosinophils 0% 0% Basophils 0% 0% Protein, CSF 155 mg/dL Adults 60 yrs: 30–60 mg/dL Sugar, CSF 10 mg/dL 40–80 mg/dL ADA 9 U/L CSF: <10.0 U/L Gram Stain Pus cells present; no microorganisms Culture and Sensitivity No growth after 48 hours at 37°C AFB Stain No acid-fast bacilli seen VDRL (CSF) Reactive HSV-1 and HSV-2 DNA PCR (CSF) Negative Table 2. Etiological Classification of Stroke in Young Adults, HIV: Human Immunodeficiency Virus, COL4A1: Collagen Type IV Alpha 1 chain Medications and substance use Cardiac and structural associations Important nonstructural associations Genetic and acquired thrombophilia Inflammatory vasculopathies Noninflammatory vasculopathies Infectious disorders Monogenic disorders Oral contraceptives Patent foramen ovale Migraine with aura Factor V Leiden mutation Primary central nervous system vasculitis Cervical artery dissection Infective endocarditis Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy Alcohol use Congenital heart disease Pregnancy Prothrombin G20210A mutation Systemic vasculitis ⁠Intracranial artery dissection Meningoencephalitis Cerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy ⁠Cannabis ⁠Valvulopathies Malignancy ⁠Protein C deficiency Radiation-induced vasculopathy ⁠HIV ⁠COL4A1 disorders Cocaine ⁠Intracardiac tumors Protein S deficiency Reversible cerebral vasoconstriction syndrome Syphilis Fabry disease Amphetamines ⁠Antithrombin III deficiency ⁠Moyamoya disease or syndrome Tuberculosis Hereditary hemorrhagic telangiectasia Opiates Antiphospholipid syndrome Homocystinuria Marfan syndrome ⁠ ⁠ ⁠Sickle cell disease Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8567222","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":594111880,"identity":"0dc3df66-9287-4671-83dc-a1b9dc455665","order_by":0,"name":"Prakash Gupta","email":"","orcid":"","institution":"Virgen Milagrosa University Foundation","correspondingAuthor":false,"prefix":"","firstName":"Prakash","middleName":"","lastName":"Gupta","suffix":""},{"id":594111882,"identity":"b6621672-ab16-4e8e-b86e-c27dc5613f7b","order_by":1,"name":"Linh Nguyen","email":"","orcid":"","institution":"Saint James school of 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posterolateral aspect of left thalamus s/o infarct (red arrow).\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8567222/v1/62f0862f7507c3bf94165be3.jpg"},{"id":103349643,"identity":"60a365f0-2dec-4390-b4df-968e0a355c53","added_by":"auto","created_at":"2026-02-24 16:45:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":110013,"visible":true,"origin":"","legend":"\u003cp\u003eSagittal FLAIR image shows tonsillar herniation, effacement of visualized sulci and cisterns and diffuse high signal intensity in cerebral and cerebellar cortex consistent with diffuse brain edema (red arrow).\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8567222/v1/e1453ce30edf0c7ca3f70db0.jpg"},{"id":103349642,"identity":"d78c8ec5-f458-482c-b218-7368873e80d8","added_by":"auto","created_at":"2026-02-24 16:45:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":55596,"visible":true,"origin":"","legend":"\u003cp\u003eNeurological complications of syphilis with estimated timeframes indicating the average duration to progression in the absence of medical treatment\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8567222/v1/00dea2b19f20b349175924cc.jpg"},{"id":103349644,"identity":"c5482dc1-c190-4a12-9c30-79894ebbb082","added_by":"auto","created_at":"2026-02-24 16:45:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":760065,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8567222/v1/e4fa7d96-5c8d-40d2-a80d-e5801fade77d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCerebellar Tonsillar Herniation Following Acute Ischemic Stroke in Meningovascular Neurosyphilis: A Case Report\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eSyphilis, caused by Treponema pallidum, can progress to neurosyphilis at any stage. It is more prevalent in high-risk groups, including men who have sex with men and individuals with human immunodeficiency virus (HIV) \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Early neurosyphilis may involve the meninges, cerebrospinal fluid (CSF), and vasculature \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e; syphilitic meningitis and meningovascular forms are more common, and timely treatment along with earlier diagnosis can help prevent late progression to conditions such as tabes dorsalis \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhile most cases resolve spontaneously and remain asymptomatic, approximately 5% progress to meningitis, which may present with seizures, aphasia, hemiplegia, or confusion. Meningovascular neurosyphilis (MVNS), a sub-type, typically occurs as early as six months to seven years after primary infection \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. It causes vascular inflammation, ischemic infarction, cerebral edema, and increased intracranial pressure (ICP) \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCerebellar tonsillar herniation, an exceptionally rare but life-threatening consequence of elevated ICP, can result in brainstem compression, hydrocephalus, and fetal cardio-respiratory failure \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Timely recognition and neurosurgical decompression are essential to prevent irreversible injuries \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe present a rare case of a 20-year-old female with neuro-psychiatric symptoms and altered sensorium, ultimately diagnosed with MVNS complicated by thalamic infarction, which progressed to diffuse cerebral edema and ultimately cerebellar tonsillar herniation. This case underscores the critical importance of early neuroimaging, CSF analysis, and prompt decompression to prevent life-threatening complications.\u003c/p\u003e"},{"header":"2. Case History and Examination","content":"\u003cp\u003eA 20-year-old female presented to our hospital with a sudden onset of a dull headache localized to the parietal region. The patient reported dizziness, nausea, vomiting, and orbital pain. The patient presented with a history of multiple episodes of watery vomiting, devoid of bile or blood. The patient reported no fever, visual disturbances, or prior history of trauma, diabetes, or hypertension. The patient's mother reported that eight months ago, the patient developed a painless, itchy lesion on her genitalia, which resolved spontaneously after two months without treatment. Two weeks ago, she had visited the emergency room with similar symptoms, which painkillers alleviated. The patient exhibited altered sensorium characterized by confusion, disorientation, amnesia, nervousness, personality changes, hostility, aggressive behaviors, hallucinations, and illusions. The patient's temperature measured 98.9\u0026deg;F, with a pulse rate of 100 beats per minute, a respiratory rate of 20 breaths per minute, blood pressure recorded at 110/90 mm Hg, and oxygen saturation at 94% in room air. On physical examination, pupils were equal, measuring 4 mm in diameter, and exhibited reactivity to light. She experienced disorientation regarding time, place, and person. Motor examinations reveal that muscle bulk, tone, and power in both upper and lower limbs are within normal limits. The plantar reflex, along with other reflexes, was intact. We did not conduct the sensory examination. Aside from the neurological examination, the examination of other systems revealed no significant findings.\u003c/p\u003e"},{"header":"3. Differential Diagnosis","content":"\u003cp\u003eAt this point, given the patient\u0026rsquo;s presentation with altered mental status, headache, visual hallucinations, and a prior painless genital lesion, the most probable differential diagnoses included viral encephalitis, bacterial or tubercular meningoencephalitis, autoimmune encephalitis and cerebral vasculitis.\u003c/p\u003e"},{"header":"4. Diagnosis, Investigation, and Treatment","content":"\u003cp\u003eRoutine labs (CBC, RFT, LFT, BMP) were normal. TSH was elevated (16.28 mU/L), and Vitamin B12 was low (143 ng/L). Serology for HBsAg, HCV, and HIV was negative. RPR and TPHA tests confirmed syphilis. CSF analysis revealed 79 cells/\u0026mu;L (100% lymphocytes), high protein levels, low glucose levels, and numerous pus cells. Gram stain and culture results were negative; the CSF VDRL test was positive. AFB stain and HSV-1/2 PCR were negative. Findings are summarized in [\u003cstrong\u003eTable 1]\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eAn MRI of the brain revealed diffusion restriction in the postero-lateral region of the left thalamus, suggestive of an acute infarct [\u003cstrong\u003eFigure 1\u003c/strong\u003e]. The patient was admitted to the intensive care unit (ICU) with a provisional diagnosis of acute ischemic stroke with possible meningoencephalitis. Empirical antimicrobial therapy was initiated on the day of admission, including intravenous ceftriaxone, vancomycin, and acyclovir. On the following day, ampicillin was added to broaden coverage. In light of the ischemic infarct, she was started on aspirin and atorvastatin. Concurrently, levothyroxine 75 mcg daily was administered for hypothyroidism, and intramuscular methylcobalamin 1000 mcg was given to correct her vitamin B12 deficiency.\u003c/p\u003e\n\u003cp\u003eFollowing the cerebrospinal fluid (CSF) analysis results, acyclovir, vancomycin, and ampicillin were discontinued, and ceftriaxone was continued as monotherapy. Given the patient\u0026rsquo;s young age and ischemic stroke, further investigations were conducted to rule out autoimmune and hypercoagulable states, including rheumatoid factor, antinuclear antibodies (ANA), serologies for HIV, hepatitis B, and C, as well as tests for natural anticoagulant levels and vasculitis markers. Based on positive VDRL and TPHA findings in both serum and CSF, the patient was diagnosed with neurosyphilis, specifically the meningovascular form.\u003c/p\u003e\n\u003cp\u003eDespite our best efforts, intravenous crystalline penicillin could not be administered due to its unavailability. The patient initially showed mild clinical improvement with ceftriaxone and corticosteroid therapy. However, on the 14th day of hospitalization, her condition deteriorated abruptly. She developed a generalized tonic-clonic seizure, after which her Glasgow Coma Scale (GCS) score declined to E2V3M2. The seizure was managed with intravenous midazolam, and she was immediately intubated and placed on supportive care.\u003c/p\u003e\n\u003cp\u003eA repeat MRI could not be performed on the same day of clinical deterioration. However, an MRI brain with MRA done the following day revealed significant findings, including tonsillar herniation, diffuse cerebral edema, and effacement of the visualized sulci and cisterns [\u003cstrong\u003eFigure 2\u003c/strong\u003e]. Neurological examination showed bilateral pupillary dilation to 4.5 mm and a positive Babinski sign, indicating severe brainstem involvement and raised ICP. Unfortunately, her neurological status continued to decline despite ongoing management, ultimately leading to her demise.\u003c/p\u003e"},{"header":"5. Conclusion and Results","content":"\u003cp\u003eMeningovascular neurosyphilis (MVNS), particularly in its early and aggressive form, may result in severe complications including ischemic infarction, diffuse cerebral edema, and cerebellar tonsillar herniation if not diagnosed and treated promptly. This case emphasizes the need to consider neurosyphilis and perform early interventions among young patients who present with altered sensorium and a history of genital lesions. Prompt CSF analysis and neuroimaging are crucial for assessing CNS involvement. Early intervention with appropriate antimicrobial therapy and management of complications, such as cerebellar herniation, often requires decompression surgery and is vital, involving a multidisciplinary approach. This approach can significantly improve outcomes, especially in resource-limited settings. The patient initially showed mild improvement but later developed seizures and a drop in GCS. Follow-up MRI revealed diffuse cerebral edema and cerebellar tonsillar herniation, leading to her death.\u003c/p\u003e"},{"header":"6. Discussion","content":"\u003cp\u003eOur case highlights a rare and severe complication post-neurosyphilis, a cerebellar tonsillar herniation secondary to diffuse cerebral edema and ICP, following an ischemic stroke in a young female with no prior diagnosis of a sexually transmitted infection (STD). Syphilis is an important but often overlooked cause of ischemic stroke, especially in young patients. According to a nationwide retrospective cohort study by Chang et al. (2022), it showed a 35% increased risk of stroke in patients with syphilis compared to matched controls. This supports the association between syphilis and cerebrovascular events\u003csup\u003e8\u003c/sup\u003e. Similarly, a Brazilian tertiary center found 13% of stroke patients had positive syphilis serology, and 4.7% met criteria for neurosyphilis, despite most having negative CSF-VDRL\u003csup\u003e9\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIschemic strokes are increasingly affecting individuals under the age of 50. Rare disorders collectively account for 22% of cases\u0026sup1;\u0026sup3;\u0026nbsp;\u003cstrong\u003e[Table 2].\u003c/strong\u003e MVNS, which affects 15% to 30% of neurosyphilis cases and usually manifests 7 years after infection, can cause ischemic stroke \u003csup\u003e10\u003c/sup\u003e. Treponema pallidum penetrates the central nervous system (CNS) hematogenously shortly after inoculation and stays latent \u003csup\u003e11\u003c/sup\u003e. Later, it results in inflammation of small vessels (Nissl endarteritis) and medium to large arteries (Heubner endarteritis), which primarily affects the anterior circulation. The natural development of untreated neurosyphilis over time, including its different neurological symptoms like meningitis, MVNS, general paresis, and tabes dorsalis, is shown in\u003cstrong\u003e\u0026nbsp;[Figure 3]\u003c/strong\u003e, just like in our patient who did not get treatment on time. Prodromal symptoms like headache and malaise often precede onset\u003csup\u003e12\u003c/sup\u003e. Prior to making the diagnosis, serologic treponemal tests such as the fluorescence treponemal antibody test, absorption test, or EIA are used to confirm the existence of a syphilis infection. The RPR and TPHA tests that were conducted on our patient produced positive findings. The next step should be to undergo a lumbar puncture. Neurosyphilis is consistent with pleocytosis, elevated protein content (\u0026gt;45 mg/dL), or a positive CSF VDRL test\u003csup\u003e12\u003c/sup\u003e, as conducted in our patient. The vascular involvement may have been exacerbated by a prolonged, undetected infection.\u003c/p\u003e\n\u003cp\u003eAlthough cerebellar tonsillar herniation due to stroke is a well-documented phenomenon, secondary to stroke caused by MVNS, it\u0026nbsp;has been rarely reported. Tonsillar herniation is a severe outcome of elevated intracranial pressure, typically arising from traumatic brain injury (TBI), which impacts around 69 million people worldwide annually\u003csup\u003e14\u003c/sup\u003e. Additional causes encompass intracerebral and subarachnoid hemorrhages. The precise incidence of tonsillar herniation remains undetermined, as it serves as a physiological endpoint for multiple underlying diseases. The Monroe-Kellie concept posits that the cranial cavity contains fixed amounts of brain tissue (1400 mL), cerebrospinal fluid (150 mL), and blood (150 mL)\u003csup\u003e15\u003c/sup\u003e. As one component rises, others must diminish to preserve equilibrium. Initially, cerebrospinal fluid and venous blood are displaced for compensation. Once these processes are depleted\u0026mdash;termed loss of intracranial compliance\u0026mdash;cerebral tissue may herniate through the foramen magnum. This results in medullary compression, which may lead to respiratory arrest, cardiac failure, coma, and death\u003csup\u003e16\u003c/sup\u003e. Therefore, herniation occurs when the cerebellar tonsils shift down through the foramen magnum, putting pressure on the medulla against the clivus or odontoid. This \u0026ldquo;coning\u0026rdquo; effect triggers Cushing\u0026rsquo;s reflex and can rapidly progress to death\u003csup\u003e17\u003c/sup\u003e. This could be a possible cause of death of our patient. Tonsillar herniation generally represents a final phase of significant intracranial pressure, particularly with brainstem compression and respiratory failure\u003csup\u003e16\u003c/sup\u003e. Nonetheless, prompt identification and timely surgical decompression may enhance results and avert mortality, as described by Cushing\u003csup\u003e7\u003c/sup\u003e. Our patient, a young woman with no traditional risk factors, was diagnosed with MVNS based on CSF findings, resulting in thalamic infarct ultimately progressing to diffuse cerebral edema and tonsillar herniation.\u003c/p\u003e\n\u003cp\u003eThe tragic outcome of the patient\u0026apos;s condition highlights the critical nature of timely intervention in cases of escalating intracranial pressure. The shift from a thalamic infarct to widespread brain swelling and then to tonsillar herniation shows the serious dangers and difficulties associated with MVNS. This case serves as a reminder that prompt identification and surgical decompression are not merely procedural steps but vital actions that can significantly alter the course of patient outcomes. The unfortunate demise due to cerebellar tonsillar herniation illustrates the urgent need for awareness and swift response in managing neurological emergencies, emphasizing that every moment counts in preserving life when faced with such severe complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent\u003c/strong\u003e:During admission, the patient and her father gave consent for all the procedures and data collection. The authors have obtained written informed consent from the patient\u0026rsquo;s legal guardian for publication.\u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eNo\u003c/b\u003e \u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eDisclosure:\u003c/h2\u003e \u003cp\u003eA preliminary version of this case was previously published in Dhulikhel Medical Update, concentrating on the diagnosis of meningovascular neurosyphilis. This report, submitted to Wiley Clinical Case Reports, offers a novel and essential perspective on cerebellar tonsillar herniation as a rare, life-threatening complication that was not addressed in the previous publication.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e1-Prakash Gupta: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing2-Linh Nguyen: Conceptualization, Investigation, Methodology, Software, Validation, Visualization, Writing \u0026ndash; original draft, Writing \u0026ndash; review \u0026amp; editing3-Raman Goit: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Writing \u0026ndash; original draft4-Prateeti Bekoju: Conceptualization, Formal analysis, Investigation, Supervision, Validation, Writing \u0026ndash; original draft5-Manoj Argariya: Writing \u0026ndash; original draft6-Karan Rana: Writing \u0026ndash; original draft7-Srivatsa Srirama Reddy: Writing \u0026ndash; original draft, 8-Parikshit Prasai: Writing \u0026ndash; original draft9-Daniel Nguyen: Writing \u0026ndash; original draft\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the patient for providing consent to publish this case report, including the use of anonymized clinical details and related images. No additional acknowledgments are declared.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhou J, Zhang H, Tang K, Liu R, Li J. An Updated Review of Recent Advances in Neurosyphilis. \u003cem\u003eFront Med (Lausanne)\u003c/em\u003e. 2022;9. doi:10.3389/fmed.2022.800383\u003c/li\u003e\n\u003cli\u003eXiang L, Zhang T, Zhang B, Zhang C, Hou S, Yue W. The associations of increased cerebral small vessel disease with cognitive impairment in neurosyphilis presenting with ischemic stroke. \u003cem\u003eBrain Behav\u003c/em\u003e. 2021;11(6). doi:10.1002/brb3.2187\u003c/li\u003e\n\u003cli\u003eFlood JM, Weinstock HS, Guroy ME, Bayne L, Simon RP, Bolan G. Neurosyphilis during the AIDS Epidemic, San Francisco, 1985-1992. \u003cem\u003eJournal of Infectious Diseases\u003c/em\u003e. 1998;177(4):931-940. doi:10.1086/515245\u003c/li\u003e\n\u003cli\u003eBerger JR, Dean D. Neurosyphilis. In: ; 2014:1461-1472. doi:10.1016/B978-0-7020-4088-7.00098-5\u003c/li\u003e\n\u003cli\u003eB\u0026auml;uerle J, Zitzmann A, Egger K, Meckel S, Weiller C, Harloff A. The Great Imitator\u0026mdash;Still Today! A Case of Meningovascular Syphilis Affecting the Posterior Circulation. \u003cem\u003eJournal of Stroke and Cerebrovascular Diseases\u003c/em\u003e. 2015;24(1):e1-e3. doi:10.1016/j.jstrokecerebrovasdis.2014.07.046\u003c/li\u003e\n\u003cli\u003eTadevosyan A, Kornbluth J. Brain Herniation and Intracranial Hypertension. \u003cem\u003eNeurol Clin\u003c/em\u003e. 2021;39(2):293-318. doi:10.1016/j.ncl.2021.02.005\u003c/li\u003e\n\u003cli\u003eMeyer GA, Winter DL. Spinal cord participation in the Cushing reflex in the dog. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 1970;33(6):662-675. doi:10.3171/jns.1970.33.6.0662\u003c/li\u003e\n\u003cli\u003eChang SH, Kao CH, Hung CH, et al. Syphilis and ischemic stroke: Old question revisited by a nationwide cohort study. \u003cem\u003eInternational Journal of Stroke\u003c/em\u003e. 2022;17(9):997-1005. doi:10.1177/17474930221079163\u003c/li\u003e\n\u003cli\u003eTarga Martins R, Castilhos RM, Silva da Silva P, Costa LS. Frequency of Screening and Prevalence of Neurosyphilis in Stroke Population. \u003cem\u003eCerebrovascular Diseases\u003c/em\u003e. 2020;49(3):301-306. doi:10.1159/000508491\u003c/li\u003e\n\u003cli\u003eShulman JG, Cervantes-Arslanian AM. Infectious Etiologies of Stroke. \u003cem\u003eSemin Neurol\u003c/em\u003e. 2019;39(04):482-494. doi:10.1055/s-0039-1687915\u003c/li\u003e\n\u003cli\u003eCarod Artal FJ. Clinical management of infectious cerebral vasculitides. \u003cem\u003eExpert Rev Neurother\u003c/em\u003e. 2016;16(2):205-221. doi:10.1586/14737175.2015.1134321\u003c/li\u003e\n\u003cli\u003eChow F, Marra C, Cho T. Cerebrovascular Disease in Central Nervous System Infections. \u003cem\u003eSemin Neurol\u003c/em\u003e. 2011;31(03):286-306. doi:10.1055/s-0031-1287658\u003c/li\u003e\n\u003cli\u003eGhanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Neurosyphilis in a clinical cohort of HIV-1-infected patients. \u003cem\u003eAIDS\u003c/em\u003e. 2008;22(10):1145-1151. doi:10.1097/QAD.0b013e32830184df\u003c/li\u003e\n\u003cli\u003eDewan MC, Rattani A, Gupta S, et al. Estimating the global incidence of traumatic brain injury. \u003cem\u003eJ Neurosurg\u003c/em\u003e. 2019;130(4):1080-1097. doi:10.3171/2017.10.JNS17352\u003c/li\u003e\n\u003cli\u003eMokri B. The Monro\u0026ndash;Kellie hypothesis. \u003cem\u003eNeurology\u003c/em\u003e. 2001;56(12):1746-1748. doi:10.1212/WNL.56.12.1746\u003c/li\u003e\n\u003cli\u003ePlum F, Posner JB. The diagnosis of stupor and coma. \u003cem\u003eContemp Neurol Ser\u003c/em\u003e. 1972;10:1-286.\u003c/li\u003e\n\u003cli\u003eWeinberg JS, Rhines LD, Cohen ZR, Langford L, Levin VA. Posterior Fossa Decompression for Life-threatening Tonsillar Herniation in Patients with Gliomatosis Cerebri: Report of Three Cases. \u003cem\u003eNeurosurgery\u003c/em\u003e. 2003;52(1):216-223. doi:10.1097/00006123-200301000-00028\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e: Comprehensive Cerebrospinal Fluid (CSF) Analysis, WBC: White Blood Cell, ADA: Adenosine Deaminase, AFB: Acid Fast Bacilli, VDRL: Venereal Disease Research Laboratory, HSV: Herpes Simplex Virus, DNA: Deoxyribonucleic Acid, PCR: Polymerase Chain Reaction\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003eReference Range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eVolume\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e1 ml\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eColor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eWatery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eTransparency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eClear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eTotal WBC Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e76 cells/\u0026nbsp;\u0026micro;L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e0-5 cells/\u0026micro;L (normal)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eDifferential Count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eNeutrophils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e0\u0026ndash;6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eLymphocytes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e40\u0026ndash;80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eMonocytes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e15\u0026ndash;45%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eEosinophils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eBasophils\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eProtein, CSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e155 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 32.0513%;\"\u003e\n \u003cp\u003eAdults \u0026lt;60 yrs: 15\u0026ndash;45; \u0026gt;60 yrs: 30\u0026ndash;60 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eSugar, CSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e10 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e40\u0026ndash;80 mg/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eADA\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e9 U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003eCSF: \u0026lt;10.0 U/L\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eGram Stain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 34.4551%;\"\u003e\n \u003cp\u003ePus cells present; no microorganisms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eCulture and Sensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eNo growth after 48 hours at 37\u0026deg;C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eAFB Stain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eNo acid-fast bacilli seen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eVDRL (CSF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReactive\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.4936%;\"\u003e\n \u003cp\u003eHSV-1 and HSV-2 DNA PCR (CSF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34.4551%;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 32.0513%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Etiological Classification of Stroke in Young Adults, HIV: Human Immunodeficiency Virus, COL4A1: Collagen Type IV Alpha 1 chain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eMedications and substance use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003eCardiac and structural associations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003eImportant nonstructural associations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003eGenetic and acquired thrombophilia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003eInflammatory vasculopathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003eNoninflammatory vasculopathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003eInfectious disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eMonogenic disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eOral contraceptives\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003ePatent foramen ovale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003eMigraine with aura\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003eFactor V Leiden mutation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003ePrimary central nervous system vasculitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003eCervical artery dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003eInfective endocarditis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eCerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eAlcohol use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003eCongenital heart disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003ePregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003eProthrombin G20210A mutation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003eSystemic vasculitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003e⁠Intracranial artery dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003eMeningoencephalitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eCerebral autosomal recessive arteriopathy with subcortical infarcts and leukoencephalopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003e⁠Cannabis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e⁠Valvulopathies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003eMalignancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003e⁠Protein C deficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003eRadiation-induced vasculopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003e⁠HIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003e⁠COL4A1 disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eCocaine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e⁠Intracardiac tumors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003eProtein S deficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003eReversible cerebral vasoconstriction syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003eSyphilis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eFabry disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eAmphetamines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003e⁠Antithrombin III deficiency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003e⁠Moyamoya disease or syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eTuberculosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eHereditary hemorrhagic telangiectasia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003eOpiates\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003eAntiphospholipid syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eHomocystinuria\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003eMarfan syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11.3782%;\"\u003e\n \u003cp\u003e⁠\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.2564%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12.8205%;\"\u003e\n \u003cp\u003e⁠\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11.2179%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13.141%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.9038%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.0641%;\"\u003e\n \u003cp\u003e⁠Sickle cell disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Meningovascular neurosyphilis, ischemic stroke, cerebellar tonsillar herniation","lastPublishedDoi":"10.21203/rs.3.rs-8567222/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8567222/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: Meningovascular neurosyphilis (MVNS) represents an uncommon manifestation of Treponema pallidum infection, potentially leading to stroke, cerebral edema, and elevated intracranial pressure. Cerebellar tonsillar herniation represents a rare yet critical complication with potentially life-threatening consequences. Timely diagnosis and intervention are critical to avert lethal consequences.\u003c/p\u003e \u003cp\u003eCase Presentation: A 20-year-old female presented with headache, dizziness, and altered sensorium, which were preceded by a self-limiting genital lesion eight weeks prior. She exhibited disorientation without any focal neurological deficits. The MRI indicated a left thalamic infarct, while cerebrospinal fluid analysis validated the presence of meningovascular neurosyphilis. Intravenous ceftriaxone and corticosteroids were administered for her treatment. On the 14th day of hospitalization, the patient experienced a generalized seizure accompanied by a rapid deterioration in consciousness. Subsequent imaging revealed widespread cerebral edema and herniation of the cerebellar tonsils. Despite receiving supportive care, she ultimately died due to complications arising from brainstem compression and increased intracranial pressure.\u003c/p\u003e \u003cp\u003eConclusion: This case illustrates the significant consequences of MVNS resulting in infarction, cerebral edema, and tonsillar herniation in a young woman without a previous STD diagnosis. Early neuroimaging, cerebrospinal fluid analysis, and timely antimicrobial therapy are essential. The provision of IV penicillin and prompt surgical decompression are essential, particularly in resource-limited settings.\u003c/p\u003e \u003cp\u003eKey Clinical Message: This case shows how a thalamic stroke caused by meningovascular neurosyphilis can quickly lead to cerebral edema and a tonsillar herniation. Neurological problems need to be diagnosed, treated, and decompressed surgically as soon as possible to avoid permanent damage.\u003c/p\u003e","manuscriptTitle":"Cerebellar Tonsillar Herniation Following Acute Ischemic Stroke in Meningovascular Neurosyphilis: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-24 16:45:45","doi":"10.21203/rs.3.rs-8567222/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-30T11:11:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-13T02:25:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-07T13:05:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"241895012598900482801936051658411167487","date":"2026-03-07T12:52:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47650156855103424955110070615075209142","date":"2026-03-05T01:25:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-04T11:44:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175177911602921491366474805957395050500","date":"2026-03-02T23:31:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22224302032925611866981051820064877763","date":"2026-03-02T17:24:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-19T21:03:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-16T12:00:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-12T12:51:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-12T12:48:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2026-01-10T09:18:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"14de3c48-eda8-49d2-a6c8-ad53c68fa2f8","owner":[],"postedDate":"February 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-30T11:36:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-24 16:45:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8567222","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8567222","identity":"rs-8567222","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}