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

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.