神经梅毒性肉芽肿1例并文献复习

Neurosyphilitic gummas: A case report and literature review

目的探讨神经梅毒性肉芽肿的影像特征及鉴别诊断。方法分析1例神经梅毒性肉芽肿病人的影像资料并复习相关文献。结果初诊CT平扫示脑桥斑片状低密度影,MRI平扫示脑桥可见T_1低信号、T_2高信号影,考虑梗死灶。复查头部MRI平扫显示,病灶边界较前清晰,考虑软化灶形成,另外,脑桥、中脑及双侧桥臂新见斑片状T_2稍高信号影;再次复查MRI平扫和增强扫描显示原斑片状T_2稍高信号影范围较前缩小,脑桥腹侧呈点片状明显不均一强化。MRA示基底动脉顶端粗细不均。病人经正规驱梅治疗后,复查头部MRI平扫及增强扫描显示,原异常强化病灶较前消失,脑干软化灶形成。结合临床病史、病变动态变化及治疗效果,最终诊断为神经梅毒,梅毒肉芽肿并血管周围炎,继发脑干梗死并软化灶形成。结论神经梅毒的影像特征缺乏特异性,术前误诊率较高,故需结合临床病史、实验室检查及影像特征对疑似病例首先进行试验性治疗,以避免不必要的颅内有创性损伤。

Objective To investigate the radiolographic features and differential diagnosis of neurosyphilitic gummas.Methods The imaging data of one patient with neurosyphilitic gummas were analyzed,and the relevant literature were reviewed.Results The initial plain head CT scan showed a patch-shaped hypodense lesion in pons.The unenhanced MR imaging revealed the lesion had hypointensity on T1-weighted image and hyperintensity on T2-weighted image.The patient was suspected of ischemic infarct.The first follow-up MRI examination displayed the margin of the lesion became well-delineated,indicating encephalomalacia.However,there was another large patch-shaped high T2 signal intensity lesion in pons,midbrain and brachium pontis bilaterally.The second follow-up MRI examination showed the high T2 signal intensity lesion became smaller than before,and the ventral pontine part of the lesion demonstrated spot-like and heterogenous enhancement after contrast administration.MR angiography manifested the lumen of basilar artery apex was of different diameter.After antisyphilitic treatment,the improvement was noted on the brain MRI,which showed the abnormal enhanced lesion was of completely resolution and only encephalomalacic areas in the pons was remained.The final diagnosis of neurosyphilis,syphilitic gumma with perivasculitis,and secondary brainstem infarction and encephalomalacia was made based on the combination of the patient’s medical history,the dynamic evolution process and therapeutic effect.Conclusions The radiographic features of syphilitic gummas are lack of specificity,and the rate of preoperative misdiagnosis is high.Combination of clinical history,laboratory test,imaging features,and experimental treatment for suspected cases is helpful to avoid unnecessary invasive intracranial operation.