To describe a rare presentation of neurosarcoidosis, with acute onset quadriparesis from acute medial medullary infarct due to neurosarcoidosis-related granulomatous angiopathy 

Neurosarcoidosis can lead to stroke by various mechanisms involving granulomatous vasculitis, vasculitis intracranial hemorrhage, cardioembolism from sarcoid-related cardiomyopathy and subdrual sarcoid mass lesions. Treatment consists of immunosuppressive therapy for sarcoidosis with antiplatelet therapy having no role in the treatment, unless there is coexisting atherosclerotic vessel disease.  

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34-year-old African American man with history of polysubstance abuse and biopsy proven pulmonary sarcoidosis, noncompliant with immunosuppressive therapy, presented with sudden onset quadriparesis after a fall. Initial trauma evaluation was negative. MRI brain revealed leptomeningeal enhancement over the medulla, diffusion restriction in bilateral medial medullar at the level of the pyramidal decussation and enhancement of multiple cranial nerves. He progressed to respiratory failure requiring intubation and transfer to ICU. CSF studies were normal. Serum ACE level was 33. CT chest was suggestive of hilar lymphadenopathy. Given the clinical course, history of sarcoidosis and neuroimaging results, a provisional diagnosis of medullary stroke secondary to neurosarcoidosis-related vasculopathy was made and he was started on high dose intravenous steroids, followed by remarkable clinical improvement. He was extubated on day 3 and discharged after 2 weeks on maintenance oral steroids with a modified Rankin score of 5. Follow-up at 14 months showed mRS improvement to 3.  

Neurosarcoidosis is a rare but important treatable cause of acute ischemic stroke and should be considered in the differential diagnosis in a young patient, particularly African-American, presenting with progressive neurologic deficits and signs of meningeal inflammation. Timely diagnosis and early initiation of steroids can improve functional outcomes.