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Images in Neurology
January 2007

Involvement of the Septum Pellucidum and Intracranial Vessel in Neurosarcoidosis

Arch Neurol. 2007;64(1):132-133. doi:10.1001/archneur.64.1.132

A previously healthy 31-year-old man went to the emergency department because of headache and forgetfulness. His sister reported that the patient had complained of a dull headache on the bifrontal areas without nausea or vomiting for 1 week and continued to develop psychomotor slowing, apathy, and forgetfulness. The patient was afebrile and physical examination results were unremarkable. The pupils were equal and reactive to light. The fundi were normal. He was disoriented to time and space. His short-term memory was impaired and he had difficulties with attention. The patient showed visual, auditory, and tactile extinction of the left stimuli on double simultaneous stimulation. Meningeal signs were not noted. Results from routine complete blood count, serum biochemistry profiles, an angiotensin-converting enzyme test, an autoimmune antibody screening, and chest radiography were normal. A lumbar puncture showed elevated opening pressure (20.5 cm H2O) with 53 white blood cells (85% lymphocytes), no red blood cells, a 2.64 g/L protein level, a 37 mg/dL (2.1 mmol/L) glucose level, and a negative gram stain; cultures for bacteria, fungi, and Mycobacterium tuberculosis, and polymerase chain reaction for herpes simplex virus in cerebrospinal fluid were negative. Magnetic resonance imaging of the brain revealed hydrocephalus and an enhancing septum pellucidum, infundibulum, aqueduct, and third and fourth ventricles (Figure 1). Magnetic resonance angiography demonstrated the obliteration of the right internal carotid artery at the supraclinoid portion (Figure 2A). Extraventricular drainage was of no benefit. Stereotactic biopsy from the septum pellucidum revealed noncaseating epithelioid cell granulomas (Figure 2B). Neurological deficits markedly improved following intravenous methylprednisolone use.