Objective:

NA

Background:

The cavernous sinus is neuroanatomically diverse, and pathology in the area can vary greatly in presentation, including proptosis, chemosis, ophthalmoplegia, Horner syndrome, and trigeminal sensory loss. Disease entities that must be considered include neoplasm, trauma, vascular causes, infectious etiologies, and non-infectious inflammatory disorders. Among these, neurosarcoidosis must be considered.

Design/Methods:

A 55-year-old healthy woman presented to the emergency department citing a two-week history of headache and left facial pain and numbness, as well as a one-day history of horizontal and oblique diplopia. Exam demonstrated horizontal and oblique diplopia with leftward gaze, mild abduction deficits of the left eye, and decreased sensation in the left V1-V2 distribution. MRI brain showed a left sphenoid mass with associated enhancement of the cavernous sinus and orbital apex. Through serum lab work, lumbar puncture, additional imaging, and sphenoid biopsy, she was found to have neurosarcoidosis. She was treated acutely with 2 days of 1 g IV methylprednisolone and achieved immediate improvement in her headache. She was discharged on prednisone 80 mg daily, and one month later, her headache, diplopia, and facial paresthesias had resolved. She has since been stable on adalimumab.

Results:

Neurosarcoidosis is a diagnosis of exclusion, and a systematic workup is crucial to ensure prompt, proper treatment. Imaging is imperative to help narrow the differential, and biopsy can help establish the diagnosis, though it is not always feasible to obtain. Specific guidelines for choice of long-term therapies are an area in which more clinical trials are needed.

Conclusions:

It is important for neurology providers to recognize presentation and exam findings for a cavernous sinus mass, understand differential diagnoses and workup for said mass, and be able to facilitate acute and long-term management of neurosarcoidosis.