Abstract Wegener’s granulomatosis (WG) is a systemic vasculitis that can affect any organic system, but primarily involves the upper and lower respiratory tracts and the kidneys. WG relatively frequently affects the nervous system (in 30-50%), usually in the form of peripheral or cranial neu- ropathy. Involvement of the brain is reported in a very small percentage of patients (2%-8%). Three major mech- anisms have been described as the cause of central nerv- ous system (CNS) disease in WG: contiguous invasion of granuloma from extracranial sites, remote intracranial granuloma and CNS vasculitis. CNS involvement caused by contiguous invasion of granuloma from extracranial sites is the rarest. We report the case of a 37-year-old man with WG, manifested as a pulmonary and paranasal si- nuses disease, with orbital and CNS involvement, caused by contiguous invasion from the paranasal sinuses. In this report, the rich spectrum of findings achieved by com- puted tomography and magnetic resonance are demon- strated. The importance of computed tomography in bony destruction PNS findings, and the importance of MR im- aging in evaluation of the direct intracranial spread from nasal, paranasal and orbital disease are also emphasized. Introduction Wegener’s granulomatosis (Wg) is a necrotizing granulomatous vasculitis of small and medium sized vessels and usually affects the upper and lower res- piratory tract and kidneys (1, 2, 3). upper respiratory tract features are typical at presentation, such as si- nusitis and nasal obstruction. The orbits, heart, skin, and joints are frequently involved (4). intraorbital Wg involvement is usually accompanied by paranasal sinus disease (5). cerebral and meningeal involvement is uncommon, occurring in only 2%- 8% of patients (2, 4, 6). We report a man with Wg presented by paranasal disease, orbital involvement and direct intracranial propagation, which is the rarest mechanism that causes cnS disease in Wg. Case report a 37-year-old man came to the department of radiology with a four year history of haemoptysis and three month history of headache, diplopia, left ptosis, blocked left nostril with occasional elimina- tion of yellow-green and haemorrhagic content in the form of drops from the nasal cavity, and computed tomography (cT) of the head and orbits was pre- formed. he was treated twice for skin lesions, with the diagnosis cellulitis et furunculosis and Suppu- rative Panniculitis, with no histopathological signs of granulomatous disease. unenhanced cT scans of the head revealed extensive bony destruction of the nasal septum, all of the turbinates, PnS walls, except the frontal sinus, right orbital roof, anterior and central skull base and mucosal thickening in the maxillary sinuses. The sphenoid sinus, the residual part of the cranial ethmoid complex and the retrobulbar part of the left orbit were almost totally filled with inflammatory mass (Fig. 1). The radiologist suspected PnS Wegener’s granulomatosis with orbital and possible brain involvement. chest radiography and cT scans of the thorax showed a left-sided cavitating lesion, 95 × 65 × 85 mm, with an air-fluid level in it, suggesting pulmonary Wg. The patient was admitted to our hospital. labs on admission showed mild leukocytosis, mild anaemia and high values of c-reactive protein. The patient’s neurological status suggested lesions of the left iii, iv, v and vi cranial nerves. Magnetic resonance (Mr) of the head showed ir- regular infiltrative lesions with low signal intensity on T1-weighted images, and intermediate to high Acta Neurol. Belg., 2011, 111, 241-244 Wegener’s granulomatosis of the paranasal sinuses with orbital and central nervous system involvement-diagnostic imaging Svjetlana Mujagic 1 , Senada Sarihodzic 1 , haris huSeinagic 1 and zinaida KaraSalihovic 2 1 clinic of radiology and nuclear Medicine, university clinical center Tuzla, Tuzla, Bosnia and herzegovina; 2 department of Pathology of Policlinic of laboratory diagnostic, university clinical center Tuzla, Tuzla, Bosnia and herzegovina