INTRODUCTION Granulomatous inflammation is a distinctive ...

overlapping features however in sarcoidosis the most common features is cranial nerve affection,
in cysticercosis the patients usually present by fits, in bilharziasis most cases involve the spinal
cord, and hydatid disease behave as a space occupying lesion.
Regarding the investigations, Sarcoidosis is best diagnosed by tissue biopsy yet recently the
combination of gallium scan and serum ACE level is not invasive and has shown specificity of 83-
99%. There are common MRI findings which are suggestive of certain diagnosis. large cystic
lesions, not surrounded by edema, is suggestive of hydatid disease, while Cysticercosis shows
multiple cysts, surrounded by variable degrees of edema, and may show scolices or enhancement.
Multiple small vessel infarcts are suggestive of Wegener granulomatosis, which present also with
meningeal enhancement, while evidence of beading of cerebral arteries on angiography is
suggestive of primary CNS angiitis.
Despite of this accumulation of data regarding the individual disorders causing granulomatous
CNS affection, it is still far beyond doubt that reaching the definite diagnosis for these disorders is
still lacking. This is attributed to heterogeneity of clinical presentation of the disorders on one
hand, with lack of awareness among the medical stuff through their various specialities on the
other hand. Adding to this hinders, the yield of investigational work up is still many steps behind
reaching a rapid conclusive final diagnosis.
Owing to the difficulty in diagnosis and the high morbidity and fatality of these conditions, a
comprehensive approach for management of suspected cases should be formulated. This approach
includes an integrated multidisciplinary team from different medical specialities, to achieve the
following objectives: to avoid missing cases with mainly systemic presentations and to formulate
an integrated management plan tackling all the systems involved. Even in cases presenting only
with neurological symptomatology proper management is sometimes hindered by the
immunocompromised status of the patient, and therefore involvement of other relevant medical
specialities would maximize the therapeutic yield. On the other hand cases without overt
neurological affection should still warrant a neurological consultation. The neurologist can help
elicit subtle neurological deficits and guide the diagnostic investigations concerning CNS
involvement to help reach a rapid early diagnosis, leading to early start of treatment and better
prognosis.
RECOMMENDATIONS
Clinical
Research
Forming integrated multidisciplinary team from different medical specialities to detect
and manage patients of CNS granulomas.
Formulating defined investigational channels to guide clinicians to a definitive
diagnosis.
Establishing treatment protocols specific for CNS granulomas to replace those based
on systemic granulomatous disorders.
Preparing training course to clinicians and neurologists illustrating clinical picture
and clues for diagnosis of CNS granulomas to increase awareness with these disorders,
and provide a higher index of suspicion to diagnoses patients early.
Searching and testing new diagnostic tools and investigations that would provide