Multiple Intracranial Hemorrhages with Venous Stagnation on Cerebral Angiogram in Neurosarcoidosis

Abstract We describe recurrent intracranial hemorrhages (ICH) in a 22-year-old man with intellectual disability and seizures. One year after his first seizure, he presented for evaluation of a second seizure and was found to have an acute left frontal ICH on computed tomography (CT). Cerebral angiography demonstrated venous stasis of unclear etiology. One month after discharge, he was readmitted with a new right frontal ICH and subsequently developed additional bilateral frontal hemorrhages. Repeat angiography demonstrated persistent contrast opacification in the late venous phase, indicating venous congestion. Evaluation for coagulopathy revealed incidental inguinal lymphadenopathy on CT, and biopsy-confirmed sarcoidosis. Brain biopsy showed non-necrotizing granulomatous inflammation consistent with neurosarcoidosis. ICH in neurosarcoidosis is extremely rare. The proposed mechanism is meningovascular granulomatous infiltration causing venous congestion and stasis, leading to venous infarction with hemorrhagic conversion. This case highlights neurosarcoidosis as an important consideration in the differential diagnosis of recurrent ICH associated with venous abnormalities.