A comparison of benign and inflammatory manifestations of Tolosa-Hunt syndrome

Clinical and diagnostic profile of Tolosa-Hunt syndrome; a 7-year retrospective observational study

BACKGROUND

Tolosa Hunt Syndrome (THS) was first delineated in 1954 and is caused by a granulomatous inflammation in the cavernous sinus, superior orbital fissure or orbit. In this study the different clinical and diagnostic findings of THS are discussed.

METHODS

Case records of patients diagnosed with THS using the International Classification of Headache Disorders 3rd edition criteria from January 2016-July 2022 were considered for the current study. Demographic, Clinical, Laboratory and Radiological data of all patients fulfilling the inclusion and exclusion criteria was collected from the patient case records through the Medical Records Department of BMCRI Super Specialty Hospital.

RESULTS

A total of 60 patients were included in the study with mean age with SD, 50.9 years (13.9) and were predominantly male (66.6%). Restriction of eye movements was the most common symptom affecting 31 (51.7%) patients. Oculomotor nerve (IIIrd Cranial Nerve) palsy was the most common nerve palsy, affecting 36 (60%) patients. Contrast enhancing lesions or T2/FLAIR Hyper-intense areas were seen in the Magnetic Resonance Imaging (MRI) of 59 (98.3%) patients. Cavernous sinus involvement, was the most common site of involvement, in 25 (41.6%) of the patients. All patients were treated with intravenous methyl prednisolone injections and responded well.

CONCLUSION

Restriction of eye movements was the most common symptom, along with cavernous sinus being the most common site of involvement in THS. MRI scans are important diagnostic tools for THS.

Cavernous Sinus MRI Findings in Inflammatory and Ischemic Oculomotor Cranial Nerve Palsies

BACKGROUND

The significance of asymmetric enhancement on cavernous sinus MRIs in the differential diagnosis of ischemic and inflammatory oculomotor cranial nerve (OCN) palsies remains controversial. This study explored the cavernous sinus MRI findings for cavernous sinus idiopathic inflammation (inflammation group), microvascular ischemic OCN palsy (ischemic group), and ocular myasthenia gravis (OMG group) patients.

METHODS

A total of 66, 117, and 60 patients were included in the inflammation, ischemic, and OMG groups, respectively. Cavernous sinus MRIs were retrospectively analyzed.

RESULTS

The abnormality rates of cavernous sinus MRIs for OMG and ischemic groups were 41.7% (25/60) and 61.5% (72/117), respectively. Inconsistency rates between clinical topical diagnosis and imaging findings for inflammation and ischemic groups were 3.0% (2/66) and 13.7% (16/117), respectively ( P = 0.020). In the inflammation group, cavernous sinus thickness, thickening enhancement, and enhancing adjacent lesions were noted in 90.9% (60/66), 71.2% (47/66), and 25.8% (17/66) of the patients, whereas in the ischemic group, they were noted in 51.3% (60/117), 38.5% (45/117), and 0.9% (3/117) of the patients, respectively ( P < 0.001). Among ischemic CN III palsy patients, 55.5% (15/27) and 16.7% (2/12) of the cases had CN III enlargement and enhancement in the diabetic and nondiabetic groups, respectively ( P = 0.037).

CONCLUSIONS

Cavernous sinus MRI abnormalities can be explained by specific pathologic mechanisms of the primary disease based on the complex neuroanatomy. However, suspicious inflammatory changes cannot exclude the possibility of ischemia and over reliance on these findings should be avoided.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Recurrence and long-term outcomes of Tolosa-Hunt syndrome

BACKGROUND AND PURPOSE

Tolosa-Hunt Syndrome (THS) is a rare disorder, and detailed clinical information and treatment outcomes have yet to be fully elucidated. This study aims to investigate the clinical features and factors associated with the treatment outcomes of THS, as defined by the established diagnostic criteria.

METHODS

This study retrospectively recruited 91 patients with a diagnosis of THS from 2003 to 2020. We analyzed the clinical features and outcomes, the initial treatment response, recurrences, and the final treatment response.

RESULTS

Isolated ocular motor nerve palsy was the most common (82.4%) finding of ophthalmoplegia, involving the oculomotor nerve in more than half of the cases (52.0%). The MRI lesions were mostly observed in the cavernous sinus (94.5%) with an extracavernous extension in about one-third of them. Five patients showed only extracavernous lesions. A total of 25 (27.5%) patients experienced recurrence. Recurrence occurred during steroid tapering as part of the initial treatment in seven, while in 18 patients, it happened after the successful termination of the initial treatment. However, all patients achieved complete remission at the final. Age was associated with a decrease in initial symptom duration (HR = 1.023, CI = 1.004-1.044) as well as an increase in recurrence-free duration (HR = 0.944, CI = 0.911-0.978). High-dose corticosteroid treatment was associated with a decrease in initial symptom duration (HR = 1.642, CI = 1.001-2.695) and total treatment duration (HR = 2.203 CI = 1.302-3.730).

CONCLUSIONS

THS can recur frequently especially in younger but have a favorable prognosis. High-dose corticosteroids can be an effective initial treatment and reduce the total treatment duration.

Systematic Review of Treatment Options and Therapeutic Responses for Lesions of the Sella and Orbit: Evidence-Based Recommendations

OBJECTIVE

Inflammatory pathologies of the sella and orbit are rare but require prompt diagnosis to initiate effective treatment. Because uniform recommendations for treatment are currently lacking, we performed an evidence-based review to identify recommendations.

METHODS

We performed a literature search of the PubMed, Embase, and Web of Science databases to identify papers evaluating treatment of inflammatory pathologies of the sella and orbit. We used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to define recommendations, specifically examining aggregated sample sizes, disease-specific patient follow-up, and clinical trials focused on inflammatory diseases of the sella and orbit.

RESULTS

A total of 169 studies were included and organized by disease pathology. Treatments for various pathologies were recorded. Treatment options included surgery, radiation, steroids, targeted treatments, immunomodulators, intravenous immune globulin, and plasmapheresis. Steroids were the most often employed treatment, second-line management options and timing varied. Pathological diagnosis was highly associated with treatment used. Most evidence were level 3 without available control groups, except for 13 trials in neuromyelitis optica with level 1 or 2 evidence.

CONCLUSIONS

This is the first evidence-based review to provide recommendations on specific treatments for pathologies of the orbit and sella. The reported data may be useful to help guide randomized clinical trials and provide resource for clinical management decisions based on the available evidence.

A case report on recurrent alternating Tolosa-Hunt syndrome due to bacterial sphenoid sinusitis: rediscussing the diagnostic terminology and classification

BACKGROUND

Tolosa-Hunt syndrome (THS) is characterized by painful ophthalmoplegia caused by idiopathic granulomatous inflammation involving the cavernous sinus region. Patients respond well to steroid therapy. THS is included in the differential diagnosis of cavernous sinus syndrome, so it is important to fully exclude other lesions in this area before treatment, otherwise steroid treatment may lead to fatal outcomes. Here we describe a patient who initially presented with symptoms that simulated THS symptoms and developed recurrent alternating painful ophthalmoplegia during follow-up, and the patient was finally diagnosed with cavernous sinusitis caused by bacterial sphenoid sinusitis.

CASE PRESENTATION

A 34-year-old woman presented with left painful ophthalmoplegia. Magnetic resonance imaging (MRI) revealed abnormal signals in the left cavernous sinus area, and these abnormal signals were suspected to be THS. After steroid treatment, the patient obtained pain relief and had complete recovery of her ophthalmoplegia. However, right painful ophthalmoplegia appeared during the follow-up period. MRI showed obvious inflammatory signals in the right cavernous sinus and right sphenoid sinus. Then nasal sinus puncture and aspiration culture were performed, and the results showed a coagulase-negative staphylococcus infection. After antibiotic treatment with vancomycin, the painful ophthalmoplegia completely resolved, and the neurological examination and MRI returned to normal.

CONCLUSION

Some other causes of painful ophthalmoplegia also fulfill the diagnostic criteria for THS in the International Classification of Headache Disorders third edition (ICHD-3) and respond well to steroid therapy. Early diagnosis of THS may be harmful to patients, and clinicians should exercise great caution when dealing with similar cases without a biopsy. Using "cavernous sinus syndrome" instead of "Tolosa-Hunt syndrome" as a diagnostic category may provide a better clinical thinking for etiological diagnosis.

Tolosa-Hunt Syndrome: A Review of Diagnostic Criteria and Unresolved Issues

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.

The demographics of Tolosa-Hunt syndrome in Qatar

Background

Tolosa Hunt syndrome (THS) is a rare disease that manifests mainly as painful unilateral ophthalmoplegia. It is caused by an inflammatory process of unknown aetiology within the cavernous sinus with a rare intracranial extension. The International Classification of Headache Disorders (ICHD)- 3 diagnostic criteria aids in its diagnosis. There is limited literature on its varied presentations, diagnosis, and management. Steroids are used in the treatment of THS with varied success.

Methods

We conducted a single-center-retrospective-study and included all patients admitted with a diagnosis of THS from January 2015 to December 2020. Descriptive and summary statistics were used to describe the study cohort's socio-demographic parameters.

Results

Among 31 THS patients (predominantly Asians (18) and Arabs (9)), visual disturbance was commonest presenting complaint. Third-nerve paralysis was seen in 70.9% cases. Magnetic-resonance-imaging (MRI) was abnormal in 64.5%. 93.5% patients received steroids, with a response-rate of 70.9% and a recurrence-rate of 9.7%. A previous history of THS and female gender were associated with recurrence (p-value 0.009 and 0.018). Recurrence was seen in 66.7% fully recovered and 33.3% partially recovered cases (p-value 0.04). Among the benign and inflammatory subtypes of THS, the ICHD-3 criteria were applicable in 85% of inflammatory THS.

Conclusions

THS is a rare disease with ethnic variation in presentation and response to treatment. In our cohort female gender and a previous history of THS were associated with recurrence. ICHD-3 diagnostic criteria had a higher validity in our patients compared to prior studies, especially among the inflammatory THS.

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We represent the largest cohort of THS patients from the Middle eastern population.

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In our cohort, medium dose steroids (60 mg daily) had a good recovery rate (71%).

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Female gender and a prior history of THS were associated with recurrence.

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Recurrence rate was low in our cohort compared to international trends (9.7%).

Multiple Spontaneous Visceral Arterial Dissections in a Patient With Tolosa-Hunt Syndrome on Corticosteroid Therapy

Multiple spontaneous visceral arterial dissections are an infrequent occurrence. The etiology, risk factors and natural history of these dissections have not been elucidated, and the optimal therapeutic strategy has not been established. We report a rare case of multiple spontaneous visceral arterial dissections involving the celiac artery, splenic artery, superior mesenteric artery, and right renal artery in a patient with Tolosa-Hunt syndrome on short-term corticosteroid therapy. The patient was subjected to conservative treatment and endovascular repair, achieving good clinical and radiological outcomes during the long-term follow-up period.

Reappraisal of the Prognostic Factors of Outcome and Recovery Time in Patients with Idiopathic Bell's Palsy: A Retrospective Single-Center Analysis

Study Objectives: This retrospective study investigated prognostic factors and recovery time in patients with Bell’s palsy after different doses and durations of oral glucocorticoid treatments. Subjects and Methods: A total of 396 patients initially diagnosed with Bell’s palsy that had visited the Department of Neurology of Chang Gung Memorial Hospital, Taoyuan, a tertiary referral medical center in Taiwan, between January 2014 and December 2018 were included. Medical records, facial electroneurography (fENoG), and blink reflex (BR) tests were reviewed and analyzed. A favorable outcome was defined as patients who improved to grade ≤ II, and an unfavorable outcome was defined as patients who improved to grade ≥ III in 6 months according to the House–Brackmann (HB) grading system. Results: The rate of favorable outcomes was 89.4% (354 of 396 patients) at the 6-month follow-up. A favorable outcome (HB less than grade II) was associated with a delayed BR (odds ratio, OR, 5.38; 95% CI, 1.82 to 15.90) and fENoG values (the lesion side/the healthy side) over 33% (OR, 6.67; 95% CI, 3.02 to 14.71). The recovery time was significantly shorter for those with a delayed BR than for those with an absent BR and shorter for those with good fENoG values (>33%) than for those with poor values (≤33%). However, treatment without or with different doses and durations of oral glucocorticoid did not influence the final outcome or recovery time in this study. Conclusions: The fENoG and BR tests were significant and highly valuable examinations for predicting the final outcome. Moreover, age younger than 60 years, a delayed BR, and fENoG values > 33% were associated with shorter recovery times.

Tolosa-Hunt Syndrome in Childhood and Adolescence: A Literature Review in the Last 10 Years

OBJECTIVES

The aim of the study is to review the articles published in the last 10 years on Tolosa-Hunt syndrome (THS) in childhood and adolescence to learn about its clinical and epidemiological characteristics and its therapeutic management.

METHODS

Based on the literature search in the major medical databases and using the descriptors "Tolosa-Hunt syndrome and children" and "Tolosa-Hunt syndrome and adolescent" we included articles published between 2009 and 2019. We found 51 articles, but only 11 met the inclusion criteria.

RESULTS

There were eight women and four men with THS, whose average age was 12.0 ± 4.3 years, ranging from 4 to 17 years. Magnetic resonance imaging showed inflammation in the cavernous sinus (100%), orbit (25%), and superior orbital fissure (8.3%), unilateral in all patients. The internal carotid artery (58.3%), third (66.7%), sixth (33.3%), and fourth (25%) cranial nerves were injured. Headache was located in the orbital region, ipsilaterally to nerve involvement and had mild to severe intensity. Corticosteroid was the treatment used in 91.7% of the patients. They were followed for an average of 13.4 ± 12.4 months. Only two patients had recurrence of the disease.

CONCLUSION

THS is infrequent in childhood and adolescence and knowledge of its clinical and epidemiological characteristics and its therapeutic management is necessary for pediatricians.

Clinical Features of Painful Ophthalmoplegia with a High-Intensity Ring Appearance around the Optic Nerve on MRI: A Case Series

Objective

Painful ophthalmoplegia includes nonspecific magnetic resonance imaging (MRI) manifestations and various clinical features including orbital pain and cranial nerve palsies. Treatment for painful ophthalmoplegia remains controversial. The aim of this report was to describe detailed clinical features, MRI findings, treatments, and prognosis of patients with painful ophthalmoplegia. Patients and Methods. We retrospectively investigated four cases of patients with painful ophthalmoplegia diagnosed using the International Classification of Headache Disorders, 3rd edition.

Results

All patients experienced unilateral orbital pain and oculomotor nerve palsy with diplopia but no vision loss. One of the four patients was diagnosed with Tolosa-Hunt syndrome based on the appearance of a granulomatous inflammation of the cavernous sinus on MRI. No specific lesions were detected on brain MRI for the other three patients; therefore, their headaches were attributed to ischaemic ocular motor nerve palsy. In all patients, a high-intensity ring appearance around the ipsilateral optic nerve was observed on MRI. Steroid therapy was administered to these patients, and good prognoses were anticipated.

Conclusion

These results indicate that prednisolone is a useful treatment for painful ophthalmoplegia that displays ipsilateral hyperintense ring lesions around the optic nerve on MRI, regardless of the presence of granulomatous inflammation of the cavernous sinus.

The Neuralgias

PURPOSE OF REVIEW

Neuralgias are characterized by pain in the distribution of a cranial or cervical nerve. Typically, they are brief, paroxysmal, painful attacks, although continuous neuropathic pain may occur. The most commonly encountered conditions are trigeminal, postherpetic, and occipital neuralgia. Less common neuralgias include glossopharyngeal, superior laryngeal, auriculotemporal, and nervus intermedius neuralgia, among others. The approach to diagnosis and treatment of this group of disorders is reviewed.

RECENT FINDINGS

Recent guidelines of medication administration, the use of botulinum toxin, and more targeted procedures have improved treatment of neuralgias. Patients who present with neuralgias should have imaging studies to investigate for structural abnormalities unless the etiology is apparent. Management of both common and rare neuralgias can be challenging and is best guided by the most recent available evidence.

A case of delirium in Tolosa-Hunt syndrome during corticosteroid therapy

BACKGROUND

Corticosteroid therapy is useful for the resolution of pain and paresis in Tolosa-Hunt syndrome; however, there is no definitive protocol for appropriate dosing, route of administration, or duration of therapy. Steroid psychosis is an adverse reaction to corticosteroid therapy; in severe cases, it can develop into psychiatric disorders such as delirium, depression, and mania. In this case study, we report a patient with Tolosa-Hunt syndrome who developed delirium while receiving corticosteroid therapy.

CASE PRESENTATION

The patient was a 70-year-old man being treated for a main complaint of pain in the right eye accompanied by oculomotor paralysis. We suspected Tolosa-Hunt syndrome based on diagnostic imaging and other findings. Steroid pulse therapy was initiated with intravenous methylprednisolone at 1000 mg/day for 3 days, followed by oral prednisolone at 60 mg/day. The pain in the right eye disappeared the day after starting this regimen, and palpebral ptosis also improved. However, 5 days after starting treatment, the patient developed progressively worsening delirium, which was considered an adverse reaction to the steroid pulse therapy. Then, prednisolone treatment was temporarily suspended, and the delirium subsequently disappeared.

CONCLUSIONS

The manifestation of steroid psychosis following corticosteroid therapy is dose dependent. Therefore, corticosteroid therapy for elderly patients requires caution and dose modulation because of likely adverse drug reactions.

Tolosa-Hunt Syndrome: Appraising the ICHD-3 beta diagnostic criteria

Introduction

The term Tolosa-Hunt Syndrome was first used more than half a century ago to describe painful ophthalmoplegia accompanied by cranial nerve palsies. In the decades since, its diagnostic criteria have evolved considerably. The beta version of the 3rd Edition of the International Classification of Headache Disorders narrows these criteria to require the demonstration of granulomatous inflammation on MRI or biopsy. We believe this may introduce challenges to accurate diagnosis.

Discussion

Requiring the demonstration of granulomatous inflammation for a diagnosis of Tolosa-Hunt Syndrome may introduce the potential for false negative and false positive diagnoses. Although the disorder presents secondary to granulomatous inflammation, MRI technology may not be able to identify it reliably, and biopsy is not always indicated for its symptomatology. Additionally, several cases have been reported of Tolosa-Hunt Syndrome diagnosed with MRI-confirmed granulomatous inflammation that later prove to be attributable to other pathologies. The emphasis on neuroimaging may therefore exclude some true Tolosa-Hunt Syndrome cases and include others resulting from other latent pathologies that are not visible on MRI.

Conclusion

We wish to offer several potential modifications to the International Classification of Headache Disorders guidelines for Tolosa-Hunt Syndrome, including making the demonstration of granulomatous inflammation on MRI or biopsy non-mandatory and lengthening patient follow-up to two years for cases in which MRI is unrevealing.

Facial pain: Overlapping syndromes

Premise This review summarises the pain syndromes that overlap between headache and facial pain and overlap between pain and cranial nerve lesion. Problem These syndromes share two features in common. First, they show both cranial nerve impairment (e.g. palsy, autonomic dysfunction) and pain; second, they have inflammatory (and/or small vessel) processes as the underlying mechanism. A typical representative of these syndromes is recurrent painful ophthalmoplegic neuropathy, which was previously called ophthalmoplegic migraine and was regarded as a migraine subtype. It is now supposed that this syndrome is caused by an inflammation of one of the ocular motor nerves. Other syndromes discussed in this review are optic neuritis, Tolosa-Hunt syndrome, ischaemic ocular motor nerve palsy, and the very rare Raeder's syndrome. Treatment of all these syndromes is mainly based on steroids. Potential solution Management of possibly underlying disorders such as multiple sclerosis or atherosclerosis should also be considered.

Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update

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.

Bilateral Painful Ophthalmoplegia: A Case of Assumed Tolosa-Hunt Syndrome

We present the case of a man of 47 years with vertical and horizontal paresis of view combined with periorbital pain that developed initially on the right side but extended after 3-4 days to the left. Gadolinum uptaking tissue in the cavernous sinus was shown by MRI of the orbital region in the T1 spin echo sequence with fat saturation (SEfs) with a slice thickness of 2 mm. As no other abnormalities were found and the pain resolved within 72 hours of treatment with cortison a bilateral Tolosa-Hunt Syndrome (THS) was assumed. THS is an uncommon cause for Painful Ophthalmoglegia (PO) and only few cases of bilateral appearance have been reported. Even though the diagnostic criteria for THS oblige unilateral symptoms we suggest that in patients with bilateral PO THS should not be excluded as a differential diagnosis. Further more when using MRI to detect granulomatous tissue in the orbital region the chosen sequence should be T1 SEfs and slice thickness should possibly be as low as 2 mm, as granulomas are often no larger than 1-2 mm.

Clinical and radiological findings suggesting disorders other than tolosa-hunt syndrome among ophthalmoplegic patients: a retrospective analysis

OBJECTIVE

To investigate clinical and radiological features of Tolosa-Hunt syndrome (THS) and examine their diagnostic value, and to propose clinical and radiological features that indicate other symptomatic painful ophthalmoplegias (SPOs) in order to distinguish them from THS.

BACKGROUND

Clinical presentations of THS are nonspecific and may overlap with many etiologies. Therefore, excluding other SPOs is essential for correct diagnosis. At the present time, the predictive value of the current International Classification of Headache Disorders (ICHD) criteria is not well established, and specific imaging markers that can discriminate SPOs from THS are lacking.

METHODS

Patients referred with painful ophthalmoplegia over 12 years were recruited retrospectively and allocated into THS or SPO groups. Typical symptoms (episodic unilateral orbital pain preceding or developing with diplopia) and imaging of THS (inflammatory lesions in the cavernous sinus/orbit by magnetic resonance imaging) were proposed based on ICHD-3 beta criteria and previous literature. Atypical clinical and radiological features suggesting alternative diagnoses were also proposed to predict SPO. Initial presentations and imaging findings were registered and correlated with diagnostic outcomes. The predictive value of clinical and imaging findings was then evaluated.

RESULTS

Of the 61 referred cases, 25 were classified as THS and 36 as SPO. Of the SPO cases, 52.8% manifested typical THS symptoms at onset. Patients with SPOs were prone to have atypical symptoms (47.2%) and radiographical findings (82.1%) in comparison to those with THS (4.0% and 4.2%, respectively; both P < .001). Both typical symptoms and imaging findings predicted a diagnosis of THS with high sensitivity (95.8% and 100%, respectively) but low specificity (47.2% and 28.6%, respectively). High sensitivity (82.1%) and specificity (95.8%) were achieved using atypical imaging features to predict SPO.

CONCLUSION

A diagnosis of THS based strictly on clinical presentations or imaging results is not completely reliable. Identification of atypical imaging features may have a useful role in discriminating SPOs and thus avoid erroneous diagnoses of THS. Future studies with larger sample sizes are warranted to evaluate their validity in general population.

Tolosa-Hunt syndrome: an arcane pathology of cavernous venous sinus

Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus, is primarily a diagnosis of exclusion. The majority of patients present with unilateral orbital pain and features suggestive of paralysis of one or more of the cranial nerves passing through the cavernous sinus and/or superior orbital fissure. MRI of the head may show unilateral enhancement of the cavernous sinus and orbital apex. Treatment is with high-dose intravenous steroids followed by tapering oral steroids. Rapid amelioration of pain within 24-48 h supports this rare diagnosis. Resolution of neuropathies may take longer. We describe a case of a young man who presented with left periorbital pain, complete ophthalmoplaegia and ptosis of the left eye. MRI showed enhancement of the left cavernous sinus and orbital apex. High dose steroids led to complete resolution of pain, while ptosis and ophthalmoplaegia improved gradually.

Factors that influence Tolosa-Hunt syndrome and the short-term response to steroid pulse treatment

Some but not all patients with Tolosa-Hunt syndrome (THS) have dramatic responses to steroid treatment. A systematic study about the factors that may influence the steroid response of THS patients has not been published. We retrospectively identified 40 patients diagnosed with THS and treated with steroids with respect to patient age at onset, gender, the cranial nerve(s) involved, as well as imaging findings and laboratory tests. Within the context of these data we evaluated the therapeutic efficacy of steroid treatment and recurrence of attacks. We did not note a significant relationship between genders, whether THS was benign or inflammatory, the distribution of cranial nerve palsies, the initial dose of steroids and the effectiveness of steroid treatment for relief of orbital pain or cranial nerve palsies at 72 h or 1 week after treatment. Our study reveals that a rapid alleviation of pain by steroid treatment is a characteristic feature of THS patients. The alleviation of cranial nerve palsy is somewhat slower and more variable, and may involve additional mechanisms. There is an effect of patient age and whether attacks will recur (recurrence was more likely in patients who were young at the time of first attack), whether THS will be benign or inflammatory (more likely to be inflammatory in young patients) and the short-term response of cranial nerve palsy to steroid treatment, which was more effective in young patients. These relationships may be of value in counseling patients presenting with THS.

Validation of ICHD-3 beta diagnostic criteria for 13.7 Tolosa-Hunt syndrome: Analysis of 77 cases of painful ophthalmoplegia

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.

Painful ophthalmoplegia with normal cranial imaging

Background

Painful ophthalmoplegia with normal cranial imaging is rare and confined to limited etiologies. In this study, we aimed to elucidate these causes by evaluating clinical presentations and treatment responses.

Methods

Cases of painful ophthalmoplegia with normal cranial MRI at a single center between January 2001 and June 2011 were retrospectively reviewed. Diagnoses of painful ophthalmoplegia were made according to the recommendations of the International Headache Society.

Results

Of the 58 painful ophthalmoplegia cases (53 patients), 26 (44.8%) were diagnosed as ocular diabetic neuropathy, 27 (46.6%) as benign Tolosa-Hunt syndrome (THS), and 5 (8.6%) as ophthalmoplegic migraine (OM). Patients with ocular diabetic neuropathy were significantly older (62.8 ± 7.8 years) than those with benign THS (56.3 ±12.0 years) or OM (45.8 ± 23.0 years) (p < 0.05). Cranial nerve involvement was similar among groups. Pupil sparing was dominant in each group. Patients with benign THS and OM responded exquisitely to glucocorticoid treatment with resolved diplopia, whereas patients with ocular diabetic neuropathy didn’t (p < 0.05). Patients with OM recovered more rapidly than the other groups did (p < 0.05). Overall, most patients (94.8%) recovered completely during the follow-up period.

Conclusions

Ocular diabetic neuropathy and benign THS accounted for most of the painful ophthalmoplegias in patients with normal cranial imaging. Patient outcomes were generally good.