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Background Diagnosing granulomatous disorders involving the nervous system is challenging due to overlapping clinical and radiological features and limited sensitivity of available tests.Methods We present a case of brainstem haemorrhagic stroke with extensive cranial neuropathies on a background of tuberculous meningitis.Results A 35-year-old Indian man presented with sudden-onset dysarthria and altered mental status following three weeks of progressive headache, lethargy and blurred vision. His history included pulmonary tuberculosis (TB) with culture-negative tuberculous meningitis affecting the right cerebellum and possible immune reconstitution inflammatory syndrome (IRIS). He completed 18 months of anti-mycobacterial therapy and corticosteroid therapy 6 months earlier.Examination revealed dysarthria, left-side predominant tetraparesis and sensory loss, with asymmetric facial diplegia and partial deficits of the left cranial nerves III, IV, V and right VIII, XII. CT showed bilateral multifocal pontine haemorrhages. MRI demonstrated additional high T2/FLAIR signal in the medulla, bilateral cerebelli with associated leptomeningeal enhancement.The relapsing course of presentation was noted including recurrent facial palsy and radiological progression on mycobacterial therapy, resulting in repeated treatment for TB-related IRIS. Previous biopsy of the right cerebellum was reassessed by neuropathology and confirmed non-necrotising granulomatous inflammation. Given the persistently negative mycobacterial cultures and previous excellent response to corticosteroids, the diagnosis was revised to neurosarcoidosis. He was treated with intravenous methylprednisolone and infliximab, with neurological improvement.Conclusion This case highlights concurrent haemorrhagic stroke and cranial polyneuropathy as a rare presentation of neurosarcoidosis. A multidisciplinary approach and careful evaluation are essential to differentiate granulomatous diseases, particularly in high-risk populations.