Management of isolated neurosarcoidosis mimicking cerebral meningiomatosis with multiple cranial neuropathies: An uncommon clinical scenario.

Background: Sarcoidosis is an immune-mediated disorder characterized by granulomatous inflammation of the affected organ. Isolated neurosarcoidosis presents as aseptic granulomatous meningitis or focal mass lesions due to granulomas. This case is notable for its radiological resemblance to meningiomatosis, which has a substantial disease burden.

Case description: A 47-year-old man presented with symptoms of vertigo and right-sided hearing impairment for the past year. After 6 months, he experienced progressive visual impairment in the right eye and a headache associated with dural stretching on the right side. Neurological evaluation revealed significant visual impairment in the right eye, limited to finger counting at 1 m. The right-sided primary optic atrophy was due to mass effect from the sarcoid granuloma on the optic nerve. Pure-tone audiometry indicated mild sensorineural hearing loss on the right side. Radiological investigations showed multiple intracranial lesions, with the largest lesion located at the right anterior clinoid, exhibiting pial breach, and perilesional edema. The institutional tumor board diagnosed cerebral meningiomatosis. Due to rapidly progressive visual deterioration caused by the right clinoidal lesion, a right pterional craniotomy with gross total excision of the lesion was performed. The histopathology evaluation report revealed neurosarcoidosis. The patient was started on glucocorticoids and immunosuppressant medication by clinical immunology. Follow-up magnetic resonance imaging of the brain after 1 year showed stable disease without any recurrence.

Conclusion: Surgical removal of lesions causing mass effect should be regarded as the primary therapy. Insufficient response to medical treatment may result in permanent deficits. When dealing with multiple intracranial lesions, the aim should be to achieve optimal results through surgical intervention.