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Kapila AT, Ray S, Lal V. Tolosa-Hunt Syndrome and IgG4 Diseases in Neuro-Ophthalmology. Ann Indian Acad Neurol 2022; 25:S83-S90. [PMID: 36589035 PMCID: PMC9795703 DOI: 10.4103/aian.aian_457_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 05/22/2025] [Accepted: 05/23/2022] [Indexed: 01/04/2023] Open
Abstract
Tolosa-Hunt syndrome (THS) remains a challenging diagnosis for many neurologists. Often believed to be a rare presentation, the classical presentation is known to involve cranial nerves and tissues surrounding the cavernous sinus. Traditionally, a diagnosis of THS is considered when all secondary conditions have been ruled out. Yet, newer findings have elaborated a complex pathogenetic process with some overlap from the IgG4 spectrum of disorders, with which it shares many phenotypic similarities. In this narrative review, we present an updated picture of the condition focusing on the latest developments in the pathogenesis, diagnosis, and clinical management of these two conditions and use illustrative examples to highlight the salient features of this rare presentation.
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Affiliation(s)
| | - Sucharita Ray
- Department of Neurology, PGIMER, Chandigarh, India,Address for correspondence: Dr. Sucharita Ray, Department of Neurology, PGIMER, Chandigarh, India. E-mail:
| | - Vivek Lal
- Department of Neurology, PGIMER, Chandigarh, India
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Khalid A, Uche EO. Idiopathic Hypertrophic Cranial Pachymeningitis With Chiari Type I Malformation: Case Report and Review of the Literature. Cureus 2022; 14:e28466. [PMID: 36046060 PMCID: PMC9419626 DOI: 10.7759/cureus.28466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/29/2022] Open
Abstract
Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare chronic inflammatory disease characterized by diffuse thickening of the dura mater. Although IHCP mostly presents as a diffuse lesion, it may also occur as focal tumour-like lesions. Here we present the first reported case of IHCP associated with a Chiari type I malformation (CMI). A 65-year-old man presented with a one-year history of chronic headache and vertigo exacerbated by standing and neck flexion. The neurological examination was unremarkable except for tongue wasting and fasciculations. MRI demonstrated features of CMI and findings suggestive of IHCP. Posterior fossa decompression resulted in significant symptomatic improvement and the diagnosis of IHCP was confirmed on histopathology. Though there is no consensus about the management of IHCP in this case, we advocate surgical decompression with prolonged steroid therapy.
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Dutta P, Anand K. Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues. J Curr Ophthalmol 2021; 33:104-111. [PMID: 34409218 PMCID: PMC8365592 DOI: 10.4103/joco.joco_134_20] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.
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Affiliation(s)
- Paromita Dutta
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
| | - Kamlesh Anand
- Guru Nanak Eye Centre, Department of Ophthalmology, Maulana Azad Medical College, New Delhi, India
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Nakajima I, Taniguchi Y, Mizobuchi T, Kishimoto T, Fukushima A, Fukuda K. Optic Neuropathy with Headache and Palpable Temporal Arteries Due to Hypertrophic Pachymeningitis Rather than Giant Cell Arteritis. Ocul Immunol Inflamm 2021; 30:1515-1518. [PMID: 33793376 DOI: 10.1080/09273948.2021.1881561] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: To report a case of optic neuropathy diagnosed by color Doppler ultrasonography and Gadolinium-enhanced cerebral magnetic resonance imaging (MRI).Case report: A 79-year-old woman presented with headache and vision loss in her left eye. Although her bilateral temporal arteries were palpable and rope-like, color Doppler ultrasonography showed normal flow in both arteries with no signs of arteritis. MRI revealed increased enhancement of the pachymeninges enveloping both cerebral hemispheres, suggestive of hypertrophic pachymeningitis.Conclusion: Symptoms and laboratory data are similar for both hypertrophic pachymeningitis and giant cell arteritis (GCA). The present case suggests the utility of ultrasonography and MRI as rapid, convenient, and noninvasive tools for differential diagnosis of optic neuropathy.
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Affiliation(s)
- Isana Nakajima
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, and Nephrology, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Tomoka Mizobuchi
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Tatsuma Kishimoto
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Atsuki Fukushima
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
| | - Ken Fukuda
- Department of Ophthalmology and Visual Science, Kochi Medical School, Kochi University, Nankoku City, Kochi, Japan
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Dutta P. Tolosa-Hunt syndrome as a manifestation of Hypertrophic Pachymeningitis. Eur J Rheumatol 2020; 8:51-52. [PMID: 32910772 DOI: 10.5152/eurjrheum.2020.20114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/29/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Paromita Dutta
- Department of Ophthalmology, Guru Nanak Eye Centre, Maulana Azad Medical College, Maharaja Ranjit Singh Marg, Delhi, India
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Cação G, Calejo M, Alves JE, Medeiros PB, Vila-Cha N, Mendonça T, Taipa R, Silva AM, Damásio J. Clinical features of hypertrophic pachymeningitis in a center survey. Neurol Sci 2018; 40:543-551. [PMID: 30588552 DOI: 10.1007/s10072-018-3689-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/17/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is characterized by cranial and/or spinal thickening of the dura mater with or without associated inflammation. Neuroimaging studies reveal dura mater thickening and focal or diffuse contrast enhancement. It is described in association with trauma, infections, tumors, autoimmune/inflammatory diseases, and cerebrospinal fluid hypotension syndrome, with some cases remaining idiopathic. METHODS A retrospective study was conducted with patients' identification through a key terms search within MRI reports in the period of July 2008 to September 2015. Clinical files, MRI, laboratory, and pathology data were reviewed. RESULTS Fifty-three patients were identified and 20 were excluded because they did not meet the inclusion criteria. Of the 33 included, 19 were female, with a mean age at symptoms onset of 51.2 ± 17.6 years. The most common presenting symptoms were headache and cranial nerves palsy, followed by seizures, delirium, lumbar pain, cognitive decline, motor deficit, and language impairment. In 17 patients, a neoplastic etiology was identified; in eight, inflammatory/autoimmune; in six, infectious; and two were classified as idiopathic. Of the eight patients with inflammatory/autoimmune etiology, four had possible IgG4-related disease (IgG4-RD) and the remaining had granulomatosis with polyangiitis, sarcoidosis, rheumatoid arthritis, and Tolosa-Hunt syndrome. Treatment was directed according to the underlying etiology. DISCUSSION In the described series, a female predominance was identified, with symptoms' onset in the 5th decade. Although headache was the most common symptom, clinical presentation was varied, emphasizing the role of MRI in HP diagnosis. The underlying etiologies were diverse, with only a few cases remaining idiopathic, also reflecting the contribution of the recently described IgG4-RD.
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Affiliation(s)
- Gonçalo Cação
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Margarida Calejo
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - José Eduardo Alves
- Neuroradiology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | | | - Nuno Vila-Cha
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Teresa Mendonça
- Internal Medicine Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Taipa
- Neuropathology Unit, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Ana Martins Silva
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Joana Damásio
- Neurology Department, Hospital de Santo António, Centro Hospitalar do Porto, Porto, Portugal.
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Zhou Z, Li Q, Zheng J. Hypertrophic Cranial Pachymeningitis Induced by Long-Term Administration of Nonsteroidal Antiinflammatory Drugs. Ann Pharmacother 2017; 44:755-9. [PMID: 20197477 DOI: 10.1345/aph.1m455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Objective To report a case of hypertrophic cranial pachymeningitis (HCP) associated with the long-term administration of nonsteroidal antiinflammatory drugs (NSAIDs). Case summary A 23-year-old man presented with recurrent headaches as the primary clinical manifestation. After the administration of the NSAIDs indomethacin and aceclofenac for 2 years, he developed signs of progressive cranial polyneuropathies (eg, II, III, V, VI, and VII palsy) and damage to the brainstem. Cranial contrast-enhanced magnetic resonance imaging (MRI) revealed curvilinear subdural enhancement and significant tentorium cerebelli and faix cerebri enhancements. Since antituberculosis treatment combined with corticosteroid therapy and analgesia with celecoxib for 40 days had not achieved satisfactory results, NSAIDs were discontinued and a single oral dose of a corticosteroid was given. No headaches were reported at a 6-month follow-up appointment. In addition, his cranial polyneuropathy improved significantly. Reexamination by contrast-enhanced MRI scan demonstrated that tentorial enhancement and thickening of the falx cerebri were markedly alleviated. Discussion No additional causes of HCP were found during systematic investigation in this patient. In addition to headache, cranial polyneuropathy and thickened cerebral dura mater appeared after administration of NSAIDs for 2 years. The symptoms that appeared during the NSAID therapy were remarkably alleviated 5 months after medication discontinuation. Adverse drug reaction (ADR) assessment revealed that long-term administration of NSAIDs may be associated with the occurrence and development of HCP. Conclusions Long-term administration of NSAIDs is a probable cause of HCP. Clinicians should be aware of this ADR and avoid prescribing NSAIDs for an extended period.
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Affiliation(s)
- Zhujuan Zhou
- Department of Neurology, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Qianning Li
- Department of Neurology, Xinqiao Hospital, Third Military Medical University
| | - Jian Zheng
- Department of Neurology, Xinqiao Hospital, Third Military Medical University
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Navalpotro-Gómez I, Vivanco-Hidalgo RM, Cuadrado-Godia E, Medrano-Martorell S, Alameda-Quitllet F, Villalba-Martínez G, Roquer J. Focal status epilepticus as a manifestation of idiopathic hypertrophic cranial pachymeningitis. J Neurol Sci 2016; 367:232-6. [PMID: 27423594 DOI: 10.1016/j.jns.2016.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 05/27/2016] [Accepted: 06/09/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Idiopathic hypertrophic cranial pachymeningitis (IHCP) is an uncommon disease of unknown etiology characterized by thickening of the cerebral dura mater with possible associated inflammation. The most frequently described clinical symptoms include headache, cranial nerve palsy, and cerebellar dysfunction. Epilepsy and/or status epilepticus as main presentation is very uncommon. CASE PRESENTATION Two consecutive cases are presented of patients manifesting focal status epilepticus secondary to IHCP, with clinical, laboratory [blood test and cerebrospinal fluid (CSF) analysis], neuroradiologic [magnetic resonance imaging (MRI) at 3 Tesla and digital subtraction angiography (DSA)], and therapeutic data. One patient underwent meningeal biopsy; pathology findings are also included. Corticosteroid therapy resulted in clinical improvement in both cases, and neuroimaging showed decreased abnormal morphology, compared to initial findings. CONCLUSION In the diagnostic approach to focal status epilepticus or epilepsy, IHCP must be considered a potential, although extremely infrequent, cause. Anti-inflammatory treatment is an effective addition to antiepileptic drug therapy in patients with IHCP.
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Affiliation(s)
| | - Rosa María Vivanco-Hidalgo
- Department of Neurology, Hospital Universitari del Mar, Barcelona, Spain; Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elisa Cuadrado-Godia
- Department of Neurology, Hospital Universitari del Mar, Barcelona, Spain; Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | | | - Jaume Roquer
- Department of Neurology, Hospital Universitari del Mar, Barcelona, Spain; Neurovascular Research Group, IMIM-Hospital del Mar (Institut Hospital del Mar d'Investigacions Mèdiques), Universitat Autònoma de Barcelona, Barcelona, Spain
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Dziedzic T, Wojciechowski J, Nowak A, Marchel A. Hypertrophic pachymeningitis. Childs Nerv Syst 2015; 31:1025-31. [PMID: 25771924 DOI: 10.1007/s00381-015-2680-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Hypertrophic pachymeningitis (HP) is a rare clinical entity characterized by diffuse or localized fibrous thickening of the dura mater. It is well known but rare especially in pediatric population disease of differing origins. The primary (idiopathic) form is diagnosed after excluding other possible etiologies. Similar results from magnetic resonance imaging (MRI) for patients with hypertrophic pachymeningitis and meningiomas may make the diagnosis confusing. Additionally, making a proper diagnosis without histological sampling can be difficult in some cases. CASE DESCRIPTION We present a case of an 18-year-old boy diagnosed with hypertrophic pachymeningitis in the area of the hypoglossal canal. The diagnosis was made after a 2-month history of hypoglossal nerve palsy and dysphagia preceded by a middle ear infection. The patient was treated surgically with suspicion of meningioma, but no evidence of a tumor was found during the operation. The postoperative period was uneventful. At the latest check-up, MRI revealed regression of all previously observed pathological changes.
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Affiliation(s)
- Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, Banacha 1a, 02-097, Warszawa, Poland,
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See no evil, hear no evil…. Surv Ophthalmol 2014; 59:251-9. [DOI: 10.1016/j.survophthal.2013.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 03/04/2013] [Accepted: 03/05/2013] [Indexed: 12/29/2022]
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Sugie K, Morikawa M, Taoka T, Hirano M, Ueno S. Serial neuroimaging in tolosa-hunt syndrome with acute bilateral complete ophthalmoplegia. J Neuroimaging 2011; 21:79-82. [PMID: 19453827 DOI: 10.1111/j.1552-6569.2009.00381.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a very rare, relapsing, and remitting painful ophthalmoplegia caused by nonspecific granulomatous inflammation in the cavernous sinus. To our knowledge, bilateral complete, simultaneous palsies of all 3 cranial nerves associated with extraocular movement have not been reported. We describe the first such patient with bilateral THS that responded quickly to corticosteroid therapy. A 54-year-old man presented with a periorbital and frontal headache with acute bilateral severe blepharoptosis and fixed eyes, which dramatically responded to corticosteroid therapy. He had diabetes mellitus type II. Brain MRI showed granulomatous inflammation in both cavernous sinuses and thickening of the surrounding dura mater of the cranial base, suggesting the coexistence of focal hypertrophic cranial pachymeningitis. Our experience indicates that steroid therapy with strict control of blood sugar should be considered in patients with THS complicated by diabetes. MRI is a valuable tool for serially monitoring the response of lesions to treatment in THS.
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Affiliation(s)
- Kazuma Sugie
- Department of Neurology, Nara Medical University School of Medicine, Kashihara, Nara, Japan.
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Cannon PS, Cruz AAV, Pinto CT, Mastropietro DA, Chahud F, Bilyk JR, Selva D, Prabhakaran VC. A multi-centre case series investigating the aetiology of hypertrophic pachymeningitis with orbital inflammation. Orbit 2011; 30:64-69. [PMID: 21322792 DOI: 10.3109/01676830.2010.539766] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION To describe our attempt in establishing a definitive diagnosis in patients with hypertrophic pachymeningitis in combination with orbital inflammatory disease and report on the outcome. MATERIALS AND METHODS This was a retrospective case series of all patients presenting with hypertrophic pachymeningitis in association with orbital inflammation in 4 centres. Ophthalmic and neurological examination data, laboratory data, histology data, treatment plans and clinical outcome data were recorded. Patients underwent orbital/brain computed tomography and magnetic resonance imaging. RESULTS Six patients were identified; the median age was 46.5 years. Headache was the commonest presenting symptom, followed by diplopia and reduced visual acuity. Three patients underwent orbital biopsy, 1 patient underwent dura mater biopsy, 1 patient underwent both and 1 patient underwent nasal biopsy. Four patients were diagnosed with Wegener granulomatosis and 2 patients with tuberculosis. Corticosteroid therapy was initiated in 4 patients, with steroid-sparing drugs added later. Two patients received anti-tuberculosis treatment and 1 patient was commenced on pulsed cyclophosphamide. On follow-up, 1 patient required an exenteration for a painful blind eye and 1 patient's visual acuity remained at no perception to light. One patient had complete resolution of symptoms on treatment, 1 patient had persistent reduced visual acuity and 1 patient was lost to follow-up. CONCLUSION We postulate that the combination of orbital inflammation and pachymeningitis is strongly suggestive of Wegener granulomatosis, although it may take a number of years to confirm. Tuberculosis should also be considered.
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Affiliation(s)
- Paul S Cannon
- Discipline of Ophthalmology & Visual Sciences, University of Adelaide, Adelaide, SA 5000, Australia.
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Idiopathic hypertrophic pachymeningitis in a child with hydrocephalus. Pediatr Neurol 2009; 40:457-60. [PMID: 19433281 DOI: 10.1016/j.pediatrneurol.2008.12.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 12/18/2008] [Accepted: 12/30/2008] [Indexed: 10/20/2022]
Abstract
Idiopathic hypertrophic pachymeningitis is a rare but increasingly recognized disorder characterized by diffuse thickening of the dura mater of unknown etiology. The inflammation usually involves the cranial or spinal dura mater, with resultant neurologic deficits. Although it is reported primarily in adults, there is one previous report describing the condition in a child. Described here is the case of a child who presented at the age of 3.5 years with idiopathic hypertrophic pachymeningitis involving the entire central nervous system, with poor response to steroids, cyclophosphamide, and intraventricular cytarabine.
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Gladstone JP. An approach to the patient with painful ophthalmoplegia, with a focus on Tolosa-Hunt syndrome. Curr Pain Headache Rep 2007; 11:317-25. [PMID: 17686398 DOI: 10.1007/s11916-007-0211-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies, including neoplasms (ie, primary intracranial tumors, local or distant metastases), vascular (eg, aneurysm, carotid dissection, and carotid-cavernous fistula), inflammatory (ie, orbital pseudotumor, giant cell arteritis, sarcoidosis, and Tolosa-Hunt syndrome), and infectious etiologies (ie, fungal and mycobacterial), as well as other miscellaneous conditions (ie, ophthalmoplegic migraine and microvascular infarcts secondary to diabetes). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that can be associated with significant morbidity or mortality if left untreated. Inflammatory conditions such as Tolosa-Hunt syndrome and orbital pseudotumor are highly responsive to corticosteroids but should be diagnoses of exclusion.
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