Abstract Details

Title A Rare Case of Ischemic Strokes due to Sarcoidosis Related Cerebral Phlebitis

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P11 - Poster Session 11 (8:00 AM-9:00 AM)

Poster/Presentation
Number 4-015

Objective Present a case of definite neurosarcoidosis with intracranial phlebitis causing stroke.

Background N/A

Design/Methods Describe a case of definite neurosarcoidosis on mycophenolate mofetil (MMF) and prednisone who developed cerebral phlebitis. We include the clinical course, significance of disease, and implications on future treatment.

Results A 64-year-old African American female with long-standing history of definite neurosarcoidosis (NS), on oral prednisone and MMF, presented with altered mental status. She had failed other steroid sparing agents with multiple relapses and suffered the consequences of long-term steroid use, including poor control of diabetes mellitus and pathological fractures. Her frequent flares left her with mild cognitive impairment, left afferent pupillary defect, vision limited to hand motion in temporal quadrants, left hemiparesis, and dysdiadochokinesia. Neurological exam on admission was significant for lack of orientation accompanied by impaired repetition and comprehension. CT of the head showed new sulcal effacement at the vertex. MRI of the brain revealed leptomeningeal enhancement with diffusion restriction in bilateral cerebral hemispheres along cortical and subcortical perivascular regions. An embolic source was suspected however TTE and CT angiogram were unrevealing. A cerebral angiogram revealed irregular interconnecting small caliber venules in both hemispheres suggestive of phlebitis. A secondary review of her pathology slides of a right frontal dural biopsy performed in 2013, supported evidence of hyaline vasculopathy with scattered pigment laden macrophages. Given the presence of presumed ongoing activity of neurosarcoidosis in this patient, advancement of therapy to infliximab was pursued.

Conclusions

Sarcoidosis is known to cause vasculopathy and in the brain can lead to ischemia or hemorrhage. Hemorrhagic presentations are usually secondary to sinus thrombosis. Ischemic strokes are due to small vessel vasculitis, large vessel inflammation, or embolism from cardiac sarcoidosis. This unique case illustrates ischemia rather than hemorrhage from venous sinus involvement, while on immunosuppressive therapy and directed a more aggressive immunosuppressive regimen.

Authors/Disclosures
Sonia Kaur Singh, MD PRESENTER	Dr. Singh has nothing to disclose.
Rohini D. Samudralwar, MD (The University of Pennsylvania)	Dr. Samudralwar has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD Serono. Dr. Samudralwar has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for TG Therapeutics. Dr. Samudralwar has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. Dr. Samudralwar has received personal compensation in the range of $500-$4,999 for serving as a Speaker with Multiple Sclerosis Association of America.

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