In this case, neurological symptoms were the first manifestation and the patient was imaged without the diagnosis of systemic sarcoidosis.

MRI & MRS criteria of the cerebral parenchymal, leptomeningeal, and cervical cord lesions were highly suggestive of neurosarcoid.

Subsequent CT scan of the chest proved typical features of pulmonary sarcoidosis with pathologically enlarged bilateral hilar, paratracheal and subcarinal lymph nodes, as well as multiple patches of ground-glass attenuation.

The patient later had positive laboratory data for sarcoidosis with increased serum and CSF ACE levels. Increased serum amyloid A protein (SAA). Normal Parathyroid hormone and calcium levels.

Neurosarcoid could involve the following:

• skull vault involvement, in the form of lytic lesions, mimicking metastasis.
• pachymeningeal thickening of low signal on T2 WI with homogenous contrast enhancement.
• leptomeningeal involvement, which is either focal or generalized, nodular or smooth, and has a predilection to basal aspects and around circle of Willis. Leptomeningeal nodules may extend to the brain via perforating vessels and perivascular spaces, like in this case.
• pituitary and hypothalamic involvement
• cranial nerve involvement
• parenchymal involvement (most common), likely via extension from leptomeningeal disease via perivascular space, likely in the form of nodules or masses.