Clinical clues suggesting headache, nuchal rigidity, and cranial nerve palsies may be present due to meningitic process. Stroke as a presenting manifestation of neurobrucellosis is uncommon in which case the diagnosis may not be suspected [6]. TIAs are also a common manifestation; in one series two out of four patients who developed TIA had no prior history of brucellosis [9]. McLean et al. [26] described a total of 18 patients with neurobrucellosis, of which four patients had a stroke: two ischemic strokes and two ICH presumably due to mycotic aneurysm. Nevertheless, neither angiogram nor autopsy was performed. Al Deeb et al. [4] in their series of 13 patients with neurobrucellosis reported a single patient with ischemic stroke who had hypodensities in CT scan with a normal DSA. Pascual et al. [28] reported two patients with vascular involvement as TIA or SAH, and both patients had normal angiograms. Vogt et al. [32] described a patient with neurobrucellosis and multiple subcortical infarcts, but angiogram was not done. Hernandez et al. [17] have reported neurobrucellosis patients with stroke. Recently, Adaletli et al. [1] have reported a patient with stroke and an angiogram showing evidence of vasculopathy like occlusion of branches of the right middle cerebral artery (MCA), vascular cutoff signs, vascular contour irregularities, and stenosis. Gul et al. [14], in their pooled analysis of 187 cases, reported six cases (3.2 %), one case each of SAH and subdural hematoma and four cases of ischemic stroke. Jochum et al. [20] have reported a case of neurobrucellosis who had a thalamic infarct as a complication, but no angiography was done on this patient.

In 2006, Bingöl et al. [9] have described four cases of neurobrucellosis presenting as TIAs. Inan et al. [18] have reported TIA and stroke as the presenting feature in neurobrucellosis. Akhondian et al. [3] have described an 11-year-old child with neurobrucellosis who had TIA as the presenting manifestation, but angiogram was not done on this patient.

In a large series of patients with neurobrucellosis, headache, fever, weight loss, sweating, and back pain were the most common presenting symptoms [14]. Meningeal irritation, hypesthesia, confusion, and hepatosplenomegaly were the most commonly encountered physical signs. Presence of systemic features such as arthralgia, fever, meningeal irritation, peripheral nervous system involvement, and cranial neuropathies or hearing loss in young patients presenting with symptoms suggestive of cerebrovascular accident in endemic regions should trigger a high degree of suspicion for neurobrucellosis.

Brucella-related cerebral aneurysms may present with SAH or maybe detected incidentally on neuroimaging. Aneurysms involving the BA, anterior cerebral artery, and MCA have been reported [5, 19, 21, 25]. In patients presenting with SAH, history of fever and other systemic complaints prompts consideration of a mycotic aneurysm due to an infective etiology. McLean et al. [26] described two patients with ICH due to a presumed mycotic aneurysm. Of the eight reported cases, three involved the BA which is an uncommon site for mycotic aneurysms, and these have been postulated to be due to basilar meningitis [26].

Patients with hemorrhagic infarcts secondary to CVT may present with seizures [13]. Other rare presentations thought to be due to cerebral venous sinus involvement are headache, papilledema, and raised intracranial pressure, without any focal deficits, mimicking pseudotumor cerebri [27]. Since most descriptions of cerebrovascular brucellosis are restricted to small case series or case reports, manifestations cannot be categorized as being typical and may vary.