A 42-year-old man presented to ER with hallucinations and delirium. Initial work up revealed both intracranial and pulmonary lesions thought to be neurosarcoidosis, for which he was put on high dose steroids. A hilar node biopsy was obtained but results were inconclusive. Neurosurgery performed a stereotactic brain biopsy for definitive diagnosis.
Brain MRI shows a remarkable accentuation of parenchymal vessels throughout the full thickness of the cortex and white matter in cerebral hemispheres, basal ganglia, brainstem and cerebellum. FLAIR images (Fig. 1) demonstrate minimal periventricular subependymal margin FLAIR signal abnormality outlining both lateral ventricles, suggesting accentuation of the periventricular subependymal vascular zone, especially in the vicinity of the frontal horns and the splenium of the corpus callosum.
Gadolinium-enhanced images (Fig. 2, 3) demonstrate diffuse engorgement of multiple vascular structures extending from hemispheric cortex through subcortical white matter, deep white matter and subependymal margins on both cerebral hemispheres as well as throughout cerebellum and brainstem, of concern for a vasculitis type process.
Susceptibility-weighted images (Fig. 4) also demonstrate a remarkable accentuation of parenchymal vessels.
DSA ruled out dural fistula (Fig. 5).