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Stroke in a young man with untreated HIV infection and neurosyphilis

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Clinical record

A 33-year-old man presented to an emergency department with acute dysphasia and a dense right hemiparesis. His National Institute Health Stroke Scale score was 12, indicating a moderate severity stroke (score range 0–42, with increasing values indicating increasing severity). His computed tomography (CT) brain scan was normal. A CT angiogram showed a filling defect in the left intracranial internal carotid artery. Intravenous thrombolysis was commenced 2.5 hours after stroke onset and completed during urgent transit to our hospital for endovascular thrombectomy. Combined stent retrieval and suction thrombectomy of the left internal carotid occlusion restored flow 4.5 hours after stroke onset. A small dissection in the left intracranial internal carotid artery was the source of the thrombotic occlusion (Figure). A magnetic resonance imaging scan of the brain showed small scattered infarctions in the left middle cerebral arterial territory.

The patient was later found to have a human immunodeficiency virus (HIV) infection that had been diagnosed 5 years earlier but for which he had not sought or received treatment. There was no history of screening for syphilis. He had a remote and brief history of recreational use of methamphetamines and cocaine (more than 12 months previously). He had no other vascular risk factors (non-smoker, normal fasting…