Neurosyphilis begins with invasion of the central nervous system (CNS) by spirochetes during the period of spirochete dissemination from the primary lesion (called secondary syphilis). The pathology of meningovascular syphilis has two major components. The cause of most cerebrovascular disease is syphilitic endarteritis, usually involving medium-to-large meningeal arteries, called Heubner's endarteritis. Brain CT or magnetic resonance imaging of patients with meningovascular syphilis and stroke typically show abnormalities consistent with ischemic lesions, which may be multiple. Conventional angiography or magnetic resonance angiography typically shows evidence of arteritis with concentric narrowing of large vessels and often focal narrowing and occasionally dilatation of smaller arteries. Syphilis of the spinal cord is a clinical rarity and usually accompanies other forms of cerebral syphilitic involvement. Ceftriaxone is currently the alternative treatment of choice in the few patients who cannot be desensitized to penicillin.