Board Review 3 – Case 12

Neuroradiology board review. This lecture is geared towards the ABR core exam for residents, but it would be useful for review for the ABR certifying exam or certificate of added qualification (CAQ) exam for neuroradiology.

More description and the answer (spoiler!) are seen below the video.

This case is a patient who has a remote history of “meningitis”. Her imaging shows marked edema in the frontal lobes on CT, with a follow up MRI confirming significant leptomeningeal and parenchymal nodular enhancement worst in the frontal lobes. There is involvement of the right optic nerve.

With severe leptomeningeal enhancement such as this, there is a differential diagnosis which includes:

  • leptomeningeal carcinomatosis
  • unusual infections (fungi, tuberculosis, or other unusual pathogens)
  • sarcoidosis

The diagnosis is: neurosarcoidosis

The most common findings of sarcoidosis are leptomeningeal enhancement centered in the basal cisterns, sometimes with parenchymal nodular or perivascular enhancement. The diagnosis of neurosarcoid consists of checking a serum ACE level, performing an LP (particularly to rule out other causes), and chest imaging (including x-ray or CT). Often the easiest tissue diagnosis is through biopsy of hilar nodes.