This 40-year-old male was admitted with refractory focal seizures. MRI brain showed bifrontal hemorrhages with prominent veins extending to adjacent regions with pachymeningeal involvement suggesting the possibility of underlying granulomatous vasculitis.

Lymphocytic pleocytosis on CSF with DSA and MRI features further indicated the same and biopsy was suggested to confirm the diagnosis.

He was given IV methylprednisolone for 5 days. In addition, rituximab 1 gram was also given for long term management. Superior sagittal sinus stenosis could be in relation to chronic venous thrombosis which could have happened due to sarcoidosis.

Follow up MRI after 15 days showed a decrease in pachymeningeal enhancement.

Acknowledgements:

• Dr. Shriram Varadharajan DM, Dr.Meena Nedunchelian DNB (Neuroradiology),
• Dr. Rajesh Shanker Iyer DM (Neurology),
• Dr. Suresh Jayabalan MCh (Neurosurgery) 
• Dr. Sangita S Mehta MD, Dr.Lavanya MD (Pathology)
• Interventional radiology (IR) team under Dr. Mathew Cherian, MD
• Kovai Medical Center & Hospital, Coimbatore, India.