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Yunqing W, Shilei C, Yong L, Qing L, Xiaohong S, Jiawei W. Cavernous Sinus MRI Findings in Inflammatory and Ischemic Oculomotor Cranial Nerve Palsies. J Neuroophthalmol 2024; 44:236-241. [PMID: 37751328 PMCID: PMC11081484 DOI: 10.1097/wno.0000000000001958] [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: 09/28/2023]
Abstract
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.
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Kmeid M, Medrea I. Review of Tolosa-Hunt Syndrome, Recent Updates. Curr Pain Headache Rep 2023; 27:843-849. [PMID: 38032539 DOI: 10.1007/s11916-023-01193-4] [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] [Accepted: 11/22/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE OF REVIEW We aim to present diagnostic considerations and management insights on Tolosa-Hunt syndrome. We highlight recent controversies in this field and emerging literature. RECENT FINDINGS The diagnostic categorization of Tolosa-Hunt syndrome remains controversial, with imaging negative cases described in the literature and an increasing literature of secondary causes falsely diagnosed as Tolosa-Hunt syndrome. Response to steroids can fulfill diagnostic criteria, but newer management strategies are available in treatment-resistant patients, such as steroid-sparing agents or radiotherapy. Tolosa-Hunt syndrome has become controversial; the entity of granulomatous inflammation of the cavernous sinus and possible extension into orbital fissure and posterior orbit of late has been re-evaluated. Recent case series and reviews have outlined multiple false positive (neoplasm or infection) and negative (no imaging findings) diagnoses. In the future, when assessing whether a patient has this entity, we caution readers to closely follow patients for secondary causes and consider this entity in differential even if MRI is non-revealing. Additionally, biopsy should be regarded as a gold standard for diagnosis and utilized, especially in uncertain cases. The diagnostic categorization of Tolosa-Hunt syndrome may need reconsideration in future versions of the ICHD.
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Affiliation(s)
- Michael Kmeid
- Division of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Ioana Medrea
- Division of Neurology, SUNY Upstate Medical University, Syracuse, NY, USA.
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He W, Zhu Y, Zhang Y, Dong L, Zhou Z, Zhou J. A case report on recurrent alternating Tolosa-Hunt syndrome due to bacterial sphenoid sinusitis: rediscussing the diagnostic terminology and classification. BMC Neurol 2023; 23:25. [PMID: 36650509 PMCID: PMC9843661 DOI: 10.1186/s12883-023-03067-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Wei He
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Yinglin Zhu
- grid.258405.e0000 0004 0539 5056School of Osteopathic Medicine, Kansas City University of Medicine and Biosciences, Joplin, MO 64801 USA
| | - Yinan Zhang
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Liang Dong
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1st You Yi Road, Yu Zhong District, Chongqing, 400016 China
| | - Zefang Zhou
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Branch of The First Affiliated Hospital of Chongqing Medical University, 191st Ren Min Road, Yu Zhong District, Chongqing, 400015 China
| | - Jiying Zhou
- grid.452206.70000 0004 1758 417XDepartment of Neurology, The First Affiliated Hospital of Chongqing Medical University, 1st You Yi Road, Yu Zhong District, Chongqing, 400016 China
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Ata F, Yousaf Z, Arachchige SNM, Rose S, Alshurafa A, Muthanna B, Bilal ABI, El Beltagi A, Zahid M. The demographics of Tolosa-Hunt syndrome in Qatar. eNeurologicalSci 2021; 24:100359. [DOI: https:/doi.org/10.1016/j.ensci.2021.100359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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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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Qu H, Li Y, Chen M, Sun H, Du S, Cheng Y, Zhan S. Cavernous sinus thrombosis: An insidious and dangerous "do-not-miss" diagnosis. Headache 2021; 61:1144-1149. [PMID: 34325491 DOI: 10.1111/head.14176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Huiyang Qu
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yanling Li
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Mengying Chen
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Honghong Sun
- Department of Radiology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuang Du
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yuxuan Cheng
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shuqin Zhan
- Department of Neurology, the Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Ata F, Yousaf Z, Arachchige SNM, Rose S, Alshurafa A, Muthanna B, Bilal ABI, El Beltagi A, Zahid M. The demographics of Tolosa-Hunt syndrome in Qatar. eNeurologicalSci 2021; 24:100359. [PMID: 34355072 PMCID: PMC8325092 DOI: 10.1016/j.ensci.2021.100359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/19/2021] [Indexed: 11/20/2022] Open
Abstract
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. We represent the largest cohort of THS patients from the Middle eastern population. In our cohort, medium dose steroids (60 mg daily) had a good recovery rate (71%). Female gender and a prior history of THS were associated with recurrence. Recurrence rate was low in our cohort compared to international trends (9.7%).
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Affiliation(s)
- Fateen Ata
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Saman Rose
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Awni Alshurafa
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Bassam Muthanna
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ammara Bint I Bilal
- Department of Radiology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed El Beltagi
- Department of Neuroscience and Neuroradiology, Hamad Medical Corporation, Doha, Qatar.,Weill-Cornel Medicine, Qatar
| | - Muhammad Zahid
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.,Weill-Cornel Medicine, Qatar
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Delvaulx P, Youssfi A, Moujane F, Cordonnier M. Atypical case of acute unilateral complete external ophthalmoplegia. J Fr Ophtalmol 2021; 44:e567-e570. [PMID: 34127305 DOI: 10.1016/j.jfo.2020.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/05/2020] [Accepted: 12/14/2020] [Indexed: 10/21/2022]
Affiliation(s)
- P Delvaulx
- Department of ophthalmology, Erasme hospital, route de Lennik 808, 1070 Bruxelles, Belgique.
| | - A Youssfi
- Department of ophthalmology, Erasme hospital, route de Lennik 808, 1070 Bruxelles, Belgique
| | - F Moujane
- Department of ophthalmology, Erasme hospital, route de Lennik 808, 1070 Bruxelles, Belgique
| | - M Cordonnier
- Department of ophthalmology, Erasme hospital, route de Lennik 808, 1070 Bruxelles, Belgique
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Escaping from the hunt. Surv Ophthalmol 2020; 66:1065-1069. [PMID: 33129799 DOI: 10.1016/j.survophthal.2020.10.005] [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: 10/02/2020] [Accepted: 10/21/2020] [Indexed: 11/21/2022]
Abstract
A 69-year-old woman presented with chronic, painful, progressive binocular diplopia. Examination showed deficits in multiple sequential cranial nerves (II, III, IV, V1,2,3, and VI). She was initially diagnosed with Tolosa-Hunt syndrome and had a partial response to systemic corticosteroids. Skull base biopsy eventually showed poorly differentiated carcinoma consistent with perineural spread of squamous cell carcinoma.
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