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Kim HJ, Lee SU, Lee ES, Choi JY, Kim JS. Recurrence and long-term outcomes of Tolosa-Hunt syndrome. J Neurol 2024; 271:935-943. [PMID: 37853245 DOI: 10.1007/s00415-023-12044-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND AND PURPOSE Tolosa-Hunt Syndrome (THS) is a rare disorder, and detailed clinical information and treatment outcomes have yet to be fully elucidated. This study aims to investigate the clinical features and factors associated with the treatment outcomes of THS, as defined by the established diagnostic criteria. METHODS This study retrospectively recruited 91 patients with a diagnosis of THS from 2003 to 2020. We analyzed the clinical features and outcomes, the initial treatment response, recurrences, and the final treatment response. RESULTS Isolated ocular motor nerve palsy was the most common (82.4%) finding of ophthalmoplegia, involving the oculomotor nerve in more than half of the cases (52.0%). The MRI lesions were mostly observed in the cavernous sinus (94.5%) with an extracavernous extension in about one-third of them. Five patients showed only extracavernous lesions. A total of 25 (27.5%) patients experienced recurrence. Recurrence occurred during steroid tapering as part of the initial treatment in seven, while in 18 patients, it happened after the successful termination of the initial treatment. However, all patients achieved complete remission at the final. Age was associated with a decrease in initial symptom duration (HR = 1.023, CI = 1.004-1.044) as well as an increase in recurrence-free duration (HR = 0.944, CI = 0.911-0.978). High-dose corticosteroid treatment was associated with a decrease in initial symptom duration (HR = 1.642, CI = 1.001-2.695) and total treatment duration (HR = 2.203 CI = 1.302-3.730). CONCLUSIONS THS can recur frequently especially in younger but have a favorable prognosis. High-dose corticosteroids can be an effective initial treatment and reduce the total treatment duration.
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Affiliation(s)
- Hyun-Jae Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sun-Uk Lee
- Neurotology Laboratory, Korea University Anam Hospital, Seoul, Republic of Korea
- Department of Neurology, Korea University Medical Center, Seoul, Republic of Korea
| | - Eek-Sung Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Clinical Neuroscience Center and Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center and Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
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Mohebbi M, Nafissi S, Alikhani M. A New Case of Granulomatosis with Polyangiitis Presented with Tolosa-Hunt Syndrome Manifestations. Case Rep Rheumatol 2024; 2024:5552402. [PMID: 38288297 PMCID: PMC10824575 DOI: 10.1155/2024/5552402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/31/2024] Open
Abstract
Background Tolosa-Hunt syndrome (THS) is a rare disorder involving the orbital and retro-orbital space. The typical symptoms include sensory loss in the trigeminal nerve's distribution, orbital pain, swelling, headaches, and cranial nerve palsies. Case Presentation. We report a 40-year-old female who initially presented with biparietal headache, unresponsive to medication, which then led to ophthalmoplegia and orbital pain. Serological findings demonstrated positive CANCA-PR3. She was initially treated with 1 g pulse methylprednisolone for three days. Based on the rheumatological evaluation and her positive lung nodule, hematuria, dysmorphic red blood cells, and positive antiproteinase 3 classic antineutrophil cytoplasm antibodies (CANCA-PR3) and also based on the diagnostic criteria for granulomatosis with polyangiitis criteria for Wegner disease, her treatment was continued with prednisolone 1 mg/kg and also rituximab at the first and 14th day of treatment. Conclusion In our case of THS, we achieved satisfactory improvement in symptoms through the administration of high-dose steroids.
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Affiliation(s)
- Maryam Mohebbi
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahriar Nafissi
- Department of Neurology, School of Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Majid Alikhani
- Department of Internal Medicine, School of Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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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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Yu S, Chen T. Pearls & Oy-sters: Idiopathic Orbital Inflammation and Tolosa-Hunt Syndrome With Intracranial Extension. Neurology 2023; 101:371-374. [PMID: 37185126 PMCID: PMC10449447 DOI: 10.1212/wnl.0000000000207368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/17/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
- Sabrina Yu
- From the Department of Ophthalmology and Visual Sciences (S.Y.), and Division of Neurology (T.C.), Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Tychicus Chen
- From the Department of Ophthalmology and Visual Sciences (S.Y.), and Division of Neurology (T.C.), Faculty of Medicine, University of British Columbia, Vancouver, Canada.
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Disseminated tuberculosis masquerading as Tolosa-Hunt syndrome in initial presentation: A case report with literature review. Radiol Case Rep 2023; 18:1353-1357. [PMID: 36712191 PMCID: PMC9873575 DOI: 10.1016/j.radcr.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 01/07/2023] [Indexed: 01/22/2023] Open
Abstract
Tolosa-Hunt syndrome (THS) is a painful ophthalmoplegia due to non-specific granulomatous inflammation in the cavernous sinus region. It is diagnosed by the International Classification of Headache Disorders (ICHD)-3 criteria. We report the case of a young lady who presented with a right-sided headache for 2 weeks, followed by right-sided diplopia for 4 days. Clinical examination revealed right trochlear nerve palsy. Magnetic resonance imaging (MRI) of her brain showed abnormal thickening and postcontrast enhancement of the right orbital apex and superior orbital fissure, suggesting THS. Examination of cerebrospinal fluid (CSF) ruled out intracranial infection. The initial presentation satisfied the ICHD-3 criteria. Further imaging revealed cervical, axillary, and intra-abdominal lymphadenopathy with granulomatous lesions in the spleen and right kidney. Ultrasound (US)-guided axillary lymph node biopsy was positive for Mycobacterium tuberculosis. QuantiFERON TB gold plus test from serum was positive. Based on radiological and histopathological findings, a diagnosis of disseminated tuberculosis involving lymph nodes, kidneys, spleen, and lungs was made. THS is a diagnosis of exclusion. This case signifies that patients diagnosed with THS based on ICHD-3 criteria should be extensively evaluated to rule out granulomatous infections such as tuberculosis. Typical THS symptoms with granulomatous inflammation can give false reassurance to clinicians and prevent investigation for more dangerous etiologies. As painful ophthalmoplegia can arise secondary to a myriad of pathologies, diagnostic workups for all possibilities should be exhausted before arriving at a diagnosis of THS. Regardless of MRI findings, workups for tuberculosis and fungal infections should be completed.
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Behera G, Gupta V, Mishra UP, Chaurasia JK. Tolosa Hunt Syndrome: A Challenging Diagnosis from Otorhinolaryngologist Perspective-A Case Report. Indian J Otolaryngol Head Neck Surg 2022; 74:5681-5684. [PMID: 36742718 PMCID: PMC9895722 DOI: 10.1007/s12070-021-02992-0] [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: 09/15/2021] [Accepted: 11/18/2021] [Indexed: 02/07/2023] Open
Abstract
Tolosa Hunt syndrome is a rare disorder characterized by idiopathic chronic granulomatous lesion involving cavernous sinus. The presenting symptoms are severe frontal headache, periorbital pain, ptosis, and diplopia. Usually, patients with headache and ptosis primarily visit neurologists or ophthalmologists. Only when imaging reveals any intracranial lesion involving paranasal sinuses, these patients get referred to otorhinolaryngologists. We would like to describe here the challenges we faced as otorhinolaryngologist, in diagnosis and management of a case of painful ophthalmoplegia as Tolosa Hunt Syndrome. A 55-year-old male presented to us with complaints of left frontal headache, periorbital pain, diplopia, and ptosis of left eye. Imaging and endoscopic biopsy revealed granulomatous lesion involving cavernous sinus with no evidence of fungal aetiology. Patient responded well to systemic steroid therapy with complete resolution of symptoms and no remission till two years of follow up. Tolosa Hunt Syndrome remains a diagnosis of exclusion. Trans-nasal endoscopic biopsy in selected cases may be contributory to the diagnosis. It responds well to systemic steroid therapy. Although chances of relapse are there yet prognosis is excellent.
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Affiliation(s)
- Ganakalyan Behera
- Department of Otorhinolaryngology - Head & Neck Surgery, All India Institute of Medical Sciences, Bhopal, 462020 India
| | - Vikas Gupta
- Department of Otorhinolaryngology - Head & Neck Surgery, All India Institute of Medical Sciences, Bhopal, 462020 India
| | - Utkal P. Mishra
- Department of Otorhinolaryngology - Head & Neck Surgery, All India Institute of Medical Sciences, Bhopal, 462020 India
| | - Jai Kumar Chaurasia
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhopal, India
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Hajjar D, Sultan D, Khalaf A, Hesso H, Kayyali A. A case of total ophthalmoplegia associated with a COVID-19 infection: case report. Oxf Med Case Reports 2022; 2022:omac050. [PMID: 35619686 PMCID: PMC9127945 DOI: 10.1093/omcr/omac050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/19/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022] Open
Abstract
We are presenting a rare case of an acute complete external ophthalmoplegia with positive polymerase chain reaction (PCR) for SARS-CoV-2. Our case is the first case that depicts development of Tolosa-Hunt Syndrome (THS) following infection with COVID-19, with a challenging diagnosis and spontaneous improvement. A 65-year-old diabetic female presented with a complete external ophthalmopegia in the left eye and a severe left-sided headache. The PCR result for SARS-CoV-2 was positive. Brain and orbital computed tomography scan and magnetic resonance imaging were both unremarkable. We diagnosed the case as THS after ruling out other differential diagnoses. The patient refused to receive prednisone, so we had to observe her closely for 6 months during which period we recorded a spontaneous recovery. Acute ophthalmoplegia is a very challenging presentation. It needs full workup to exclude the wide range of differential diagnoses.
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Affiliation(s)
- Doaa Hajjar
- Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria
| | - Dana Sultan
- Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria
| | - Abdullah Khalaf
- Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria
| | - Hussein Hesso
- Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria
| | - Ammar Kayyali
- Department of Ophthalmology, Aleppo University Hospital, Aleppo, Syria
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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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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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11
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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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Kesserwani H, Heersink M. Recurrent Amaurosis Fugax Secondary to Tolosa-Hunt Syndrome: A Case Report and Review of Phenotypes and Pathology. Cureus 2021; 13:e15281. [PMID: 34221749 PMCID: PMC8237908 DOI: 10.7759/cureus.15281] [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] [Indexed: 11/25/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a fascinating condition that is ipso facto a cavernous sinus syndome. As such it is associated with inflammation of the cavernous sinus walls and contents with spread to contiguous structures such as the orbital apex and superior orbital fissure. Therefore it does not come as a surprise that there is overlap with the condition of orbital pseudotumor. Furthermore, the typical presentation of THS involves variable affliction of the contents of the cavernous sinus with ocular and facial pain, ophthalmoplegia, facial numbness and Horner syndrome. To our knowledge, we present one of the only reported cases of recurrent amaurosis fugax and transient visual obscurations secondary to THS. Despite being an odd-ball presentation, these manifestations make intuitive sense as we demonstrate luminal narrowing of the right carotid siphon in the setting of cavernous wall enhancement, peri-arteritis of the carotid siphon being well-documented pathologically in the literature. The basis for the transient visual obscurations is more speculative but worthy of further study.
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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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Prete B, Sowka J. Painful ophthalmoplegia as an initial presentation of sarcoidosis. Clin Exp Optom 2021; 100:291-293. [DOI: 10.1111/cxo.12468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/16/2016] [Accepted: 07/24/2016] [Indexed: 01/03/2023] Open
Affiliation(s)
| | - Joseph Sowka
- College of Optometry, Nova Southeastern University, Fort Lauderdale, Florida, USA,
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Gama BP, Silva-Néto RP. Tolosa-Hunt Syndrome in Childhood and Adolescence: A Literature Review in the Last 10 Years. Neuropediatrics 2021; 52:1-5. [PMID: 32892335 DOI: 10.1055/s-0040-1715632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The aim of the study is to review the articles published in the last 10 years on Tolosa-Hunt syndrome (THS) in childhood and adolescence to learn about its clinical and epidemiological characteristics and its therapeutic management. METHODS Based on the literature search in the major medical databases and using the descriptors "Tolosa-Hunt syndrome and children" and "Tolosa-Hunt syndrome and adolescent" we included articles published between 2009 and 2019. We found 51 articles, but only 11 met the inclusion criteria. RESULTS There were eight women and four men with THS, whose average age was 12.0 ± 4.3 years, ranging from 4 to 17 years. Magnetic resonance imaging showed inflammation in the cavernous sinus (100%), orbit (25%), and superior orbital fissure (8.3%), unilateral in all patients. The internal carotid artery (58.3%), third (66.7%), sixth (33.3%), and fourth (25%) cranial nerves were injured. Headache was located in the orbital region, ipsilaterally to nerve involvement and had mild to severe intensity. Corticosteroid was the treatment used in 91.7% of the patients. They were followed for an average of 13.4 ± 12.4 months. Only two patients had recurrence of the disease. CONCLUSION THS is infrequent in childhood and adolescence and knowledge of its clinical and epidemiological characteristics and its therapeutic management is necessary for pediatricians.
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Affiliation(s)
- Bárbara Pinheiro Gama
- Department of Neurology, Federal University of Delta of Parnaíba, Fátima, Parnaíba, Brazil
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Diplopia. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Tolosa-Hunt Syndrome: A Painful Ophthalmoplegia. Case Rep Neurol Med 2020; 2020:8883983. [PMID: 33204552 PMCID: PMC7666634 DOI: 10.1155/2020/8883983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 10/04/2020] [Accepted: 10/31/2020] [Indexed: 02/05/2023] Open
Abstract
Tolosa–Hunt syndrome is a painful ophthalmoplegia characterized by recurrent unilateral orbital pain, ipsilateral oculomotor paralysis, and a rapid response to steroids. Our report describes a 37-year-old young woman who presented with right ptosis, ipsilateral ophthalmoplegia, and painful headache with no other neurological deficits in which all biological and neuroimaging investigations were normal. Complete recovery within one week of corticosteroid therapy was observed. This is probably the first case of Tolosa–Hunt syndrome reported in Dakar, Senegal.
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Madhavan AA, DeLone DR, Verdoorn JT. Bilateral facial nerve involvement in a patient with Tolosa–Hunt syndrome. Neuroradiol J 2020; 33:424-427. [DOI: 10.1177/1971400920939293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Tolosa–Hunt syndrome is characterized by unilateral retro-orbital headaches and cranial nerve palsies, usually involving cranial nerves III–VI. It is rare for other cranial nerves to be involved, although this has previously been reported. We report a 19-year-old woman presenting with typical features of Tolosa–Hunt syndrome but ultimately developing bilateral facial nerve palsies and enhancement of both facial nerves on magnetic resonance imaging. The patient presented with unilateral retro-orbital headaches and palsies of cranial nerves III–VI. She was diagnosed with Tolosa–Hunt syndrome but was non-compliant with her corticosteroid treatment due to side effects. She returned with progressive left followed by right facial nerve palsy. Her corresponding follow-up magnetic resonance imaging scans showed sequential enhancement of the left and right facial nerves. She ultimately had clinical improvement with IV methylprednisolone. To our knowledge, Tolosa–Hunt syndrome associated with bilateral facial nerve palsy and corroborative facial nerve enhancement on magnetic resonance imaging has not previously been described. Moreover, our patient’s clinical course is instructive, as it demonstrates that this atypical presentation of Tolosa–Hunt syndrome can indeed respond to corticosteroid treatment and should not be mistaken for other entities such as Bell’s palsy.
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19
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Affiliation(s)
- Run Yu
- From the Division of Endocrinology, UCLA David Geffen School of Medicine, Los Angeles, California..
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20
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Mikhail M, Basilious A, Jabehdar Maralani P, Sundaram AN. Tolosa-Hunt syndrome: case series on the timed use of diagnostic magnetic resonance imaging. Can J Ophthalmol 2020; 55:e135-e139. [DOI: 10.1016/j.jcjo.2020.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
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21
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Munawar K, Nayak G, Fatterpekar GM, Sen C, Zagzag D, Zan E, Hagiwara M. Cavernous sinus lesions. Clin Imaging 2020; 68:71-89. [PMID: 32574933 DOI: 10.1016/j.clinimag.2020.06.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/16/2022]
Abstract
The cavernous sinus is a complex structure susceptible to a wide variety of vascular, neoplastic and inflammatory pathologies. Vascular pathologies include ICA aneurysms, carotid-cavernous fistulas, cavernous sinus thrombosis, and cavernous hemangioma. Neoplasms that involve the cavernous sinus include pituitary adenoma, meningioma, schwannoma, lymphoma, perineural tumor spread, metastases, and direct tumor invasion. Infectious and inflammatory diseases include Tolosa-Hunt syndrome, sarcoidosis, granulomatosis with polyangiitis, IgG-4 related disease and invasive fungal infections. In this article, we review the clinical and imaging findings of a number of pathologies involving the cavernous sinus, focusing on key features that can narrow the differential diagnosis and, in some cases, support a particular diagnosis.
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Affiliation(s)
- Kamran Munawar
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Gopi Nayak
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Girish M Fatterpekar
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Chandra Sen
- NYU Langone Health, Department of Neurosurgery, New York, NY, United States of America
| | - David Zagzag
- NYU Langone Health, Department of Pathology, New York, NY, United States of America
| | - Elcin Zan
- NYU Langone Health, Department of Radiology, New York, NY, United States of America
| | - Mari Hagiwara
- NYU Langone Health, Department of Radiology, New York, NY, United States of America.
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22
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Van Deun L, de Witte M, Goessens T, Halewyck S, Ketelaer MC, Matic M, Moens M, Vaes P, Van Lint M, Versijpt J. Facial Pain: A Comprehensive Review and Proposal for a Pragmatic Diagnostic Approach. Eur Neurol 2020; 83:5-16. [PMID: 32222701 DOI: 10.1159/000505727] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/01/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Facial pain, alone or combined with other symptoms, is a frequent complaint. Moreover, it is a symptom situated at, more than any other pain condition, a crosspoint where several disciplines meet, for example, dentists; manual therapists; ophthalmologists; psychologists; and ear-nose-throat, pain, and internal medicine physicians besides neurologists and neurosurgeons. Recently, a new version of the most widely used classification system among neurologists for headache and facial pain, the International Classification of Headache Disorders, has been published. OBJECTIVE The aims of this study were to provide an overview of the most prevalent etiologies of facial pain and to provide a generic framework for the neurologist on how to manage patients presenting with facial pain. METHODS An overview of the different etiologies of facial pain is provided from the viewpoint of the respective clinical specialties that are confronted with facial pain. Key message: Caregivers should "think outside their own box" and refer to other disciplines when indicated. If not, a correct diagnosis can be delayed and unnecessary treatments might be given. The presented framework is aimed at excluding life- or organ-threatening diseases, providing several clinical clues and indications for technical investigations, and ultimately leading to the correct diagnosis and/or referral to other disciplines.
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Affiliation(s)
- Laura Van Deun
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Muriel de Witte
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Clinical Psychology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Thaïs Goessens
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Clinical Psychology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Stijn Halewyck
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Otorhinolaryngology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Marie-Christine Ketelaer
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium
| | - Milica Matic
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Anesthesiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Maarten Moens
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Neurosurgery, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Peter Vaes
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Manual Therapy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Michel Van Lint
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium.,Department of Ophthalmology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Jan Versijpt
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Headache and Facial Pain Clinic, Brussels, Belgium, .,Department of Neurology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium,
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23
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Mullen E, Rutland JW, Green MW, Bederson J, Shrivastava R. Reappraising the Tolosa‐Hunt Syndrome Diagnostic Criteria: A Case Series. Headache 2019; 60:259-264. [DOI: 10.1111/head.13692] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Evan Mullen
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - John W. Rutland
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - Mark W. Green
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA
| | - Joshua Bederson
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
| | - Raj Shrivastava
- Department of Neurosurgery Icahn School of Medicine at Mount Sinai New York NY USA
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24
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Harris GR, Breazzano MP, Shyu I, Donahue SP, Lavin PJM. Oculomotor Synkinesis (Aberrant Reinnervation of the Third Cranial Nerve) Associated with Atypical Tolosa-Hunt Syndrome. Neuroophthalmology 2019; 44:262-266. [PMID: 33012913 DOI: 10.1080/01658107.2019.1576738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
A 70-year-old woman with systemic lupus erythematosus developed a painful pupil-involving right third nerve palsy, ipsilateral fourth nerve palsy, and periorbital paraesthesia. Magnetic resonance imaging demonstrated enhancement and thickening of the right third nerve, and she was diagnosed with presumed Tolosa-Hunt syndrome. Repeated imaging seven months later showed resolution of the enhancing thickened oculomotor nerve, but the patient developed signs of oculomotor synkinesis. This presentation demonstrates a rare case of oculomotor synkinesis secondary to inflammation.
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Affiliation(s)
- Glenn R Harris
- Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark P Breazzano
- Department of Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Irene Shyu
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sean P Donahue
- Department of Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick J M Lavin
- Department of Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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25
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Kim HM, Yang HK, Hwang JM. Quantitative analysis of pupillometry in isolated third nerve palsy. PLoS One 2018; 13:e0208259. [PMID: 30496292 PMCID: PMC6264827 DOI: 10.1371/journal.pone.0208259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/14/2018] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To objectively assess pupillary involvement according to various etiologies of acquired isolated third nerve palsy using automated pupillometry, and evaluate the efficacy of digital pupillometry in discriminating compressive lesions from microvascular ischemic third nerve palsy. DESIGN Retrospective, observational case series. METHODS A total of 171 subjects were included in this study, consisting of 60 subjects with presumed microvascular ischemic third nerve palsy, 51 with non-ischemic third nerve palsy, and 60 controls whose pupillary light responses were measured using a dynamic automated pupillometer. Subjects with non-ischemic third nerve palsy were divided into subgroups according to their etiology; inflammatory and compressive groups including tumor and aneurysm. Pupillometry parameters including minimum and maximum pupil diameters, constriction latency and ratio, maximum and average constriction velocities and dilation velocity were noted. The diagnostic ability of pupillometry parameters for discriminating compressive vs microvascular ischemic third nerve palsy was evaluated. The inter-eye difference of the involved eye and the uninvolved fellow eye was calculated to adjust for individual variability. RESULTS Among all parameters, reduced pupillary constriction ratio was the most specific parameter for detecting non-ischemic third nerve palsy, as a large inter-eye difference beyond the normative range of controls was found in 0% of ischemic, 20% of inflammatory and 60% of compressive third nerve palsy. With the diagnostic criteria using inter-eye differences of 1) minimum pupil diameter > 0.45 mm, or 2) pupillary constriction ratio < -7.5% compared to the fellow eye, the sensitivity and specificity for diagnosing compressive third nerve palsy were 95% and 88%, respectively. In the compressive group, positive correlations were found between the degree of external ophthalmoplegia and constriction ratio (r = 0.615, p<0.001), average constriction velocity (r = 0.591, p = 0.001) and maximum constriction velocity (r = 0.582, p = 0.001). CONCLUSIONS Abnormal pupillary constriction ratio was highly specific for detecting compressive third nerve palsy, although the sensitivity was not high. Digital pupillometry demonstrated relatively good performance for discriminating compressive lesions from microvascular ischemic third nerve palsy.
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Affiliation(s)
- Hyeong Min Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hee Kyung Yang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Min Hwang
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- * E-mail:
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26
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Monmany J, Granell E, López L, Domingo P. Resolved heart tamponade and controlled exophthalmos, facial pain and diabetes insipidus due to Erdheim-Chester disease. BMJ Case Rep 2018; 2018:bcr-2018-225224. [PMID: 30337283 PMCID: PMC6254461 DOI: 10.1136/bcr-2018-225224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
A 69-year-old woman suffering from exophthalmos and facial pain came to us referred for aetiological diagnosis of exophthalmos. Orbital MRI showed thinned extrinsic ocular musculature, intraconal fat infiltration, retro-ocular compression and thickening of maxillary and sphenoid sinus walls. She had been suffering from diabetes insipidus for the last 7 years. During our diagnosis process, she presented signs of cardiac tamponade. Transthoracic heart ultrasound revealed large pericardial effusion and a heterogeneous mass that compressed the right ventricle. No osteosclerotic lesions on appendicular bones were present. Pericardiocentesis temporarily controlled tamponade and corticoid therapy temporarily abated exophthalmos. Pericardiectomy definitively resolved tamponade. Histological examination of pericardial tissue was conclusive of Erdheim-Chester disease. Exophthalmos responded to pegylated interferon-alpha-2a. Facial bone pain disappeared after zoledronic acid and interferon treatment. During interferon therapy, the patient suffered from a severe generalised desquamative exanthema that slowly resolved after discontinuing interferon. Diabetes insipidus remains controlled with desmopressin.
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Affiliation(s)
- Jaume Monmany
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Esther Granell
- Diagnòstic per la Imatge, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Laura López
- Anatomia Patològica, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Pere Domingo
- Medicina Interna, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
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27
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Goyal P, Lee S, Gupta N, Kumar Y, Mangla M, Hooda K, Li S, Mangla R. Orbital apex disorders: Imaging findings and management. Neuroradiol J 2018; 31:104-125. [PMID: 29415610 DOI: 10.1177/1971400917740361] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Orbital apex disorders include orbital apex syndrome, superior orbital fissure syndrome and cavernous sinus syndrome. These disorders result from various etiologies, including trauma, neoplastic, developmental, infectious, inflammatory as well as vascular causes. In the past, these have been described separately based on anatomical locations of disease process; however, these three disorders share similar causes, diagnostic evaluation and management strategies. The etiology is diverse and management is directed to the causative process. This imaging review summarizes the pertinent anatomy of the orbital apex and illustrates representative pathological processes that may affect this region. The purpose of this review is to provide an update on the current status of diagnostic imaging and management of patients with orbital apex disorders.
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Affiliation(s)
- Pradeep Goyal
- 1 21611 St. Vincent's Medical center , Bridgeport, CT, USA
| | | | | | - Yogesh Kumar
- 4 Columbia University at Bassett Healthcare, Cooperstown, NY
| | | | - Kusum Hooda
- 6 Yale New Haven Health at 1939 Bridgeport Hospital , Bridgeport, CT, USA
| | - Shuo Li
- 6 Yale New Haven Health at 1939 Bridgeport Hospital , Bridgeport, CT, USA
| | - Rajiv Mangla
- 7 SUNY Upstate Medical University, Syracuse, NY, USA
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Carreón E, Muñiz S, Di Capua D, Porta-Etessam J. Tolosa-Hunt syndrome with spontaneous remission and recurrence. NEUROLOGÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.nrleng.2015.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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29
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Mullen E, Green M, Hersh E, Iloreta AM, Bederson J, Shrivastava R. Tolosa-Hunt Syndrome: Appraising the ICHD-3 beta diagnostic criteria. Cephalalgia 2017; 38:1696-1700. [DOI: 10.1177/0333102417745271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction The term Tolosa-Hunt Syndrome was first used more than half a century ago to describe painful ophthalmoplegia accompanied by cranial nerve palsies. In the decades since, its diagnostic criteria have evolved considerably. The beta version of the 3rd Edition of the International Classification of Headache Disorders narrows these criteria to require the demonstration of granulomatous inflammation on MRI or biopsy. We believe this may introduce challenges to accurate diagnosis. Discussion Requiring the demonstration of granulomatous inflammation for a diagnosis of Tolosa-Hunt Syndrome may introduce the potential for false negative and false positive diagnoses. Although the disorder presents secondary to granulomatous inflammation, MRI technology may not be able to identify it reliably, and biopsy is not always indicated for its symptomatology. Additionally, several cases have been reported of Tolosa-Hunt Syndrome diagnosed with MRI-confirmed granulomatous inflammation that later prove to be attributable to other pathologies. The emphasis on neuroimaging may therefore exclude some true Tolosa-Hunt Syndrome cases and include others resulting from other latent pathologies that are not visible on MRI. Conclusion We wish to offer several potential modifications to the International Classification of Headache Disorders guidelines for Tolosa-Hunt Syndrome, including making the demonstration of granulomatous inflammation on MRI or biopsy non-mandatory and lengthening patient follow-up to two years for cases in which MRI is unrevealing.
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Affiliation(s)
- Evan Mullen
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mark Green
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eliza Hersh
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alfred-Marc Iloreta
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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AKPINAR ÇK, ÖZBENLİ T, DOĞRU H, İNCESU L. Tolosa-Hunt Syndrome - Cranial Neuroimaging Findings. Noro Psikiyatr Ars 2017; 54:251-254. [PMID: 29033638 PMCID: PMC5630104 DOI: 10.5152/npa.2016.13791] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/02/2016] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION The etiology of Tolosa-Hunt Syndrome (THS) is still unknown. The initial standard magnetic resonance imaging (MRI) may not be sufficient for diagnosis, so dynamic contrast-enhanced MRI may be necessary to demonstrate the presence of lesions. METHODS Seven patients diagnosed with THS according to the International Headache Society criteria (beta version) were included into the study. Patients were assessed in terms of type, age, symptoms and findings, accompanying disease, localization of the determined lesion, response to treatment, and clinical progress. The "Tolosa-Hunt protocol" was applied in all patients, and the cavernous sinuses, orbital apices, and orbits were evaluated. The parameters used for the patients were as follows: Turbospin echo T1 and T2 weighted sequences on the axial plane, turbospin echo fat-saturated T2 weighted sequence on the coronal plane, turbospin echo T2 weighted sequence on the sagittal plane, spin echo fat-saturated T1 sequences repeated on the axial and coronal planes followed by intravenous administration of gadolinium. In all sequences the slice thickness was 3 mm. RESULTS Four of seven cases diagnosed with THS were males, and the average age of the patients was 45.7±18.1 years (range 25-69 years). A follow-up MRI in patient 5 after three months showed decreased signal intensity and enhancement of the affected cavernous sinus. CONCLUSION Conventional MRI may be insufficient to show the granulomatous inflammation, and an MRI method referred to as the Tolosa-Hunt protocol should be applied to those who are thought to have THS.
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Affiliation(s)
| | - Taner ÖZBENLİ
- Department of Neurology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Hakan DOĞRU
- Department of Neurology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
| | - Lütfi İNCESU
- Department of Radiology, Ondokuz Mayıs University School of Medicine, Samsun, Turkey
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Abstract
Premise This review summarises the pain syndromes that overlap between headache and facial pain and overlap between pain and cranial nerve lesion. Problem These syndromes share two features in common. First, they show both cranial nerve impairment (e.g. palsy, autonomic dysfunction) and pain; second, they have inflammatory (and/or small vessel) processes as the underlying mechanism. A typical representative of these syndromes is recurrent painful ophthalmoplegic neuropathy, which was previously called ophthalmoplegic migraine and was regarded as a migraine subtype. It is now supposed that this syndrome is caused by an inflammation of one of the ocular motor nerves. Other syndromes discussed in this review are optic neuritis, Tolosa-Hunt syndrome, ischaemic ocular motor nerve palsy, and the very rare Raeder's syndrome. Treatment of all these syndromes is mainly based on steroids. Potential solution Management of possibly underlying disorders such as multiple sclerosis or atherosclerosis should also be considered.
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Affiliation(s)
- Stefan Evers
- 1 Department of Neurology, Lindenbrunn Hospital, Coppenbrügge, Germany.,2 Faculty of Medicine, University of Münster, Germany
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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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33
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Pérez CA, Evangelista M. Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update. Pediatr Neurol 2016; 62:18-26. [PMID: 27473647 DOI: 10.1016/j.pediatrneurol.2016.06.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 06/12/2016] [Accepted: 06/18/2016] [Indexed: 01/03/2023]
Abstract
BACKGROUND Tolosa-Hunt syndrome is a painful ophthalmoplegia caused by an inflammatory process of unknown etiology in the region of the cavernous sinus, orbital apex, or superior orbital fissure. This disease is rare in the pediatric population. The objective of this study was to provide a clinical framework for the evaluation and treatment of children with this disorder. A systematic approach to the diagnosis of painful ophthalmoplegia in children is proposed. METHODS We present a 15-year-old girl whose clinical presentation and neuroradiological findings support a diagnosis of Tolosa-Hunt syndrome as defined by the 2013 International Classification of Headache Disorders (Third Edition, ICHD-3 beta) diagnostic criteria. An exhaustive systematic literature search based on these criteria yielded 15 additional cases of Tolosa-Hunt syndrome in children. Clinical, demographic, and radiological features were retrospectively analyzed. The results and statistical analyses are reported. RESULTS A total of 16 individuals were included in the final analysis. This review summarizes the current knowledge and recommendations for the diagnosis and management of pediatric Tolosa-Hunt syndrome. It highlights demographic, clinical, and radiological features of this disease in children and underscores areas of the literature where evidence is still lacking. CONCLUSIONS Overall, Tolosa-Hunt syndrome seems to follow a similar course in children compared to adults. The diagnostic approach and treatment require specific considerations. New observations and possible features of pediatric Tolosa-Hunt syndrome are discussed. Further research is needed to optimize clinical detection and medical management of this disease.
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Affiliation(s)
- Carlos A Pérez
- Division of Child and Adolescent Neurology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Monaliza Evangelista
- Division of Community and General Pediatrics, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas
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Höhne C, Schuh E, Kümpfel T, Straube A. Cryopyrin-associated periodic fever syndrome manifesting as Tolosa-Hunt syndrome. Cephalalgia 2016; 36:1392-1396. [DOI: 10.1177/0333102416629239] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/02/2015] [Accepted: 01/01/2016] [Indexed: 01/03/2023]
Abstract
Background Tolosa-Hunt syndrome (THS) is characterized by unilateral orbital pain, ipsilateral oculomotor paresis and a prompt response to treatment with corticosteroids. Several reports have demonstrated that the clinical features of THS are not specific to one causal aetiology and can lead to misdiagnosis. Case report We report the case of a patient diagnosed with THS after an episode of unilateral orbital pain and diplopia with demonstration of granulomatous inflammation of both cavernous sinus on cerebral magnetic resonance imaging and an immediate response to treatment with corticosteroids. Progression of the disease over the following years, accompanied by increasing signs of inflammation on cerebral magnetic resonance imaging and cerebrospinal fluid pleocytosis, led to further diagnostic tests. Genetic analyses revealed a heterozygote low-penetrance mutation (Q703K) of the cryopyrin/ NLRP3 gene compatible with a cryopyrin-associated periodic fever syndrome. Discussion This case report demonstrates that THS can be a central nervous system manifestation of cryopyrin-associated periodic fever syndrome, which therefore represents a differential diagnosis of THS, even in elderly patients.
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Affiliation(s)
- C Höhne
- Department of Neurology, Ludwig-Maximilians University, Munich, Germany
| | - E Schuh
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians University, Munich, Germany
| | - T Kümpfel
- Institute of Clinical Neuroimmunology, Ludwig-Maximilians University, Munich, Germany
| | - A Straube
- Department of Neurology, Ludwig-Maximilians University, Munich, Germany
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Carreón E, Muñiz S, Di Capua D, Porta-Etessam J. Tolosa-Hunt syndrome with spontaneous remission and recurrence. Neurologia 2016; 33:68-70. [PMID: 26976551 DOI: 10.1016/j.nrl.2015.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/13/2015] [Accepted: 12/14/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- E Carreón
- Servicio de Neurología, Hospital Universitario Virgen de la Arrixaca, Murcia, España
| | - S Muñiz
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España
| | - D Di Capua
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España
| | - J Porta-Etessam
- Servicio de Neurología, Unidad de Cefaleas, Hospital Clínico Universitario San Carlos, Madrid, España.
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Neuro-Opthalmological Aspects of Headaches from the Neurologist’s Aspect. Neuroophthalmology 2016. [DOI: 10.1007/978-3-319-28956-4_65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Tarulli A. Diplopia. Neurology 2016. [DOI: 10.1007/978-3-319-29632-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Warburton RE, Brookes CCD, Golden BA, Turvey TA. Orbital apex disorders: a case series. Int J Oral Maxillofac Surg 2015; 45:497-506. [PMID: 26725107 DOI: 10.1016/j.ijom.2015.10.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/05/2015] [Accepted: 10/16/2015] [Indexed: 12/27/2022]
Abstract
Orbital apex syndrome is an uncommon disorder characterized by ophthalmoplegia, proptosis, ptosis, hypoesthesia of the forehead, and vision loss. It may be classified as part of a group of orbital apex disorders that includes superior orbital fissure syndrome and cavernous sinus syndrome. Superior orbital fissure syndrome presents similarly to orbital apex syndrome without optic nerve impairment. Cavernous sinus syndrome includes hypoesthesia of the cheek and lower eyelid in addition to the signs seen in orbital apex syndrome. While historically described separately, these three disorders share similar causes, diagnostic course, and management strategies. The purpose of this study was to report three cases of orbital apex disorders treated recently and to review the literature related to these conditions. Inflammatory and vascular disorders, neoplasm, infection, and trauma are potential causes of orbital apex disorders. Management is directed at the causative process. The cases described represent a rare but important group of conditions seen by the maxillofacial surgeon. A review of the clinical presentation, etiology, and management of these conditions may prompt timely recognition and treatment.
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Affiliation(s)
- R E Warburton
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - C C D Brookes
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - B A Golden
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - T A Turvey
- Department of Oral and Maxillofacial Surgery, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Hung CH, Chang KH, Chen YL, Wu YM, Lai CL, Chang HS, Lyu RK, Wu YR, Chen CM, Huang CC, Chu CC, Chen CH, Ro LS. Clinical and radiological findings suggesting disorders other than tolosa-hunt syndrome among ophthalmoplegic patients: a retrospective analysis. Headache 2015; 55:252-64. [PMID: 25688645 DOI: 10.1111/head.12488] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2014] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To investigate clinical and radiological features of Tolosa-Hunt syndrome (THS) and examine their diagnostic value, and to propose clinical and radiological features that indicate other symptomatic painful ophthalmoplegias (SPOs) in order to distinguish them from THS. BACKGROUND Clinical presentations of THS are nonspecific and may overlap with many etiologies. Therefore, excluding other SPOs is essential for correct diagnosis. At the present time, the predictive value of the current International Classification of Headache Disorders (ICHD) criteria is not well established, and specific imaging markers that can discriminate SPOs from THS are lacking. METHODS Patients referred with painful ophthalmoplegia over 12 years were recruited retrospectively and allocated into THS or SPO groups. Typical symptoms (episodic unilateral orbital pain preceding or developing with diplopia) and imaging of THS (inflammatory lesions in the cavernous sinus/orbit by magnetic resonance imaging) were proposed based on ICHD-3 beta criteria and previous literature. Atypical clinical and radiological features suggesting alternative diagnoses were also proposed to predict SPO. Initial presentations and imaging findings were registered and correlated with diagnostic outcomes. The predictive value of clinical and imaging findings was then evaluated. RESULTS Of the 61 referred cases, 25 were classified as THS and 36 as SPO. Of the SPO cases, 52.8% manifested typical THS symptoms at onset. Patients with SPOs were prone to have atypical symptoms (47.2%) and radiographical findings (82.1%) in comparison to those with THS (4.0% and 4.2%, respectively; both P < .001). Both typical symptoms and imaging findings predicted a diagnosis of THS with high sensitivity (95.8% and 100%, respectively) but low specificity (47.2% and 28.6%, respectively). High sensitivity (82.1%) and specificity (95.8%) were achieved using atypical imaging features to predict SPO. CONCLUSION A diagnosis of THS based strictly on clinical presentations or imaging results is not completely reliable. Identification of atypical imaging features may have a useful role in discriminating SPOs and thus avoid erroneous diagnoses of THS. Future studies with larger sample sizes are warranted to evaluate their validity in general population.
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Affiliation(s)
- Chih-Hsien Hung
- Department of Neurology, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan; Department of Neurology, Kaohsiung Medical University Hospital; Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
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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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Abdelghany M. Corrections to “Validation of ICHD-3 beta diagnostic criteria for 13.7 Tolosa-Hunt syndrome: Analysis of 77 cases of painful ophthalmoplegia”. Cephalalgia 2015; 35:285. [DOI: 10.1177/0333102414534328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mahmoud Abdelghany
- Department of Medicine, Conemaugh Memorial Medical Center, Johnstown, PA, USA
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Sánchez Vallejo R, Lopez-Rueda A, Olarte AM, San Roman L. MRI findings in Tolosa-Hunt syndrome (THS). BMJ Case Rep 2014; 2014:bcr-2014-206629. [PMID: 25368129 DOI: 10.1136/bcr-2014-206629] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Antonio Lopez-Rueda
- Department of Radiology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | - Ana Maria Olarte
- Department of Radiology, Hospital Universitario Sagrat Cor, Barcelona, Spain
| | - Luis San Roman
- Department of Radiology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
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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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Zhang X, Zhang W, Liu R, Dong Z, Yu S. Factors that influence Tolosa-Hunt syndrome and the short-term response to steroid pulse treatment. J Neurol Sci 2014; 341:13-6. [PMID: 24703581 DOI: 10.1016/j.jns.2014.03.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/24/2014] [Accepted: 03/14/2014] [Indexed: 10/25/2022]
Abstract
Some but not all patients with Tolosa-Hunt syndrome (THS) have dramatic responses to steroid treatment. A systematic study about the factors that may influence the steroid response of THS patients has not been published. We retrospectively identified 40 patients diagnosed with THS and treated with steroids with respect to patient age at onset, gender, the cranial nerve(s) involved, as well as imaging findings and laboratory tests. Within the context of these data we evaluated the therapeutic efficacy of steroid treatment and recurrence of attacks. We did not note a significant relationship between genders, whether THS was benign or inflammatory, the distribution of cranial nerve palsies, the initial dose of steroids and the effectiveness of steroid treatment for relief of orbital pain or cranial nerve palsies at 72 h or 1 week after treatment. Our study reveals that a rapid alleviation of pain by steroid treatment is a characteristic feature of THS patients. The alleviation of cranial nerve palsy is somewhat slower and more variable, and may involve additional mechanisms. There is an effect of patient age and whether attacks will recur (recurrence was more likely in patients who were young at the time of first attack), whether THS will be benign or inflammatory (more likely to be inflammatory in young patients) and the short-term response of cranial nerve palsy to steroid treatment, which was more effective in young patients. These relationships may be of value in counseling patients presenting with THS.
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Affiliation(s)
- Xingwen Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
| | - Wei Zhang
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ruozhuo Liu
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhao Dong
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China
| | - Shengyuan Yu
- Department of Neurology, Chinese PLA General Hospital, Beijing 100853, China.
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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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Hung CH, Chang KH, Chu CC, Liao MF, Chang HS, Lyu RK, Wu YM, Chen YL, Lai CL, Tseng HJ, Ro LS. Painful ophthalmoplegia with normal cranial imaging. BMC Neurol 2014; 14:7. [PMID: 24400984 PMCID: PMC3890526 DOI: 10.1186/1471-2377-14-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/07/2014] [Indexed: 11/24/2022] Open
Abstract
Background Painful ophthalmoplegia with normal cranial imaging is rare and confined to limited etiologies. In this study, we aimed to elucidate these causes by evaluating clinical presentations and treatment responses. Methods Cases of painful ophthalmoplegia with normal cranial MRI at a single center between January 2001 and June 2011 were retrospectively reviewed. Diagnoses of painful ophthalmoplegia were made according to the recommendations of the International Headache Society. Results Of the 58 painful ophthalmoplegia cases (53 patients), 26 (44.8%) were diagnosed as ocular diabetic neuropathy, 27 (46.6%) as benign Tolosa-Hunt syndrome (THS), and 5 (8.6%) as ophthalmoplegic migraine (OM). Patients with ocular diabetic neuropathy were significantly older (62.8 ± 7.8 years) than those with benign THS (56.3 ±12.0 years) or OM (45.8 ± 23.0 years) (p < 0.05). Cranial nerve involvement was similar among groups. Pupil sparing was dominant in each group. Patients with benign THS and OM responded exquisitely to glucocorticoid treatment with resolved diplopia, whereas patients with ocular diabetic neuropathy didn’t (p < 0.05). Patients with OM recovered more rapidly than the other groups did (p < 0.05). Overall, most patients (94.8%) recovered completely during the follow-up period. Conclusions Ocular diabetic neuropathy and benign THS accounted for most of the painful ophthalmoplegias in patients with normal cranial imaging. Patient outcomes were generally good.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Long-Sun Ro
- Department of Neurology, Linkou Campus, Chang Gung Memorial Hospital and University College of Medicine, Gueishan Township, Taiwan.
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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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Affiliation(s)
- Jonathan Zurawski
- Medstar Washington Hospital Center Department of Medicine, Washington, DC 20010, USA.
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Ling JD, Chao D, Al Zubidi N, Lee AG. Big red flags in neuro-ophthalmology. Can J Ophthalmol 2013; 48:3-7. [PMID: 23419292 DOI: 10.1016/j.jcjo.2012.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/23/2012] [Indexed: 10/26/2022]
Abstract
Specific red flag clinical signs in ophthalmology might indicate serious underlying systemic disease. This review illustrates five big red flags in neuro-ophthalmology of interest to comprehensive ophthalmologists. These clinical signs include: (i) retinochoroidal venous collaterals, (ii) optic disc edema with a macular star, (iii) chronic red eyes refractory to topical therapy, (iv) aberrant regeneration not secondary to ischemia, and (v) the misdiagnosis of immune disease in immunosuppressed patients. We also describe the common causative factors suggested by these red flags (i.e., optic nerve sheath meningioma, infectious neuroretinitis, carotid cavernous fistula, compressive third nerve lesions, and the incorrect diagnosis of Tolosa-Hunt syndrome [THS]), as well as the distinctive laboratory or radiographic signs for each condition.
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