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Bireley JD, Santucci J, Li Y, Cohen DA. Clinical Reasoning: An Unusual Cause of Diplopia and Ptosis in a 67-Year-Old Woman. Neurology 2023; 101:e1646-e1651. [PMID: 37527939 PMCID: PMC10585670 DOI: 10.1212/wnl.0000000000207676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/06/2023] [Indexed: 08/03/2023] Open
Abstract
Diplopia is a relatively common chief complaint encountered in an outpatient neurology clinic and carries a broad differential diagnosis. In this case, a 67-year-old woman presented with new horizontal, binocular diplopia and ptosis of 8-month duration, which persisted without significant progression. This case highlights the need for a comprehensive list of differential diagnoses for patients with acquired ophthalmoplegia and ptosis. Key learning points include an illustration of the stepwise diagnostic approach to evaluate for common etiologies, the importance of interpreting test results in the appropriate clinical setting, and the significance of recognizing specific signs and symptoms in achieving the correct diagnosis.
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Affiliation(s)
- John Daniel Bireley
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Joshua Santucci
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Yuebing Li
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH
| | - Devon A Cohen
- From the Department of Neurology (J.D.B., J.S., Y.L.), Neurological Institute, and Department of Ophthalmology (D.A.C.), Cole Eye Institute, Cleveland Clinic, OH.
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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)
| | | | - Vivek Lal
- Department of Neurology, PGIMER, Chandigarh, India
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Paydar A, Jenner ZB, Simkins TJ, Chang YM, Hacein-Bey L, Ozturk A, Birkeland A, Assadsangabi R, Raslan O, Shadmani G, Apperson M, Ivanovic V. Autoimmune disease of head and neck, imaging, and clinical review. Neuroradiol J 2022; 35:545-562. [PMID: 35603923 PMCID: PMC9513912 DOI: 10.1177/19714009221100983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Autoimmune disease of the head and neck (H&N) could be primary or secondary to systemic diseases, medications, or malignancies. Immune-mediated diseases of the H&N are not common in daily practice of radiologists; the diagnosis is frequently delayed because of the non-specific initial presentation and lack of familiarity with some of the specific imaging and clinical features. In this review, we aim to provide a practical diagnostic approach based on the specific radiological findings for each disease. We hope that our review will help radiologists expand their understanding of the spectrum of the discussed disease entities, help them narrow the differential diagnosis, and avoid unnecessary tissue biopsy when appropriate based on the specific clinical scenarios.
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Affiliation(s)
| | - Zachary B Jenner
- University of California Davis
Medical Center, Sacramento, CA, USA
| | - Tyrell J Simkins
- Department of Neurology, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical
Center, Boston, MA, USA
| | | | - Arzu Ozturk
- Department of Medicine, UC Davis, Sacramento, CA, USA
| | | | - Reza Assadsangabi
- Department of Radiology, University of Southern
California, Los Angeles, CA, USA
| | - Osama Raslan
- Department of Radiology, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Ghazal Shadmani
- School of Medicine in Saint Louis, Washington University, St Louis, MO, USA
| | - Michelle Apperson
- Department of Neurology, University of California Davis
Medical Center, Sacramento, CA, USA
| | - Vladimir Ivanovic
- Department of Radiology, Medical College of
Wisconsin, Milwaukee, WI, USA
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Romano N, Urru A, Sasso R, Castaldi A. Imaging of superior ophthalmic vein: A pictorial overview. Clin Imaging 2022; 89:136-146. [DOI: 10.1016/j.clinimag.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 06/20/2022] [Accepted: 06/28/2022] [Indexed: 11/03/2022]
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Seo YH, Lee JH, Oh SY. Tolosa-Hunt Syndrome with Multiple Orbital Myositis in a Patient with Crohn’s Disease. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2022. [DOI: 10.3341/jkos.2022.63.5.495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Purpose: We report a case of Tolosa-Hunt syndrome with multiple orbital myositis identified via orbital magnetic resonance imaging in a patient with Crohn's disease who developed right eye pain and binocular horizontal diplopia.Case summary: A 46-year-old woman visited our clinic with a 2-month history of right eye pain and migraine, as well as a 3-day history of acute horizontal diplopia. She had previously been diagnosed with Crohn's disease and was taking immunosuppressive drugs. In the eye movement test, esotropia and an abduction limitation of -3.0 in the right eye were observed on the Krimsky test. There were no specific findings in anterior segment and fundus examinations. Orbital magnetic resonance imaging showed multiple extraocular muscle enhancement in the right eye and multiple extraocular muscle hypertrophy in the left eye. The patient was diagnosed with binocular multiple orbital myositis and right Tolosa-Hunt syndrome; she was treated with high-dose steroids for 3 days followed by lower dose oral medications. During the first week of treatment, the right eye pain disappeared and the right eye abduction limitation showed slight improvement. After 3 months of treatment, the right eye abduction limitation and esotropia completely disappeared.Conclusions: Orbital myositis and Tolosa-Hunt syndrome are idiopathic, nonspecific chronic granulomatous diseases with painful ophthalmoplegia. We describe a rare case in which the two diseases appear together.
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Van Bogaert C, Mathey C, Vierasu I, Trotta N, Rocq L, Wolfromm A, De Wilde V, Goldman S. Painful ophthalmoplegia in a patient with a history of marginal zone lymphoma. Eur J Hybrid Imaging 2021; 5:18. [PMID: 34617167 PMCID: PMC8494508 DOI: 10.1186/s41824-021-00113-2] [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: 08/05/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
A 73-year-old man with a history of marginal zone lymphoma was admitted to the emergency room for diplopia and ipsilateral headache. The Fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) demonstrated intense and symmetrical hypermetabolism of the cavernous sinuses, and hypermetabolic lesions diffusely in the lymph nodes and bones. The diagnosis of high-grade relapse of lymphomatous disease was made. In this context, the homogenous and symmetric lesion of the cavernous sinuses, without any other encephalic or meningeal lesions, raised the hypothesis of a paraneoplastic origin. A plausible paraneoplastic link between the neuro-ophthalmological lesion and the malignant disorder is IgG4-related disease, a condition that may be associated with lymphoma. As in our case, this diagnosis is often presumptive because histopathological confirmation is difficult to obtain.
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Affiliation(s)
- C Van Bogaert
- Department of Nuclear Medicine, CUB-Hôpital Erasme, Anderlecht, Belgium.
| | - C Mathey
- Department of Nuclear Medicine, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - I Vierasu
- Department of Nuclear Medicine, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - N Trotta
- Department of Nuclear Medicine, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - L Rocq
- Department of anatomopatholgy, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - A Wolfromm
- Department of haematology, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - V De Wilde
- Department of haematology, CUB-Hôpital Erasme, Anderlecht, Belgium
| | - S Goldman
- Department of Nuclear Medicine, CUB-Hôpital Erasme, Anderlecht, Belgium
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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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Kim H, Oh SY. The clinical features and outcomes of Tolosa-Hunt syndrome. BMC Ophthalmol 2021; 21:237. [PMID: 34044807 PMCID: PMC8161661 DOI: 10.1186/s12886-021-02007-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 05/20/2021] [Indexed: 01/03/2023] Open
Abstract
Background The objective of this study was to investigate the clinical features and outcomes of Tolosa-Hunt syndrome (THS). Methods A retrospective review of the medical records was performed on patients with THS between March 2016 and January 2020. A total of eleven patients fulfilling the International Classification of Headache Disorders (ICHD-3 beta) diagnostic criteria for THS were included in this study. Results The average age of the patients with THS was 57.18 ± 15.32 years and the mean duration of recovery was 26.91 ± 24.35 days. All eleven patients had orbital or periorbital pain as the first symptom followed by diplopia. Ptosis was found in five patients (45.45 %) in the involved eye. Sixth cranial nerve (CN) palsy was most common (eight cases, 72.73 %), followed by third and fourth CN palsy (five cases, 45.45 %, respectively), optic neuritis (two cases, 18.18 %), and trigeminal nerve and facial nerve palsy (one case, 9.09 %, respectively). One patient with optic neuritis failed to recover visual acuity and the other ten patients completely recovered their ocular motor limitation. All patients were initially treated with steroids. One patient relapsed after five weeks and one patient had a history of THS five years earlier. Conclusions THS responded well to steroid treatment, but if it was accompanied by optic neuritis as optic nerve involvement, we suggest follow-up with high dose steroid treatment especially was important.
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Affiliation(s)
- Hyuna Kim
- Department of Ophthalmology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Shin Yeop Oh
- Department of Ophthalmology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158, Paryong-ro, Masanhoewon-gu, 51353, Changwon, Korea.
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Weidauer S, Hofmann C, Wagner M, Hattingen E. Neuroradiological and clinical features in ophthalmoplegia. Neuroradiology 2019; 61:365-387. [PMID: 30747268 DOI: 10.1007/s00234-019-02183-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 02/04/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Especially in acute onset of ophthalmoplegia, efficient neuroradiological evaluation is necessary to assist differential diagnosis, clinical course, and treatment options. METHODS Different manifestations of ophthalmoplegia are explained and illustrated by characteristic neuroradiological and clinical findings. RESULTS To present those ophthalmoplegic disorders in a clear manner, this review refers to different neuroanatomical structures and compartments. From neuroophthalmological point of view, diseases going ahead with ophthalmoplegia can be divided into (1) efferent infranuclear/peripheral disturbances involving oculomotor cranial nerves, (2) conjugate gaze abnormalities due to internuclear or supranuclear lesions, and (3) diseases of the extraocular eye muscles or their impairment due to intraorbital pathologies. CONCLUSION The knowledge of the relationship between neurological findings in ophthalmoplegia and involved neuroanatomical structures is crucial, and neuroradiology can be focused on circumscribed anatomical regions, using optimized investigation protocols.
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Affiliation(s)
- Stefan Weidauer
- Department of Neurology, Sankt Katharinen Hospital, Teaching Hospital of the Goethe University, Seckbacher Landstraße 65, 60389, Frankfurt am Main, Germany.
| | - Christian Hofmann
- Department of Ophthalmology, Neuroophthalmology, Goethe University, Frankfurt am Main, Germany
| | - Marlies Wagner
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe University, Frankfurt am Main, Germany
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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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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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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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Cavernous Sinus: A Comprehensive Review of its Anatomy, Pathologic Conditions, and Imaging Features. Clin Neuroradiol 2014; 25:109-25. [PMID: 25410584 DOI: 10.1007/s00062-014-0360-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/07/2014] [Indexed: 10/24/2022]
Abstract
The purpose of this article was to review the anatomy of the cavernous sinus (CS), illustrate numerous lesions that can affect the CS, and emphasize the imaging characteristics for each lesion to further refine the differential diagnoses. The CS, notwithstanding its small size, contains a complicated and crucial network that consists of the carotid artery, the venous plexus, and cranial nerves. The wide-ranging types of pathologies that can involve the CS can be roughly classified as tumoral, congenital, infectious/inflammatory/granulomatous, and vascular. Conditions that affect the CS usually lead to symptoms that are similar to each other; thus, for diagnosis, imaging procedures are required. Radiological evaluations are also required to detect pre- and postoperative CS invasion. Magnetic resonance imaging, which can be supplemented with thin-section contrast-enhanced sequences, is the preferred imaging technique for evaluating the CS. For correct diagnosis of CS lesions and accurate evaluations of CS invasions, it is essential to carefully analyze the anatomical structures within the CS and to acquire precise knowledge about the imaging features of CS lesions, which may frequently overlap.
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Hittinger M, Berlis A, Pfadenhauer K. Inflammatory Pseudo-tumour Orbitae (PTO): An Atypical Manifestation of Giant Cell Arteritis (GCA). Clin Neuroradiol 2014; 25:411-4. [PMID: 25231428 DOI: 10.1007/s00062-014-0346-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 09/04/2014] [Indexed: 11/28/2022]
Affiliation(s)
- M Hittinger
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Augsburg Hospital, Stenglinstraße 2, 86156, Augsburg, Germany.
| | - A Berlis
- Department of Diagnostic and Interventional Radiology and Neuroradiology, Augsburg Hospital, Stenglinstraße 2, 86156, Augsburg, Germany
| | - K Pfadenhauer
- Department of Neurology, Augsburg Hospital, Stenglinstraße 2, 86156, Augsburg, Germany
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DeLange JM, Robertson CE, Krecke KN, Garza I. A case report of hemicrania continua-like headache due to ipsilateral inflammatory orbital pseudotumor. Headache 2014; 54:1541-2. [PMID: 25168202 DOI: 10.1111/head.12440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2014] [Indexed: 11/27/2022]
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Abstract
BACKGROUND We are reporting a rare case of a 60-year-old woman with a past history of end-stage renal disease and non-Hodgkin lymphoma who presented to our hospital with confusion, unilateral headache, painful ophthalmoplegia and ptosis. The patient was diagnosed clinically with Tolosa-Hunt syndrome (THS). RESULTS THS is a diagnosis of exclusion. Other diseases were ruled out. Magnetic resonance imaging (MRI) of the brain and orbit was negative twice within a week. The patient was treated with corticosteroids with marked improvement of the orbital pain and headache and mild improvement of the cranial nerves palsy. CONCLUSION Clinical diagnosis of THS could be supported by radiological findings. According to the International Classification of Headache Disorders (ICHD)-3 beta diagnostic criteria, the diagnosis must be confirmed with an abnormal MRI and/or pathological sample. We add to the previous findings of THS with a normal MRI. Although MRI plays a crucial role in differential diagnosis, it should not, nor should the biopsy, be a must for the diagnosis. Limitations of using MRI in some patients are another problem.
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Affiliation(s)
| | - Daniel Orozco
- Department of Neurology, Conemaugh Memorial Medical Center, PA, USA
| | - William Fink
- Department of Medicine, Conemaugh Memorial Medical Center, PA, USA
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Taylor EJ, Anders UM, Martel JR, Martel JB. Tolosa-Hunt syndrome masquerading as a carotid artery dissection. Clin Ophthalmol 2014; 8:707-10. [PMID: 24741291 PMCID: PMC3984061 DOI: 10.2147/opth.s62787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose To demonstrate the difficulties of diagnosing a patient with Tolosa-Hunt syndrome (THS) due to its complicated presentation and extensive diagnostic testing, and how to manage the treatment of a patient in an emergent setting. Patients and methods A female patient with THS affecting the left eye was examined using two magnetic resonance imaging (MRI) scans. The patient was treated with high-dose methylprednisolone (Solu-Medrol®) and prednisone. A follow-up MRI and magnetic resonance angiogram (MRA) was also performed 4 months later. Results The second MRI scan disclosed a 5×9×10 mm lesion in the left superior orbital fissure/cavernous sinus. After administration of methylprednisolone and prednisone, the patient’s pain completely resolved, and the left eye regained full duction and eyelid mobility. The MRI and MRA obtained after the treatment showed no abnormalities. Conclusion The rarity of THS makes it difficult to diagnose, especially when there is a question of accuracy and reproducibility of the testing performed. An ophthalmologic consultation in such cases is crucial.
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Affiliation(s)
- Elise J Taylor
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA
| | - Ursula M Anders
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA
| | - Joseph R Martel
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA ; Graduate Medical Education, California Northstate University College of Medicine, Elk Grove, CA, USA ; Department of Ophthalmology, Sutter Medical Health, Sacramento, CA, USA ; Department of Ophthalmology, Dignity Health, Carmichael, CA, USA
| | - James B Martel
- Research Center, Martel Eye Medical Group, Rancho Cordova, CA, USA ; Graduate Medical Education, California Northstate University College of Medicine, Elk Grove, CA, USA ; Department of Ophthalmology, Sutter Medical Health, Sacramento, CA, USA ; Department of Ophthalmology, Dignity Health, Carmichael, CA, USA
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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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19
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Abstract
AbstractThe spectrum of orbital inflammatory diseases ranges broadly from specific diseases as connective tissue disorders, thyroid ophthalmopathy to non-specific inflammations, which may involve one or multiple structures of the orbit and/ or the surrounding sinus. Idiopathic orbital myositis (IOM) may be a localized process or it can be secondary to systemic diseases. We report 4 patients affected by IOM; in all relapsing diplopia was the main complaint, associated with orbital pain in 3 and with abnormal visual evoked responses in 2. Computed tomography (CT), magnetic resonance imaging (MRI) supported the diagnosis revealing enlargement, altered signal intensity of affected muscles. Repeated MRI scans and extensive laboratory examinations comprising of the search for a remote malignacy, lymproliferative, connective tissue diseases, thyroid ophthalmopathy were necessary to confirm the diagnosis. Oral or/and intravenous steroids were main treatments; relapses often occurred when steroid was tapered down. Intravenous immuneglobulins and azathioprine was used in one refractory case
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20
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Hung CH, Chang KH, Wu YM, Chen YL, Lyu RK, Chang HS, Wu YR, Chen CM, Huang CC, Chu CC, Liao MF, Wai YY, Hsu SP, Ro LS. A comparison of benign and inflammatory manifestations of Tolosa-Hunt syndrome. Cephalalgia 2013; 33:842-52. [PMID: 23475292 DOI: 10.1177/0333102412475238] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Tolosa-Hunt syndrome (THS) manifests as a benign or an inflammatory type disease. The nosography differences between these types remain to be elucidated. We aimed to analyze and compare the clinical presentations of benign and inflammatory THS. METHODS The ward patients who presented with THS from January 1990 to May 2011 were retrospectively reviewed. THS was diagnosed according to the recommendations of the International Headache Society. RESULTS Of the 53 THS cases (49 patients), 30 (56.6%) were classified as benign and 23 (43.4%) as inflammatory THS. There were strong similarities between the groups in terms of clinical manifestations, laboratory findings, responses to glucocorticoid treatment, and outcomes. However, patients with inflammatory THS tended to be younger (mean age, 43.4 years; P 0.05) and have optic nerve dysfunction (56.5%; P 0.05) and longer disease duration (2.3 ± 1.0 months; P 0.05) compared to those with benign THS (mean age, 56.4 years; mean disease duration, 1.6 ± 0.7 months). The patients with additional involvement of both the optic nerve and the second division of the trigeminal nerve experienced a longer disease duration ( P 0.05). Additionally, patients with orbital pseudotumors had diplopia that responded poorly to treatment with glucocorticoids ( P 0.05). High-dose (>0.5 mg/kg/day) and low-dose (≤0.5 mg/kg/day) prednisolone were equally effective in relieving symptoms in both groups ( P > 0.05). CONCLUSION Benign and inflammatory THS were highly similar in terms of nosography. The responses to glucocorticoid treatment were generally good except in patients with orbital pseudotumors.
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Affiliation(s)
- Chih-Hsien Hung
- Department of Neurology, E-Da Hospital, I-Shou University, Taiwan
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21
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Atypical clinical presentation of isolated extraocular muscle sarcoid. Case Rep Ophthalmol Med 2013; 2012:370258. [PMID: 23320221 PMCID: PMC3540650 DOI: 10.1155/2012/370258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 12/14/2012] [Indexed: 11/18/2022] Open
Abstract
A case of painless isolated extraocular muscle sarcoid and a literature review are presented. The atypical features in our case include a lack of overt inflammatory symptoms and signs, such as pain, ptosis, and diplopia. The presentation of minimal symptoms without improvement warrant a biopsy to establish the diagnosis and to administer appropriate treatment in order to prevent potential long-term complications from sarcoidosis.
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22
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Caldas AR, Brandao M, Paula FS, Castro E, Farinha F, Marinho A. Hypertrophic cranial pachymeningitis and skull base osteomyelitis by pseudomonas aeruginosa: case report and review of the literature. J Clin Med Res 2012; 4:138-44. [PMID: 22505989 PMCID: PMC3320125 DOI: 10.4021/jocmr777w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2011] [Indexed: 11/29/2022] Open
Abstract
Hypertrophic cranial pachymeningitis (HCP) is an uncommon disorder characterized by localized or diffuse thickening of the dura mater, and it usually presents with multiple cranial neurophaties. It has been associated with a variety of inflammatory, infectious, traumatic, toxic and neoplasic diseases, when no specific cause is found the process is called idiopathic. The infectious cases occur in patients under systemic immunosuppression, which have an evident contiguous source or those who have undergone neurosurgical procedures. We describe a case of a 62-year-old immunosuppressed woman with diabetes and rheumatoid arthritis, which had HCP and osteomyelitis of the skull base caused by pseudomonas aeruginosa, presenting with headache and diplopia. We believe this is the second documented case of pachymeningitis secondary to this microorganism. As a multifactorial disease, it is essencial to determine the specific causative agent of HCP before making treatment decisions, and great care is needed with immunocompromised patients.
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Affiliation(s)
- Ana Rita Caldas
- Medicine Department, Santo Antonios' Hospital, Largo Prof. Abel Salazar, 4099-001 Porto, Portugal
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23
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Bilateral idiopathic orbital inflammatory syndrome with grossly elevated creatinine kinase levels. Eye (Lond) 2011; 26:613-4. [PMID: 22193876 DOI: 10.1038/eye.2011.341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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24
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Turkoglu R, Balak N. Atypical presentation of orbital pseudotumor with visual loss as an initial manifestation. J Clin Neurol 2011; 7:50-2. [PMID: 21519529 PMCID: PMC3079162 DOI: 10.3988/jcn.2011.7.1.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2010] [Revised: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND An orbital pseudotumor typically presents with periorbital pain, cranial nerve palsies and proptosis. Although visual deterioration is not unexpected in this pathology, its presentation solely with visual loss is unusual. CASE REPORT In this short report, we summarize a case of orbital pseudotumor which presented solely with a decrease in visual acuity, and discuss the clinical and radiological findings. CONCLUSIONS This atypical presentation likely resulted from the orbital pseudotumor originating in the optic foramen, leaving the neurovascular structures of the superior orbital fissure untouched initially. In the early clinical period, an orbital pseudotumor may manifest itself solely by visual loss. It should therefore be included in the differential diagnosis of visual pathologies-even in the absence of orbital pain and symptoms related to ocular movements.
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Affiliation(s)
- Recai Turkoglu
- Department of Neurology, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey
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25
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AJR teaching file: Cavernous sinus mass in a woman presenting with painful ophthalmoplegia. AJR Am J Roentgenol 2010; 195:WS1-4. [PMID: 20729414 DOI: 10.2214/ajr.09.7199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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26
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Cheng CC, Tsou YA, Lin MH, Tseng GC, Tai CJ, Tsai MH. Metastasis of Breast Cancer to the Sphenoid Sinus Presenting as Tolosa-Hunt Syndrome. Tzu Chi Med J 2010. [DOI: 10.1016/s1016-3190(10)60062-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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27
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Vohra ST, Escott EJ, Stevens D, Branstetter BF. Categorization and characterization of lesions of the orbital apex. Neuroradiology 2010; 53:89-107. [DOI: 10.1007/s00234-010-0712-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Accepted: 04/21/2010] [Indexed: 11/30/2022]
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28
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Hoang J, Eastwood J, Glastonbury C. What's in a name? Eponyms in head and neck imaging. Clin Radiol 2010; 65:237-45. [DOI: 10.1016/j.crad.2009.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/28/2009] [Accepted: 10/06/2009] [Indexed: 11/30/2022]
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29
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Lee HK, Lee SG. Clinical Observations on Tolosa-Hunt Syndrome. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2009. [DOI: 10.3341/jkos.2009.50.11.1717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Han Kee Lee
- Department of Ophthalmology, College of Medicine, Inje University, Busan, Korea
- Department of Ophthalmology, Research Foundation, Inje University, Busan, Korea
| | - Sul Gee Lee
- Department of Ophthalmology, College of Medicine, Inje University, Busan, Korea
- Department of Ophthalmology, Research Foundation, Inje University, Busan, Korea
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30
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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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31
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Lutt JR, Lim LL, Phal PM, Rosenbaum JT. Orbital Inflammatory Disease. Semin Arthritis Rheum 2008; 37:207-22. [PMID: 17765951 DOI: 10.1016/j.semarthrit.2007.06.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 06/05/2007] [Accepted: 06/17/2007] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To familiarize rheumatologists and internists with the signs, symptoms, and management of orbital inflammatory disease (OID). METHODS A comprehensive literature review related to OID was performed and reported from the perspectives of rheumatology, ophthalmology, and radiology. RESULTS OID is a general term encompassing inflammatory diseases that affect some or all of the structures contained within the orbit external to the globe. Orbital involvement as a part of the initial symptom complex is not uncommon for systemic diseases such as Graves' disease, Wegener's granulomatosis, and sarcoidosis. The management of these and other causes of OID, such as idiopathic orbital inflammation (formerly known as "orbital pseudotumor"), orbital myositis, and Tolosa-Hunt syndrome frequently involves systemic immunosuppression. Before immunosuppression is considered, however, infectious and malignant causes of inflammation must be ruled out. DISCUSSION Rheumatologists should be familiar with the differential diagnosis of OID and often need to assist colleagues in ophthalmology and internal medicine with the management of this group of diseases.
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Affiliation(s)
- Joseph R Lutt
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA.
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32
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Schuknecht B, Sturm V, Huisman TAGM, Landau K. Tolosa-Hunt syndrome: MR imaging features in 15 patients with 20 episodes of painful ophthalmoplegia. Eur J Radiol 2007; 69:445-53. [PMID: 18166288 DOI: 10.1016/j.ejrad.2007.11.034] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 11/15/2007] [Accepted: 11/20/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE (a) To assess MR features in patients with Tolosa-Hunt syndrome (THS) and to (b) correlate MR findings with criteria derived from previously reported pathologic observations. METHODS Fifteen patients with twenty episodes of painful ophthalmoplegia prospectively selected according to International Headache Society (IHS) standards underwent MR examinations focused on the cavernous sinus. Initial examinations in 20 and follow-up MR images in 17 episodes were retrospectively reviewed by 3 independent observers. RESULTS The primary criteria: an enhancing soft tissue lesion within the cavernous sinus, increase in size and lateral bulging of the anterior cavernous sinus contour were consistently present in 15 initial episodes and in 5 recurrences (20/20). Agreement among observers was 100%. The secondary criteria: internal carotid artery narrowing in 7 patients, extension towards the superior orbital fissure in 13 and orbital apex involvement in 8 patients were unanimously agreed upon in 87.5%, 86.6% and 80%. Complete resolution of findings was observed on follow-up studies. CONCLUSION In patients with THS the MR features conform to previously reported pathologic findings. MR features are evocative of THS when an increase in size and bulging of the dural contour of the anterior CS supplemented by carotid artery involvement and extension towards the orbit are present. Resolution of findings within 6 months is required to support the diagnosis.
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Affiliation(s)
- B Schuknecht
- MRI Medical Radiological Institute Zurich, Switzerland.
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33
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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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34
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Abstract
The spectrum of orbital inflammatory disease (OID) ranges broadly from specific disease diagnoses, for example, Wegener's granulomatosis or sarcoidosis, to nonspecific inflammation which may involve one or multiple structures of the orbit. Mimics of idiopathic OID must be considered in a comprehensive differential diagnosis and include malignancies, congenital mass lesions, infectious diseases, and occult or distant trauma. Idiopathic OID may be secondary to an underlying systemic inflammatory disease, which must be diagnosed in order to develop a comprehensive therapeutic plan, or may represent localized pathologic processes without systemic involvement. Evaluation of the patient with suspected OID must include a careful history, physical examination, directed laboratory, and radiologic studies, and may sometimes require tissue for diagnostic studies. Therapeutic options for inflammatory diseases are expanding as biologically targeted agents become available that act on specific segments of the inflammatory cascades. The purpose of this paper is to provide a framework for the evaluation and management of patients with the spectrum of diseases known as OID and to discuss some of the new advances in immunologic monitoring and targeted immune therapies that will likely play an increasingly important role in the care of these patients.
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Affiliation(s)
- L K Gordon
- Jules Stein Eye Institute, University of California at Los Angeles and Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, CA, USA.
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35
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Abstract
Differential diagnosis of pain in the face as the presenting complaint can be difficult. We propose an approach based on history and neurological examination, which allows a working diagnosis to be made at the bedside, including aetiological hypotheses, leading to a choice of investigations. Neuralgias are characterised by stabs of short lasting, lancinating pain, and, although neuralgias are often primary, imaging may be needed to exclude symptomatic forms. Facial pain with cranial nerve symptoms and signs is almost exclusively of secondary origin and requires urgent examination. Facial pain with focal autonomic signs is mostly primary and belongs to the group of the idiopathic trigeminal autonomic cephalalgias, but can occasionally be secondary. Pure facial pain is most often due to sinusitis and the chewing apparatus, but also a multitude of other causes. The pain can also be idiopathic. Imaging as well as non-neurological specialist assessment is often necessary in these cases.
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Affiliation(s)
- Massimiliano M Siccoli
- Neurology Department, University Hospital, Frauenklinikstrasse 26, 8091 Zurich, Switzerland
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36
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Lemke AJ, Kazi I, Felix R. Magnetic resonance imaging of orbital tumors. Eur Radiol 2006; 16:2207-19. [PMID: 16583212 DOI: 10.1007/s00330-006-0227-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2005] [Revised: 01/05/2006] [Accepted: 02/23/2006] [Indexed: 11/30/2022]
Abstract
This contribution provides an overview of diseases of eye and orbit and their appearance on magnetic resonance imaging. In recent years the diagnosis of eye and orbit pathology has profited significantly from increasingly sophisticated technical developments in the field of tomographic methods. Due to the small size of the examination area the improvement in spatial resolution and soft tissue contrast leads to an increase in image quality. In most clinical questions concerning eye and orbit pathologies magnetic resonance imaging is superior to computed tomography and should be early performed.
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Affiliation(s)
- A J Lemke
- Campus Virchow-Klinikum, Klinik für Strahlenheilkunde, Charité, Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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37
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McCall T, Fassett DR, Lyons G, Couldwell WT. Inflammatory pseudotumor of the cavernous sinus and skull base. Neurosurg Rev 2006; 29:194-200. [PMID: 16565875 DOI: 10.1007/s10143-006-0017-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2005] [Revised: 11/02/2005] [Accepted: 11/04/2005] [Indexed: 11/29/2022]
Abstract
Inflammatory pseudotumor is a non-neoplastic process of unknown etiology characterized by a proliferation of connective tissue with an inflammatory infiltrate. Intracranial inflammatory pseudotumors classically involve the cavernous sinus but can also occur in the supratentorial or infratentorial compartments and spinal canal. Symptoms are dependent on location, and, when present in the cavernous sinus, typically include cranial nerve palsies of those nerves in the cavernous sinus. These lesions are rapidly responsive to steroid therapy. Surgery is typically indicated for biopsy only, but complete resection may be justified for lesions outside the cavernous sinus.
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Affiliation(s)
- Todd McCall
- Department of Neurosurgery, University of Utah, 30 North 1900 East, Suite 3B409, Salt Lake City, UT, 84132, USA
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38
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Abstract
Painful ophthalmoplegias have numerous etiologies and are often the presenting sign of a severe disease. Anatomic localization of the lesion is essential in interpreting neuroimaging.
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Affiliation(s)
- V Biousse
- Neuro-Ophthalmology Unit, Emory Eye Center, Atlanta, GA 30322, USA.
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39
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Foubert-Samier A, Sibon I, Maire JP, Tison F. Long-term cure of Tolosa-Hunt syndrome after low-dose focal radiotherapy. Headache 2005; 45:389-91. [PMID: 15836581 DOI: 10.1111/j.1526-4610.2005.05077_5.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Tolosa-Hunt syndrome (THS) is a rare cause of painful ophtalmoplegia due to chronic granulomatous inflammation of the cavernous sinus. While corticoids are the treatment of reference, corticodependence and corticoresistance are frequent, hence radiotherapy has been proposed as an alternative treatment. We report a case of long-term improvement (8 years) of THS after low-dose (20 Gy) radiotherapy in a patient with recurrences and corticodependence.
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40
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Muthukumar N, Senthilbabu S, Usharani K. Idiopathic hypertrophic cranial pachymeningitis masquerading as Tolosa-Hunt syndrome. J Clin Neurosci 2005; 12:589-92. [PMID: 16051099 DOI: 10.1016/j.jocn.2004.08.016] [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] [Received: 09/27/2003] [Accepted: 08/05/2004] [Indexed: 10/25/2022]
Abstract
Idiopathic hypertrophic cranial pachymeningitis is a rare condition. A case of idiopathic hypertrophic cranial pachymeningitis presenting as Tolosa-Hunt syndrome is being reported. The importance of neuroimaging in patients with suspected Tolosa-Hunt syndrome is discussed. Tolosa-Hunt syndrome might represent a focal manifestation of Idiopathic hypertrophic cranial pachymeningitis. Future studies are necessary to further clarify the relationship between these two conditions.
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Affiliation(s)
- N Muthukumar
- Department of Neurosurgery, Madurai Medical College, Madurai, India.
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41
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Mandrioli J, Frank G, Sola P, Leone ME, Guaraldi G, Guaraldi P, Collina G, Roncaroli F, Cortelli P. Tolosa-Hunt syndrome due to actinomycosis of the cavernous sinus: the infectious hypothesis revisited. Headache 2004; 44:806-11. [PMID: 15330828 DOI: 10.1111/j.1526-4610.2004.04149.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Tolosa-Hunt syndrome is characterized by ophthalmoplegia with unilateral severe retro-orbital pain associated to a granulomatous inflammatory process occupying the cavernous sinus or the superior orbital fissure. The etiology is unknown and diagnosis is based upon a clinical response to steroid treatment and exclusion of neoplasm, trauma, aneurysms, infectious, and inflammatory diseases. CASE DESCRIPTION A 43-year-old man was admitted because of a 1-week history of acute onset left-sided retro-orbital pain, followed by left sixth cranial nerve palsy. Magnetic resonance imaging was normal and Tolosa-Hunt syndrome was suspected. Steroid treatment controlled pain with recovery of ophthalmoplegia. Four months later, when a good response to treatment was still present, brain magnetic resonance imaging revealed a lesion enlarging the left cavernous sinus, isointense with the gray matter on T1-weighted sequences, hypointense on T2-weighted images, and with homogeneous enhancement after gadolinium injection. Two months later, ocular pain and sixth cranial nerve palsy recurred and new brain magnetic resonance imaging showed an extension of the tissue occupying the left cavernous sinus, over the sella, to the right cavernous sinus, making possible an endoscopic transphenoidal biopsy. RESULTS Histopathological study revealed a granulomatous aspecific inflammation containing actinomycetes colonies. The patient was treated with intravenous penicillin G followed by amoxicillin per os, with improvement of pain and ophthalmoplegia. A control magnetic resonance imaging 1 month after therapy showed a consistent reduction of the enlarged cavernous sinus, and 3 months later neurological examination and brain magnetic resonance imaging were completely normal. CONCLUSIONS The present case suggests that the International Classification of Headache Disorders (2nd edition) definition of Tolosa-Hunt syndrome does not reflect the complexity of the syndrome and that some cases of secondary painful ophthalmoplegias can fit the criteria for the primary form. Since the biopsy can only rarely be performed, we agree with other authors that clinical and radiological follow-up should be performed for at least 2 years. Moreover, we propose that in patients with painful ophthalmoplegia having transient response to steroid therapy, a trial with antibiotic therapy should be taken into account.
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Affiliation(s)
- Jessica Mandrioli
- Department of Neuroscience, University of Modena and Reggio Emilia, Italy
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42
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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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43
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Gladstone JP, Dodick DW. Painful ophthalmoplegia: Overview with a focus on tolosa-hunt syndrome. Curr Pain Headache Rep 2004; 8:321-9. [PMID: 15228894 DOI: 10.1007/s11916-004-0016-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Painful ophthalmoplegia is an important presenting complaint to emergency departments, ophthalmologists, and neurologists. The etiological differential diagnosis of painful ophthalmoplegia is extensive and consists of numerous sinister etiologies including vascular (eg, aneurysm, carotid dissection, carotid-cavernous fistula), neoplasms (eg, primary intracranial tumors, local or distant metastases), inflammatory conditions (eg, orbital pseudotumor, sarcoidosis, Tolosa-Hunt syndrome), infectious etiologies (eg, fungal, mycobacterial), and other conditions (eg, microvascular infarcts secondary to diabetes, ophthalmoplegic migraine, giant cell arteritis). A systematic approach to the evaluation of painful ophthalmoplegia can lead to prompt recognition of serious disorders that if left untreated, can be associated with significant morbidity or mortality. 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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Affiliation(s)
- Jonathan P Gladstone
- Department of Neurology, Mayo Clinic Scottsdale, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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Abstract
Orbital inflammation is a common problem in adults and children, accounting for the majority of all orbital processes. The presentation may be acute, subacute, or insidious. When the onset is acute, the process can be mistaken for orbital cellulitis. In insidious cases, such as the sclerosing subtype of inflammation, the chronic painless course may prompt concerns about a neoplastic infiltration such as lymphoma. Orbital inflammation can be divided into nonspecific, idiopathic, and other specific diagnoses. The differential diagnosis includes allergic, infectious (fungal, mycobacterial, and parasitic), and neoplastic (lymphoma or metastatic) disease. Orbital inflammation impacts neurologists and neuro-ophthalmologists because all of the entities can cause afferent dysfunction (decreased vision, abnormal color perception, afferent pupillary defect, and visual field defect) and dysmotility. The pattern of motility deficit may mimic the more familiar cranial nerve palsies. Advances in the diagnosis and management of nonspecific orbital inflammation and the specific entities that cause orbital inflammation are discussed.
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Affiliation(s)
- Kimberly P Cockerham
- Neuro-ophthalmology, Orbital Disease and Plastic Reconstruction, Allegheny General Hospital, 420 East North Avenue, Suite 116, Pittsburgh, PA 15212, USA.
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