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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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2
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Oghene J, Boppana SH, Reddy P, Beutler BD, Dalal D. Double Down on Double Vision: An Unusual Case of Painful Diplopia. Cureus 2021; 13:e20838. [PMID: 35111483 PMCID: PMC8794403 DOI: 10.7759/cureus.20838] [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] [Accepted: 12/30/2021] [Indexed: 11/06/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a rare neuro-immunological disorder characterized by severe periorbital headaches and ophthalmoplegia. In some patients, THS may occur in parallel with other autoimmune disorders. The underlying etiology of THS remains to be definitively established. However, inflammation of the cavernous sinus or orbital apex represents a hallmark feature; magnetic resonance imaging, therefore, plays a key role in establishing a diagnosis. We describe a patient who presented with concomitant THS and granulomatosis with polyangiitis. In addition, we describe the clinical and imaging findings of THS and review treatment options for this rare condition.
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Affiliation(s)
- John Oghene
- Department of Internal Medicine and Primary Care, Brown University, Warren Alpert Medical School, Providence, USA
| | - Sri Harsha Boppana
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
| | - Pooja Reddy
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Deepan Dalal
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
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3
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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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4
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Corredor MM, Holmberg PJ. Ophthalmoplegia and cranial nerve deficits in an adolescent with headache. SAGE Open Med Case Rep 2021; 9:2050313X211024487. [PMID: 34178348 PMCID: PMC8202257 DOI: 10.1177/2050313x211024487] [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: 12/30/2020] [Accepted: 05/24/2021] [Indexed: 11/25/2022] Open
Abstract
Tolosa–Hunt syndrome is an idiopathic, inflammatory condition involving the cavernous sinus and is characterized by unilateral, painful ophthalmoparesis. The condition often begins with retro-orbital pain followed by select cranial nerve involvement. We report the case of a 17-year-old female whose presentation with progressive left-sided headache and ophthalmoparesis culminated in the diagnosis of Tolosa–Hunt syndrome. While many of her signs and symptoms have been previously reported in the rare pediatric cases of Tolosa–Hunt syndrome described in the literature, this case illustrates a unique presentation involving cranial nerves V and VII in addition to the more commonly reported cranial nerve III, IV, and VI palsies.
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Affiliation(s)
- Margarita M Corredor
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter J Holmberg
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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5
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Madhavan AA, DeLone DR, Verdoorn JT. Bilateral facial nerve involvement in a patient with Tolosa–Hunt syndrome. Neuroradiol J 2020; 33:424-427. [DOI: 10.1177/1971400920939293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Tolosa–Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III–VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa–Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III–VI. She was diagnosed with Tolosa–Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa–Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient’s clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa–Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell’s palsy.
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6
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Arthur A, Sivadasan A, Mannam P, Prabakhar AT, Aaron S, Mathew V, Karthik M, Benjamin RN, Iqbalahmed SA, Rynjah GL, Alexander M. Tolosa-Hunt Syndrome: Long-Term Outcome and Role of Steroid-Sparing Agents. Ann Indian Acad Neurol 2020; 23:201-205. [PMID: 32189862 PMCID: PMC7061504 DOI: 10.4103/aian.aian_368_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/25/2018] [Accepted: 11/05/2018] [Indexed: 01/03/2023] Open
Abstract
Background: Tolosa-Hunt Syndrome (THS) is one of the causes of cavernous sinus syndrome causing painful ophthalmoplegia. Literature on long-term outcome of this rare condition is scarce. Aims and Objectives: The aim is to study the recurrence and role of steroid-sparing agents in THS. Methodology: All cases of THS treated at a tertiary-level teaching hospital during a 10-year period were studied. Clinical and radiological profile, response to treatment and recurrences were noted. Results: A total of 44 cases were studied. The mean age was 49.5 years, Males constituted 23/44 (52%). The first symptom was pain in 90%. Ptosis with ophthalmoplegia was the most common deficit 29/44 (66%). Lesions confined to cavernous sinus 27/44 (61%) was the most frequent magnetic resonance imaging finding. All patients received steroids as the initial treatment and 15/44 (34%) received steroid-sparing agents. Follow-up ranged from 6 to 120 months (Mean 39 months). Two patients had alternative diagnosis of leptomeningeal malignancy and hypertrophic pachymeningitis on follow-up. Recurrences occurred in 18/37 (48.6%). Time for recurrence varied from 8 months to 7 years. (Mean 18 months). No clinical or radiological predictors for recurrence were identified. Patients who received steroid-sparing agents had a significantly lower recurrence 3/15 (20%) versus 14/26 (53.8%)P < 0.034. Conclusions: Around 50% of patients with THS can have recurrence. Steroid-sparing agents appear to prevent recurrence. A prospective multicenter randomized controlled trial may help to evaluate the risk and benefits of steroid-sparing therapy and to identify any possible predictors for recurrence.
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Affiliation(s)
- Anupriya Arthur
- Department of Ophthalmology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Pavitra Mannam
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A T Prabakhar
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - M Karthik
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Rohith Ninan Benjamin
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Shaikh Atif Iqbalahmed
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Gideon Lyngsyun Rynjah
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Anand P, Chwalisz BK. Inflammatory Disorders of the Skull Base: a Review. Curr Neurol Neurosci Rep 2019; 19:96. [DOI: 10.1007/s11910-019-1016-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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8
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Rodriguez-Homs LG, Goerlitz-Jessen M, Das SU. A 17-Year-Old Girl With Unilateral Headache and Double Vision. J Investig Med High Impact Case Rep 2019; 7:2324709619838309. [PMID: 31010318 PMCID: PMC6480981 DOI: 10.1177/2324709619838309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Tolosa-Hunt syndrome is characterized by a painful ophthalmoplegia secondary to a granulomatous inflammation in or adjacent to the cavernous sinus. Magnetic resonance imaging will show enhancement of the cavernous sinus and/or the orbital apex. Although this syndrome is extremely rare in children, it should be a diagnostic consideration in patients presenting with painful ophthalmoplegia with variable involvement of cranial nerves II to VI. The differential diagnosis for unilateral cavernous sinus lesion is broad, including vascular lesions (cavernous sinus thrombosis), inflammatory processes (sarcoidosis, autoimmune), neoplastic processes (schwannoma, lymphoma), as well as infectious etiologies. We describe a pediatric patient presenting with neurological symptoms from a unilateral cavernous sinus magnetic resonance imaging abnormality and the thorough diagnostic approach to arrive at the diagnosis of Tolosa-Hunt syndrome.
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Affiliation(s)
| | | | - Samrat U Das
- 1 Duke University School of Medicine, Durham, NC, USA
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9
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Świątkowska-Stodulska R, Stodulski D, Babińska A, Piskunowicz M, Sworczak K. Bilateral Tolosa-Hunt syndrome mimicking pituitary adenoma. Endocrine 2017; 58:582-586. [PMID: 29032531 PMCID: PMC5693964 DOI: 10.1007/s12020-017-1422-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 09/04/2017] [Indexed: 12/11/2022]
Abstract
The authors report a rare case of bilateral Tolosa-Hunt syndrome, which occurred in a 80-year-old female and remitted spontaneously. Inflammatory lesions were found not only in typical locations, i.e. superior orbital fissures and cavernous sinuses, but also in the pituitary; these imitated gland's macroadenoma in imaging studies.
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Affiliation(s)
| | - Dominik Stodulski
- Department of Otolaryngology, Medical University of Gdańsk, Gdańsk, Poland
| | - Anna Babińska
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | | | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, Gdańsk, Poland
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10
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Ho KWD, Drew PA, Chuquilin M. Merkel Cell Carcinoma with Distant Metastasis to the Clivus Causing Symptoms Mimicking Tolosa-Hunt Syndrome: A Case Report and Literature Review. Front Neurol 2017; 8:409. [PMID: 28868044 PMCID: PMC5563365 DOI: 10.3389/fneur.2017.00409] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/28/2017] [Indexed: 01/03/2023] Open
Abstract
Merkel cell carcinoma (MCC) is an uncommon but highly malignant neuroendocrine tumor of the skin. MCC can metastasize, but involvement of the central nervous system is rare. Here, we report a case of rapidly progressing metastatic MCC to the clivus and bilateral cavernous sinus in an immunocompromised patient. This case is unique in that it is the first case report showing MCC metastasis to the clivus from a distant site. It also demonstrates that a MCC metastasis can masquerade with symptoms of Tolosa–Hunt syndrome. A literature review on MCC with CNS metastasis is presented.
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Affiliation(s)
- Kwo Wei David Ho
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Peter A Drew
- Department of Pathology, University of Florida, Gainesville, FL, United States
| | - Miguel Chuquilin
- Department of Neurology, University of Florida, Gainesville, FL, United States
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11
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La Mantia L, Curone M, Rapoport AM, Bussone G. Tolosa–Hunt Syndrome: Critical Literature Review Based on IHS 2004 Criteria. Cephalalgia 2016; 26:772-81. [PMID: 16776691 DOI: 10.1111/j.1468-2982.2006.01115.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In 2004, the International Headache Society (IHS) re-defined the diagnostic criteria of Tolosa–Hunt syndrome (THS) specifying that granuloma, demonstrated by magnetic resonance imaging (MRI) or biopsy, is required for diagnosis. We reviewed the literature on THS published from 1988 (year of publication of first IHS criteria) to 2002, analysing individual cases in relation to the new IHS criteria. One hundred and twenty-four cases were identified. As far as it was possible to discern, clinical presentation was similar in all, but 44 (35±) were reported to have inflammation on MRI or bioptic evidence of granuloma, 41/124 (33±) had normal neuroimaging findings and 39 (31±) had a specific lesion, so the THS was secondary. These data confirm that clinical criteria for THS are common to several conditions and their application alone does not guarantee a correct diagnosis. The requirement for inflammation on MRI will result in better classification of painful ophthalmoplegias; nevertheless, an MRI protocol that best defines inflammation should be specified. The status of cases which fulfil the clinical criteria but have normal MRI remains to be clarified.
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Affiliation(s)
- L La Mantia
- Department of Clinical Neurology, Neurological Institute C Besta, Milan, Italy
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12
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Pérez CA, Evangelista M. Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update. Pediatr Neurol 2016; 62:18-26. [PMID: 27473647 DOI: 10.1016/j.pediatrneurol.2016.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/12/2016] [Accepted: 06/18/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tolosa-Hunt syndrome is a painful ophthalmoplegia caused by an inflammatory process of unknown etiology in the region of the cavernous sinus, orbital apex, or superior orbital fissure. This disease is rare in the pediatric population. The objective of this study was to provide a clinical framework for the evaluation and treatment of children with this disorder. A systematic approach to the diagnosis of painful ophthalmoplegia in children is proposed. METHODS We present a 15-year-old girl whose clinical presentation and neuroradiological findings support a diagnosis of Tolosa-Hunt syndrome as defined by the 2013 International Classification of Headache Disorders (Third Edition, ICHD-3 beta) diagnostic criteria. An exhaustive systematic literature search based on these criteria yielded 15 additional cases of Tolosa-Hunt syndrome in children. Clinical, demographic, and radiological features were retrospectively analyzed. The results and statistical analyses are reported. RESULTS A total of 16 individuals were included in the final analysis. This review summarizes the current knowledge and recommendations for the diagnosis and management of pediatric Tolosa-Hunt syndrome. It highlights demographic, clinical, and radiological features of this disease in children and underscores areas of the literature where evidence is still lacking. CONCLUSIONS Overall, Tolosa-Hunt syndrome seems to follow a similar course in children compared to adults. The diagnostic approach and treatment require specific considerations. New observations and possible features of pediatric Tolosa-Hunt syndrome are discussed. Further research is needed to optimize clinical detection and medical management of this disease.
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Affiliation(s)
- Carlos A Pérez
- Division of Child and Adolescent Neurology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Monaliza Evangelista
- Division of Community and General Pediatrics, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
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13
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Iaconetta G, Stella L, Esposito M, Cappabianca P. Tolosa-Hunt Syndrome Extending in the Cerebellopontine Angle. Cephalalgia 2016; 25:746-50. [PMID: 16109058 DOI: 10.1111/j.1468-2982.2005.00924.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- G Iaconetta
- Department of Neurological Sciences, Faculty of Medicine, Federico II University, Naples, Italy.
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Celebisoy N, Sirin H, Gökçay F. Ophthalmoplegic Migraine: Two Patients, one at Middle Age with Abducens Palsy. Cephalalgia 2016; 25:151-3. [PMID: 15658953 DOI: 10.1111/j.1468-2982.2004.00814.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- N Celebisoy
- Ege University Medical School Department of Neurology, ýzmir 35100, Turkey
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A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus. Case Rep Med 2016; 2016:9763621. [PMID: 27087813 PMCID: PMC4818810 DOI: 10.1155/2016/9763621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/07/2016] [Indexed: 01/03/2023] Open
Abstract
We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement.
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Hao R, He Y, Zhang H, Zhang W, Li X, Ke Y. The evaluation of ICHD-3 beta diagnostic criteria for Tolosa-Hunt syndrome: a study of 22 cases of Tolosa-Hunt syndrome. Neurol Sci 2015; 36:899-905. [PMID: 25736249 DOI: 10.1007/s10072-015-2124-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 02/22/2015] [Indexed: 01/03/2023]
Abstract
The objective of the study was to evaluate the amended International Classification of Headache Disorders (third edition, beta version, ICHD-3 beta) with a retrospective analysis. A total of 22 patients diagnosed with painful ophthalmoplegia and Tolosa-Hunt syndrome (THS) in our hospital were retrospectively studied. The following clinical data were collected: symptoms, signs, location of inflammatory tissue, time interval of paresis following the onset of pain, pain and signs of resolution, follow-up and relapse. Pain and diplopia were found in 22 (100 %) and 20 cases (91 %). The sympathetic nerve was involved in 6 cases (27 %). Paresis followed the pain for an average of 8 ± 5.87 days. Serial magnetic resonance imaging (MRI) revealed granulomatous lesion that was visible in 20 patients (91 %). 19 patients (86 %) demonstrated the lesions located in the cavernous sinus, orbital apex or superior orbital fissure. One lesion extended to the intracranial structure. Pain was relieved in 20 cases (91 %) within 72 h and no patient had complete relief from paresis. According to our study, we think the time course of relief should be undefined. Headache location is hard to describe accurately. Normal MRI should be involved in THS diagnoses. The lesion of THS can extend beyond the cavernous sinus and the orbit. The time interval between headache and paresis can exceed 2 weeks.
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Affiliation(s)
- Rui Hao
- Tianjin Eye Hospital, Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, China
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17
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Zhang X, Zhou Z, Steiner TJ, Zhang W, Liu R, Dong Z, Wang X, Wang R, Yu S. Validation of ICHD-3 beta diagnostic criteria for 13.7 Tolosa-Hunt syndrome: Analysis of 77 cases of painful ophthalmoplegia. Cephalalgia 2014; 34:624-32. [PMID: 24477599 DOI: 10.1177/0333102413520082] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/28/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Three editions of International Classification of Headache Disorders (ICHD) diagnostic criteria for Tolosa-Hunt syndrome (THS) have been published in 1988, 2004 and 2013, in ICHD-3 beta, there have been considerable changes [corrected]. The validity of these new diagnostic criteria remains to be established. METHODS We retrospectively identified 77 patients with non-traumatic painful ophthalmoplegia (PO) admitted between 2003 and 2013. We reviewed patients' age at onset and gender, time courses between onset of pain and development of cranial nerve palsy, the cranial nerves involved, imaging findings, therapeutic efficacy of steroid treatment and recurrence of attacks. RESULTS THS was the most frequent type of PO (46/77). In THS patients, the third cranial nerve was most commonly involved (76.3%). The median time interval between pain and cranial nerve palsy was two days, although in five patients (10.9%) the interval ranged from 16 to 30 days. Definitely abnormal MRI findings were found in 24 patients (52.2%). CONCLUSIONS It is essential to rule out other causes of PO in diagnosing THS, with MRI playing a crucial role in differential diagnosis. It may be helpful to understand and master the entity of THS for researchers and clinicians to adjust the gradation and ranking of the diagnostic criteria.
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Affiliation(s)
- Xingwen Zhang
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Zhibing Zhou
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Timothy J Steiner
- Department of Neuroscience, Norwegian University of Science and Technology, Norway
| | - Wei Zhang
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Xiaolin Wang
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Rongfei Wang
- Department of Neurology, Chinese PLA General Hospital, PR China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, PR China
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Tolosa-Hunt syndrome preceded by facial palsy in a child. Pediatr Neurol 2011; 44:61-4. [PMID: 21147390 DOI: 10.1016/j.pediatrneurol.2010.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 08/10/2010] [Accepted: 08/23/2010] [Indexed: 11/22/2022]
Abstract
We report on a previously healthy 11-year-old boy with unilateral periorbital mild headache and facial nerve palsy, followed during the next 5 months by recurrent unilateral headaches and subsequent extrinsic paresis of the third cranial nerve and paresis of the sixth cranial nerve, each of which improved with steroids. Cranial magnetic resonance imaging revealed increased thickening of the left cavernous sinus and adjacent structures, with marked gadolinium enhancement. Eight months after the initial signs, he developed left retro-orbital headache that lasted 16 days and was relieved 24 hours after resuming steroid treatment. Recurrent multiple cranial neuropathies, neuroimaging findings, and long-lasting headache that responded to steroids indicated Tolosa-Hunt syndrome, further confirmed by extensive investigation and a long follow-up to exclude other causes. This patient illustrates the complexity of disorders with multiple cranial nerve palsies, and adds to the sparse literature on Tolosa-Hunt syndrome in children, describing the first pediatric case preceded by facial palsy.
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Ben Abdelghani K, Baili L, Turki S, Hadj Ali I, Kheder A. [Exophthalmos revealing Tolosa-Hunt syndrome]. Rev Neurol (Paris) 2010; 166:1034-7. [PMID: 20739039 DOI: 10.1016/j.neurol.2010.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 04/04/2010] [Accepted: 07/08/2010] [Indexed: 10/19/2022]
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Colnaghi S, Versino M, Marchioni E, Pichiecchio A, Bastianello S, Cosi V, Nappi G. ICHD-II Diagnostic Criteria for Tolosa—Hunt Syndrome in Idiopathic Inflammatory Syndromes of the Orbit and/or the Cavernous Sinus. Cephalalgia 2008; 28:577-84. [DOI: 10.1111/j.1468-2982.2008.01569.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A bibliographical search was conducted for papers published between 1999 and 2007 to verify the validity of International Classification of Headache Disorders (ICHD)-II criteria for the Tolosa-Hunt syndrome (THS) in terms of (i) the role of magnetic resonance imaging (MRI); (ii) which steroid treatment should be considered as adequate; and (iii) the response to treatment. Of 536 articles, 48, reporting on 62 patients, met the inclusion criteria. MRI was positive in 92.1% of the cases and it normalized after clinical resolution. There was no evidence of which steroid schedule should be considered as adequate; high-dose steroids are likely to be more effective both to induce resolution and to avoid recurrences. Pain subsided within the time limit required by the ICHD-II criteria, but signs did not. We conclude that THS diagnostic criteria can be improved on the basis of currently available data. MRI should play a pivotal role both to diagnose and to follow-up THS.
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Affiliation(s)
- S Colnaghi
- Department of Neurology, University of Pavia, Pavia
- Department of Neuro-Otology and Neuro-Ophthalmology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
- UCADH—University Centre for Adaptive Disorders and Headache, University of Pavia, Pavia
| | - M Versino
- Department of Neurology, University of Pavia, Pavia
- Department of Neuro-Otology and Neuro-Ophthalmology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
- UCADH—University Centre for Adaptive Disorders and Headache, University of Pavia, Pavia
| | - E Marchioni
- UCADH—University Centre for Adaptive Disorders and Headache, University of Pavia, Pavia
- Department of Clinical Neurology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
| | - A Pichiecchio
- Department of Neuroradiology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
| | - S Bastianello
- Department of Neurology, University of Pavia, Pavia
- Department of Neuroradiology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
| | - V Cosi
- Department of Neurology, University of Pavia, Pavia
- Department of Clinical Neurology, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
| | - G Nappi
- UCADH—University Centre for Adaptive Disorders and Headache, University of Pavia, Pavia
- Scientific Direction, IRCCS ‘Neurological Institute C. Mondino’ Foundation, Pavia
- Department of Neurology and ENT, University ‘La Sapienza’, Roma, Italy
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Kang H, Park KJ, Son S, Choi DS, Ryoo JW, Kwon OY, Choi NC, Lim BH. MRI in Tolosa-Hunt Syndrome Associated With Facial Nerve Palsy. Headache 2006; 46:336-9. [PMID: 16492248 DOI: 10.1111/j.1526-4610.2006.00348_3.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A 44-year-old woman developed a severe right frontotemporal headache, retro-orbital pain, and, later, diplopia owing to right sixth nerve palsy. The brain MRI demonstrated strong enhancement of the right cavernous sinus. The sixth nerve palsy and headache improved with steroid therapy after 6 weeks. At that time, she suffered right peripheral facial nerve palsy. Enhancement of the distal canalicular and labyrinthic segment of the right facial nerve was found on contrast-enhanced MRI. To our knowledge, this is a very rare case of Tolosa-Hunt syndrome with facial nerve palsy, with simultaneous enhancement of the cavernous sinus and facial nerve on contrast-enhanced MRI.
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Affiliation(s)
- Heeyoung Kang
- Department of Neurology, Gyeongsang Institute of Health Sciences, Gyeongsang National University College of Medicine, Chiram-dong, Jinju, Korea
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Affiliation(s)
- Do Gyun Kim
- Department of Pediatrics, College of Medicine, Chonnam National University, Gwangju, Korea
| | - Young Ok Kim
- Department of Pediatrics, College of Medicine, Chonnam National University, Gwangju, Korea
| | - Young Jong Woo
- Department of Pediatrics, College of Medicine, Chonnam National University, Gwangju, Korea
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Abstract
We review the question of diagnosis of painful and relatively isolated ophthalmoplegia due to diseases affecting the ocular motor nerves. For each clinical setting, we provide an overview of the main causes and a practical way to approach the diagnosis. As vascular malformations should always be kept in mind in patients with painful ophthalmoplegia, emergency neuroradiological investigations may be needed. However, the etiological scope is wide and the rationale for choosing the more appropriate examination and its optimal timing depends exclusively on the clinical evaluation. Despite advances in investigation techniques, diagnosis may remain difficult or even unresolved in a certain number of patients. We discuss successively paralysis of the third, sixth and fourth nerve, paralysis of several ocular motor nerves, recurrent ophthalmoplegia and ischaemic ocular motor palsies, which are the most frequent cause.
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Affiliation(s)
- A Vighetto
- Service de Neurologie D, Hôpital neurologique Pierre-Wertheimer et Université Claude-Bernard Lyon I, Lyon.
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Kilpatrick SR. Craniofacial Neural Disorders: A Guide for Diagnosis and Management. Cranio 2004; 22:304-13. [PMID: 15532315 DOI: 10.1179/crn.2004.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
The purpose of this article is to provide a succinct diagnosis and management regimen for neural disorders of the craniofacial region. This guide is an attempt to organize available data in a format for use by the craniofacial pain practitioner. The management regimens are brief because the management of many of these disorders may be outside the scope of dentistry. Also, the purpose of this guide is to be user-friendly and complete. Terminology is based on a literature review so individual disorders may be researched more completely.
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Abstract
Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia due to a granulomatous inflammation in the cavernous sinus. Corticosteroid therapy dramatically resolves both the clinical and radiological findings of THS. We present MRI findings of six patients with a clinical history of at least one episode of unilateral or bilateral orbital-periorbital pain, clinical findings of associated paresis of one or more of 3rd, 4th, 5th or 6th cranial nerves. All of the patients revealed an enlargement of the symptomatic cavernous sinus on magnetic resonance imaging (MRI) scans. Five patients revealed total resolution of the clinical findings within 1-8 weeks, following systemic corticosteroid treatment. One patient revealed only minor regression of clinical findings within 2 weeks after the initiation of the treatment, so the cavernous sinus lesion was reevaluated as meningioma on MRI, and the patient underwent surgical resection of the mass with resultant histopathological finding of cavernous sinus meningioma. A follow-up MRI scan was performed for five patients at the end of 8-weeks of steroid therapy. Three of these five patients showed total resolution of the cavernous sinus lesions whereas two of them revealed a partial regression of the cavernous sinus lesions. MRI findings before and after systemic corticosteroid therapy are important diagnostic criteria to put the definitive diagnosis of THS and to differentiate it from other cavernous sinus lesions that simulate THS both clinically and radiologically.
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Affiliation(s)
- Sinan Cakirer
- Department of Radiology, Istanbul Sişli Etfal Hospital, 67 Ada, Kardelen 4/2, Daire 37, 80220 Ataşehir, Istanbul, Turkey.
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