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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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Zhang N, Shao C, Pan Y, Xiong G, Wang J, Liu Z, Chen B. Multiple Spontaneous Visceral Arterial Dissections in a Patient With Tolosa-Hunt Syndrome on Corticosteroid Therapy. Ann Vasc Surg 2021; 74:523.e1-523.e7. [PMID: 33838239 DOI: 10.1016/j.avsg.2021.01.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/17/2021] [Accepted: 01/28/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Naiding Zhang
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changming Shao
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yifeng Pan
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Guiya Xiong
- Department of Science and Research, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jian Wang
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhenjie Liu
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Bing Chen
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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Ravindran K, Schmalz P, Torun N, Ronthal M, Chang YM, Thomas AJ. Angiographic Findings in the Tolosa-Hunt Syndrome and Resolution after Corticosteroid Treatment. Neuroophthalmology 2018; 42:159-163. [PMID: 29796050 DOI: 10.1080/01658107.2017.1365268] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/04/2017] [Accepted: 08/05/2017] [Indexed: 01/03/2023] Open
Abstract
The Tolosa-Hunt syndrome is a rare clinical condition characterized by painful opthalmoparesis associated with idiopathic granulomatous inflammation of the orbital apex and cavernous sinus. Historically, this condition was thought to result from arteritic changes in the internal carotid artery and cavernous sinus. Modern digital angiographic techniques were unavailable when THS was initially described, and few reports exist on its high-resolution angiographic findings. Painful ophthalmoparesis, especially of the oculomotor nerve, warrants vascular imaging because of the concern for an underlying aneurysm. Here, we describe angiographic findings of THS which may be useful for clinicians when encountering patients presenting with painful ophthalmoplegia.
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Affiliation(s)
| | - Philip Schmalz
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nurhan Torun
- Division of Ophthalmology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Ronthal
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Takasuna H, Sasaki R, Shiraishi M, Doi M, Wakui D, Ito H, Oshio K, Tanaka Y. Steroid-resistant Tolosa-Hunt syndrome with a de novo intracavernous aneurysm: A case report. Surg Neurol Int 2016; 7:S779-S784. [PMID: 27920936 PMCID: PMC5122815 DOI: 10.4103/2152-7806.193925] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/10/2016] [Indexed: 11/25/2022] Open
Abstract
Background: We report a case of steroid-resistant Tolosa–Hunt syndrome (THS) with recurrent bilateral painful ophthalmoplegia, accompanied with sphenoid sinusitis, pituitary abscess, and an aneurysm arising from the cavernous portion of the internal carotid artery. Case Description: A 53-year-old woman suffered severe left painful ophthalmoplegia. A magnetic resonance image (MRI) revealed thickness of the left cavernous sinus (CS). Steroid was administrated under the diagnosis of THS, and the symptom transiently diminished. However, painful ophthalmoplegia fluctuated bilaterally after tapering the steroid. An MRI showed development of bilateral cavernous lesions associated with sphenoid sinusitis, pituitary abscess, and an aneurysm in the left C4 segment. Biopsy and drainage of the lesions were performed with an endoscopic transsphenoidal procedure. The histological examination showed nonspecific granulomatous inflammation. The methotrexate (MTX) was effective to reduce the CS and pituitary lesions; however, the aneurysm slightly increased and remained unchanged in size thereafter. Conclusions: To our knowledge, this is the first report of a growing de novo C4 aneurysm in THS. Surgical intervention and administration of MTX should be attempted in steroid-resistant THS. Careful observation with serial MRI and MR angiography is important to manage the complicated THS.
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Affiliation(s)
- Hiroshi Takasuna
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Rie Sasaki
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Makoto Shiraishi
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masatomo Doi
- Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Daisuke Wakui
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kotaro Oshio
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuichiro Tanaka
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
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Ceylan ME, Evrensel A, Noyan CO, Dönmez A. Tolosa-Hunt syndrome and comorbidity of obsessive compulsive disorder and aortic aneurysm. BMJ Case Rep 2016; 2016:bcr-2016-216727. [PMID: 27872048 DOI: 10.1136/bcr-2016-216727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Alper Evrensel
- Department of Psychiatry, Üsküdar University, Istanbul, Turkey
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Shiode T, Oya S, Matsui T. A Case of the Internal Carotid Artery-Posterior Communicating Artery Aneurysm Mimicking Tolosa-Hunt Syndrome. NMC Case Rep J 2014; 2:1-3. [PMID: 28663952 PMCID: PMC5364924 DOI: 10.2176/nmccrj.2014-0125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/14/2014] [Indexed: 11/24/2022] Open
Abstract
A 53-year-old woman experienced a right retrobulbar pain followed by ipsilateral extraocular palsies in all directions without dilated pupils or ptosis. Because a plain head computed tomography (CT) scan obtained on her initial visit showed no abnormal findings, such as subarachnoid hemorrhage or a giant cavernous aneurysm, her condition was provisionally diagnosed as Tolosa–Hunt syndrome and elective magnetic resonance (MR) imaging was scheduled. The day after her initial visit, however, she suddenly developed complete ptosis and a dilated pupil on the right side. Emergency MR imaging and angiography revealed a clover leaf-shaped aneurysm projecting to the cavernous sinus at the junction of the internal carotid artery and the posterior communicating artery. Her condition was diagnosed as impending rupture of the aneurysm, and she underwent emergency open surgery. Her symptoms completely resolved within the following 2 weeks. Our case demonstrated that a medium-sized internal carotid artery–posterior communicating artery aneurysm can cause simultaneous oculomotor and abducens nerve palsies with retrobulbar pain if the shape of the aneurysm is complicated. Although these symptoms are very similar to those of Tolosa–Hunt syndrome, we believe that prompt radiological examinations such as MR or 3D CT angiography should be performed to prevent subsequent rupture of the aneurysm.
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Affiliation(s)
- Taketo Shiode
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama
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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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Conforti R, Cirillo M, Marrone V, Galasso R, Capaldo G, Giugliano T, Scuotto A, Piluso G, Melone MA. Giant thrombosed intracavernous carotid artery aneurysm presenting as Tolosa-Hunt syndrome in a patient harboring a new pathogenic neurofibromatosis type 1 mutation: a case report and review of the literature. Neuropsychiatr Dis Treat 2014; 10:135-40. [PMID: 24476631 PMCID: PMC3901779 DOI: 10.2147/ndt.s49784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Neurofibromatosis type 1 (NF1) is a relatively common single-gene disorder, and is caused by heterozygous mutations in the NF1 gene that result in a loss of activity or in a nonfunctional neurofibromin protein. Despite the common association of NF1 with neurocutaneous features, its pathology can extend to numerous tissues not derived from the neural crest. Among the rare cerebrovascular abnormalities in NF1, more than 85% of cases are of purely occlusive or stenotic nature, with intracranial aneurysm being uncommon. Predominantly, the aneurysms are located in the internal carotid arteries (ICAs), being very rare bilateral aneurysms. This report describes a very unusual case of fusiform aneurysms of both ICAs in a Caucasian NF1 patient, with a new pathogenic intragenic heterozygous deletion of the NF1 gene, presenting at age 22 years with Tolosa-Hunt syndrome, because of partial thrombosis of the left giant intracavernous aneurysm. Medical treatment with anticoagulant therapy allowed a good outcome for the patient. In conclusion, early identification of cerebral arteriopathy in NF1 and close follow-up of its progression by neuroimaging may lead to early medical or surgical intervention and prevention of significant neurologic complications.
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Affiliation(s)
- Renata Conforti
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Mario Cirillo
- Radiology Unit, Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences
| | - Valeria Marrone
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Rosario Galasso
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Guglielmo Capaldo
- Division of Neurology, Department of Clinical and Experimental Medicine and Surgery
| | - Teresa Giugliano
- Department of Biochemistry, Biophysics and General Pathology, School of Medicine, Second University of Naples, Naples, Italy
| | - Assunta Scuotto
- Neuroradiology Unit, Department of Clinical and Experimental Medicine and Surgery
| | - Giulio Piluso
- Department of Biochemistry, Biophysics and General Pathology, School of Medicine, Second University of Naples, Naples, Italy
| | - Mariarosa Ab Melone
- Division of Neurology, Department of Clinical and Experimental Medicine and Surgery ; Institute of Protein Biochemistry, National Research Council, Naples, Italy
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