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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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Alhakeem A, Elziny MM, Elmahdi M. A Case Report on a Unique Explanation for Headache With Ophthalmoplegia: The Tolosa-Hunt Syndrome. Cureus 2022; 14:e26093. [PMID: 35875300 PMCID: PMC9296152 DOI: 10.7759/cureus.26093] [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] [Accepted: 06/19/2022] [Indexed: 11/05/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is an extremely rare disorder characterized by painful unilateral ophthalmoplegia triggered by idiopathic inflammation of the cavernous sinus affecting the third, fourth, and/or sixth cranial nerve. Corticosteroid therapy effectively improves THS symptoms; thus, early clinical suspicion and diagnosis are essential. We report the case of a 37-year-old patient who presented with left-sided eye pain and double vision for four days. Physical examination was significant for oculomotor, trochlear and abducent nerves palsies on the left eye with slow light reflex. Contrast-enhanced magnetic resonance imaging of the head displayed mild asymmetry of the cavernous sinus regions with fullness on the left side and focal lateral thickening, confirming the THS diagnosis. The patient’s symptoms improved dramatically upon starting oral corticosteroid therapy.
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Imai M, Sunaga A, Aoki R, Osada T, Hoshikawa K, Oda S, Shimoda M. Possibility of arterial spin labeling perfusion magnetic resonance imaging sequences with steroid therapy for Tolosa-Hunt syndrome: A case report and review of literature. Surg Neurol Int 2022; 13:27. [PMID: 35127227 PMCID: PMC8813633 DOI: 10.25259/sni_969_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/28/2021] [Indexed: 11/19/2022] Open
Abstract
Background: The diagnostic criteria for Tolosa-Hunt syndrome (THS) were updated in 2013 in the 3rd Edition of the International Classification of Headache Disorders. It is now possible to diagnose THS based on the presence of granulomatous inflammation demonstrated on magnetic resonance imaging (MRI) without confirmation by biopsy. No previous study has reported the use of arterial spin labeling (ASL) perfusion MRI for diagnosing THS. Here, we report a case of THS in which ASL was used in the initial identification and to monitor therapeutic response following steroid therapy. Case Description: An 86-year-old man was complaining chiefly of the left orbital pain, as well as occipital pain, nausea, epiphora, and diplopia. Neurologically, his eye movements showed left adduction disorder and palsy of the right cranial nerve III. Magnetic resonance angiography revealed no abnormality in the left internal carotid artery. Contrast-enhanced MRI showed a region of slightly high signal in the left cavernous sinus. ASL was obtained using pCASL (TR/TE, 9000/98. 48 ms; postlabeling delay: 1525 ms; axial plane) revealed hyperperfusion from the intercavernous sinus to the vicinity of the left cavernous sinus due to a local increase in cerebral blood flow. The symptoms disappeared on day 62 of the treatment and he was in complete remission. Follow-up ASL was performed every other month showed reduced perfusion as the symptoms improved and confirmed the absence of a tumor over the follow-up period. Conclusion: This simple technique will play an important role in confirming no recurrence after steroid therapy treatment.
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Bridging the Gap between Ophthalmology and Emergency Medicine in Community-Based Emergency Departments (EDs): A Neuro-Ophthalmology Guide for ED Practitioners. Clin Pract 2021; 11:919-932. [PMID: 34940005 PMCID: PMC8700032 DOI: 10.3390/clinpract11040106] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/28/2021] [Accepted: 11/19/2021] [Indexed: 01/13/2023] Open
Abstract
Coordination of care for patients with neuro-ophthalmic disorders can be very challenging in the community emergency department (ED) setting. Unlike university- or tertiary hospital-based EDs, the general ophthalmologist is often not as familiar with neuro-ophthalmology and the examination of neuro-ophthalmology patients in the acute ED setting. Embracing image capturing of the fundus, using a non-mydriatic camera, may be a game-changer for communication between ED physicians, ophthalmologists, and tele-neurologists. Patient care decisions can now be made with photographic documentation that is then conveyed through HIPAA-compliant messaging with accurate and useful information with both ease and convenience. Likewise, external photos of the anterior segment and motility are also helpful. Finally, establishing clinical and imaging guidelines for common neuro-ophthalmic disorders can help facilitate complete and appropriate evaluation and treatment.
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Oghene J, Boppana SH, Reddy P, Beutler BD, Dalal D. Double Down on Double Vision: An Unusual Case of Painful Diplopia. Cureus 2021; 13:e20838. [PMID: 35111483 PMCID: PMC8794403 DOI: 10.7759/cureus.20838] [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] [Accepted: 12/30/2021] [Indexed: 11/06/2022] Open
Abstract
Tolosa-Hunt syndrome (THS) is a rare neuro-immunological disorder characterized by severe periorbital headaches and ophthalmoplegia. In some patients, THS may occur in parallel with other autoimmune disorders. The underlying etiology of THS remains to be definitively established. However, inflammation of the cavernous sinus or orbital apex represents a hallmark feature; magnetic resonance imaging, therefore, plays a key role in establishing a diagnosis. We describe a patient who presented with concomitant THS and granulomatosis with polyangiitis. In addition, we describe the clinical and imaging findings of THS and review treatment options for this rare condition.
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Affiliation(s)
- John Oghene
- Department of Internal Medicine and Primary Care, Brown University, Warren Alpert Medical School, Providence, USA
| | - Sri Harsha Boppana
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, USA
| | - Pooja Reddy
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
| | - Bryce D Beutler
- Department of Radiology, University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Deepan Dalal
- Department of Rheumatology, Brown University, Warren Alpert Medical School, Providence, USA
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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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Corredor MM, Holmberg PJ. Ophthalmoplegia and cranial nerve deficits in an adolescent with headache. SAGE Open Med Case Rep 2021; 9:2050313X211024487. [PMID: 34178348 PMCID: PMC8202257 DOI: 10.1177/2050313x211024487] [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: 12/30/2020] [Accepted: 05/24/2021] [Indexed: 11/25/2022] Open
Abstract
Tolosa–Hunt syndrome is an idiopathic, inflammatory condition involving the cavernous sinus and is characterized by unilateral, painful ophthalmoparesis. The condition often begins with retro-orbital pain followed by select cranial nerve involvement. We report the case of a 17-year-old female whose presentation with progressive left-sided headache and ophthalmoparesis culminated in the diagnosis of Tolosa–Hunt syndrome. While many of her signs and symptoms have been previously reported in the rare pediatric cases of Tolosa–Hunt syndrome described in the literature, this case illustrates a unique presentation involving cranial nerves V and VII in addition to the more commonly reported cranial nerve III, IV, and VI palsies.
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Affiliation(s)
- Margarita M Corredor
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Peter J Holmberg
- Division of Pediatric Hospital Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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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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Zhang N, Shao C, Pan Y, Xiong G, Wang J, Liu Z, Chen B. Multiple Spontaneous Visceral Arterial Dissections in a Patient With Tolosa-Hunt Syndrome on Corticosteroid Therapy. Ann Vasc Surg 2021; 74:523.e1-523.e7. [PMID: 33838239 DOI: 10.1016/j.avsg.2021.01.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/17/2021] [Accepted: 01/28/2021] [Indexed: 11/27/2022]
Abstract
Multiple spontaneous visceral arterial dissections are an infrequent occurrence. The etiology, risk factors and natural history of these dissections have not been elucidated, and the optimal therapeutic strategy has not been established. We report a rare case of multiple spontaneous visceral arterial dissections involving the celiac artery, splenic artery, superior mesenteric artery, and right renal artery in a patient with Tolosa-Hunt syndrome on short-term corticosteroid therapy. The patient was subjected to conservative treatment and endovascular repair, achieving good clinical and radiological outcomes during the long-term follow-up period.
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Affiliation(s)
- Naiding Zhang
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Changming Shao
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yifeng Pan
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Guiya Xiong
- Department of Science and Research, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jian Wang
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhenjie Liu
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Bing Chen
- Department of Vascular Surgery, 2nd Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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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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Bhatkar S, Mahesh KV, Sachdeva J, Goel A, Goyal MK, Takkar A, Ray S, Shree R, Balaini N, Singh P, Singh R, Patnaik SN, Prabhat N, Lal V. Magnetic resonance imaging (MRI) versus computed tomographic scan (CT scan) of brain in evaluation of suspected cavernous sinus syndrome. Neuroradiol J 2020; 33:501-507. [PMID: 33283671 DOI: 10.1177/1971400920970921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE The cavernous sinus is a unique region owing to anatomical factors and the pathologies affecting it. The diagnosis of cavernous sinus syndrome (CSS) predominantly relies on clinicoradiological correlation. We studied the utility of computed tomographic (CT) scan versus magnetic resonance imaging (MRI) in the diagnosis of CSS. METHODS A prospective observational study was conducted in a tertiary care center in north India. All patients presenting with a clinical syndrome of cavernous sinus involvement with radiologically confirmed lesions were enrolled in the study. MRI and CT scan with cavernous sinus cuts were done and reviewed by experienced neuroradiologists for cavernous sinus lesions and compared with the final diagnosis. Sensitivity and specificity were calculated. RESULTS We included 48 patients in our study. A final diagnosis was achieved in 41 out of 48 (85.6%) patients. Fungal infections (16 (33.3%)) constituted the commonest cause of CSS, followed by neoplastic involvement (13 (27.1%)) and Tolosa-Hunt syndrome (12 (25%)). Vascular involvement was seen in three (6.3%) patients. Other rare causes were seen in four (8.3%) patients. CT scan had an overall sensitivity of 14.6% in achieving a final diagnosis, whereas MRI had an overall sensitivity of 70.7%, with a statistically significant difference (p < 0.001). CONCLUSIONS Although CT scan is a relatively cheap and accessible resource, its role in CSS diagnosis and management is limited because of poor yield. Hence, it is prudent to do an MRI as an initial investigation in cases of CSS.
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Affiliation(s)
- Sanath Bhatkar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Karthik Vinay Mahesh
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Julie Sachdeva
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Abeer Goel
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manoj K Goyal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Takkar
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sucharita Ray
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritu Shree
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neeraj Balaini
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paramjit Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Narayan Patnaik
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nandita Prabhat
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vivek Lal
- Department of Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Arthur A, Sivadasan A, Mannam P, Prabakhar AT, Aaron S, Mathew V, Karthik M, Benjamin RN, Iqbalahmed SA, Rynjah GL, Alexander M. Tolosa-Hunt Syndrome: Long-Term Outcome and Role of Steroid-Sparing Agents. Ann Indian Acad Neurol 2020; 23:201-205. [PMID: 32189862 PMCID: PMC7061504 DOI: 10.4103/aian.aian_368_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/25/2018] [Accepted: 11/05/2018] [Indexed: 01/03/2023] Open
Abstract
Background: Tolosa-Hunt Syndrome (THS) is one of the causes of cavernous sinus syndrome causing painful ophthalmoplegia. Literature on long-term outcome of this rare condition is scarce. Aims and Objectives: The aim is to study the recurrence and role of steroid-sparing agents in THS. Methodology: All cases of THS treated at a tertiary-level teaching hospital during a 10-year period were studied. Clinical and radiological profile, response to treatment and recurrences were noted. Results: A total of 44 cases were studied. The mean age was 49.5 years, Males constituted 23/44 (52%). The first symptom was pain in 90%. Ptosis with ophthalmoplegia was the most common deficit 29/44 (66%). Lesions confined to cavernous sinus 27/44 (61%) was the most frequent magnetic resonance imaging finding. All patients received steroids as the initial treatment and 15/44 (34%) received steroid-sparing agents. Follow-up ranged from 6 to 120 months (Mean 39 months). Two patients had alternative diagnosis of leptomeningeal malignancy and hypertrophic pachymeningitis on follow-up. Recurrences occurred in 18/37 (48.6%). Time for recurrence varied from 8 months to 7 years. (Mean 18 months). No clinical or radiological predictors for recurrence were identified. Patients who received steroid-sparing agents had a significantly lower recurrence 3/15 (20%) versus 14/26 (53.8%)P < 0.034. Conclusions: Around 50% of patients with THS can have recurrence. Steroid-sparing agents appear to prevent recurrence. A prospective multicenter randomized controlled trial may help to evaluate the risk and benefits of steroid-sparing therapy and to identify any possible predictors for recurrence.
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Affiliation(s)
- Anupriya Arthur
- Department of Ophthalmology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Ajith Sivadasan
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Pavitra Mannam
- Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - A T Prabakhar
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sanjith Aaron
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Vivek Mathew
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - M Karthik
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Rohith Ninan Benjamin
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Shaikh Atif Iqbalahmed
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Gideon Lyngsyun Rynjah
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mathew Alexander
- Department of Neurological Sciences, Neurology Unit, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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A case of delirium in Tolosa-Hunt syndrome during corticosteroid therapy. JA Clin Rep 2018; 4:58. [PMID: 32026006 PMCID: PMC6967251 DOI: 10.1186/s40981-018-0193-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Corticosteroid therapy is useful for the resolution of pain and paresis in Tolosa-Hunt syndrome; however, there is no definitive protocol for appropriate dosing, route of administration, or duration of therapy. Steroid psychosis is an adverse reaction to corticosteroid therapy; in severe cases, it can develop into psychiatric disorders such as delirium, depression, and mania. In this case study, we report a patient with Tolosa-Hunt syndrome who developed delirium while receiving corticosteroid therapy. CASE PRESENTATION The patient was a 70-year-old man being treated for a main complaint of pain in the right eye accompanied by oculomotor paralysis. We suspected Tolosa-Hunt syndrome based on diagnostic imaging and other findings. Steroid pulse therapy was initiated with intravenous methylprednisolone at 1000 mg/day for 3 days, followed by oral prednisolone at 60 mg/day. The pain in the right eye disappeared the day after starting this regimen, and palpebral ptosis also improved. However, 5 days after starting treatment, the patient developed progressively worsening delirium, which was considered an adverse reaction to the steroid pulse therapy. Then, prednisolone treatment was temporarily suspended, and the delirium subsequently disappeared. CONCLUSIONS The manifestation of steroid psychosis following corticosteroid therapy is dose dependent. Therefore, corticosteroid therapy for elderly patients requires caution and dose modulation because of likely adverse drug reactions.
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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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Suspected retroorbital inflammation resulting in bilateral occlusion of the internal carotid arteries. J Neurol Sci 2017; 380:51-53. [DOI: 10.1016/j.jns.2017.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/01/2017] [Accepted: 06/25/2017] [Indexed: 11/20/2022]
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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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Cavernous sinus syndrome: A prospective study of 73 cases at a tertiary care centre in Northern India. Clin Neurol Neurosurg 2017; 155:63-69. [PMID: 28260625 DOI: 10.1016/j.clineuro.2017.02.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 12/22/2016] [Accepted: 02/20/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To study the clinical and etiological profile of patients with cavernous sinus syndrome (CSS) and identify factors which could determine the etiology and influence the outcome of these patients. PATIENTS AND METHODS This prospective observational study included 73 consecutive patients satisfying the criteria of CSS (i.e. involvement of any 2 of the 3rd, 4th, 5th and 6th cranial nerves or any one of them with radiological evidence of cavernous sinus involvement). All these patients were subjected to detailed haematological, biochemical and radiological investigations and diagnosed and treated as per guidelines. The clinical and investigational data was recorded and analysed meticulously. RESULTS A definitive etiological diagnosis of CSS could be achieved in 86% of patients. Tumours, fungal infections and Tolosa Hunt syndrome (THS) were most common causes. On univariate analysis, diabetes, severe vision loss (visual acuity of <3/60 in at least one eye), and presence of nasal discharge showed a significantly positive association with a fungal CSS. Evidence of paranasal sinusitis, bone erosion and ICA (internal carotid artery) involvement on Gadolinium enhanced MRI (magnetic resonance imaging) of brain were significantly associated with a fungal CSS (p=0.0001), whereas involvement of orbital apex had a negative association with a neoplastic etiology (p=0.014). On multiple logistic regression, orbital apex involvement on MRI was associated with diagnosis of THS (p=0.019, OR: 18.7; 95% CI: 1.6-217.4) while MRI evidence of paranasal sinusitis (p=0.014, OR: 45; 95% CI: 2.1-94.3) and bone erosion ((p=0.019, OR: 12.5; 95% CI: 1.5-103) correlated with diagnosis of fungal CSS. 65.2% of patients (fungal CSS- 70%) had a good prognosis at six months follow up. CONCLUSION Most patients with CSS can be diagnosed accurately and managed properly with good outcomes.
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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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A Rare Case of Tolosa-Hunt-Like Syndrome in a Poorly Controlled Diabetes Mellitus. Case Rep Med 2016; 2016:9763621. [PMID: 27087813 PMCID: PMC4818810 DOI: 10.1155/2016/9763621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/07/2016] [Indexed: 01/03/2023] Open
Abstract
We report a case of a 50-year-old female with diabetes mellitus who presented with progressive second, third, fifth, sixth, and eighth cranial nerve palsy. Diagnostic investigation revealed hyperglycemic state, and brain imaging showed a right cavernous sinus enhancement suggestive of and consistent with Tolosa-Hunt syndrome. The patient was started on steroids with tight glycemic control for eight weeks; subsequently, the cranial nerve palsies resolved as well as documented resolution of the right cavernous sinus enhancement.
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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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Kastirr I, Kamusella P, Andresen R. Bilateral Painful Ophthalmoplegia: A Case of Assumed Tolosa-Hunt Syndrome. J Clin Diagn Res 2016; 10:TD16-7. [PMID: 27134970 DOI: 10.7860/jcdr/2016/16703.7496] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 12/11/2015] [Indexed: 01/03/2023]
Abstract
We present the case of a man of 47 years with vertical and horizontal paresis of view combined with periorbital pain that developed initially on the right side but extended after 3-4 days to the left. Gadolinum uptaking tissue in the cavernous sinus was shown by MRI of the orbital region in the T1 spin echo sequence with fat saturation (SEfs) with a slice thickness of 2 mm. As no other abnormalities were found and the pain resolved within 72 hours of treatment with cortison a bilateral Tolosa-Hunt Syndrome (THS) was assumed. THS is an uncommon cause for Painful Ophthalmoglegia (PO) and only few cases of bilateral appearance have been reported. Even though the diagnostic criteria for THS oblige unilateral symptoms we suggest that in patients with bilateral PO THS should not be excluded as a differential diagnosis. Further more when using MRI to detect granulomatous tissue in the orbital region the chosen sequence should be T1 SEfs and slice thickness should possibly be as low as 2 mm, as granulomas are often no larger than 1-2 mm.
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Affiliation(s)
- Ilko Kastirr
- Medical Assistant, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
| | - Peter Kamusella
- Medical Specialist, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
| | - Reimer Andresen
- Head of Department, Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel , Lübeck and Hamburg, Germany
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Gupta SN, Gupta VS, Borad N. Spectrum of migraine variants and beyond: The individual syndromes in children. Brain Dev 2016; 38:10-26. [PMID: 26081103 DOI: 10.1016/j.braindev.2015.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 05/07/2015] [Accepted: 05/10/2015] [Indexed: 01/03/2023]
Abstract
"Migraine-related conditions" are probably the second most common condition after seizure encountered in pediatric neurology requiring frequent Emergency Department visits. Among migraines, migraine-related condition presents with an acute onset sign or symptom other than headache or visual aura of unknown etiology. A delay in diagnosis is a common occurrence. Previously, the authors proposed a common clinical profile and suggested that the future review should seek the applicability of the common profile in aid to clinical diagnosis of migraine-related individual syndromes. Authors describe the clinical characteristics and differential diagnosis of the spectrum of migraine variants and beyond in children.
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Affiliation(s)
- Surya N Gupta
- Section of Child Neurology, Women's and Children's Hospital, Charleston Area Medical Center, Charleston, WV, USA.
| | - Vikash S Gupta
- MS-IV, Texila American University, Woolford Ave, Georgetown, Guyana.
| | - Nirali Borad
- Department of Physiology, P.D.U. Government Medical College, Rajkot, Gujarat, India.
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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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Arshad A, Nabi S, Panhwar MS, Rahil A. Tolosa-Hunt syndrome: an arcane pathology of cavernous venous sinus. BMJ Case Rep 2015; 2015:bcr-2015-210646. [PMID: 26294359 DOI: 10.1136/bcr-2015-210646] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Tolosa-Hunt syndrome, an idiopathic granulomatous inflammation of the cavernous sinus, is primarily a diagnosis of exclusion. The majority of patients present with unilateral orbital pain and features suggestive of paralysis of one or more of the cranial nerves passing through the cavernous sinus and/or superior orbital fissure. MRI of the head may show unilateral enhancement of the cavernous sinus and orbital apex. Treatment is with high-dose intravenous steroids followed by tapering oral steroids. Rapid amelioration of pain within 24-48 h supports this rare diagnosis. Resolution of neuropathies may take longer. We describe a case of a young man who presented with left periorbital pain, complete ophthalmoplaegia and ptosis of the left eye. MRI showed enhancement of the left cavernous sinus and orbital apex. High dose steroids led to complete resolution of pain, while ptosis and ophthalmoplaegia improved gradually.
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Affiliation(s)
- Adeel Arshad
- Department of Internal Medicine, Hamad Medical Corporation, Weill Cornell University, Doha, Qatar
| | - Shahzaib Nabi
- Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | | | - Ali Rahil
- Department of Internal Medicine, Hamad Medical Corporation, Weill Cornell University, Doha, Qatar
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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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Yamamoto D, Tsuda E, Saitoh M, Imai T, Shimohama S. [A case of atypical Tolosa-Hunt syndrome with a contrast enhanced lesion of the oculomotor and trigeminal nerves on MRI]. Rinsho Shinkeigaku 2014; 54:903-6. [PMID: 25420565 DOI: 10.5692/clinicalneurol.54.903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 30-year-old woman was admitted to our hospital because of intractable orbital pain and ptosis on the left side. On admission, she had left oculomotor, ophthalmic and maxillary nerves palsy. MRI revealed a contrast enhanced lesion of the left oculomotor and trigeminal nerves through the covernous sinus and orbita. We diagnosed her condition as Tolosa-Hunt syndrome. The orbital pain was resolved within 48-hours by the pulse therapy with intra-venous methylpredonisolone. The cranial nerve palsy was gradually improved, but never reached complete remission. The left oculomotor and trigeminal nerves also remained enhanced on MRI until 200 days from the onset. Although there have been few reports to demonstrate the contrast enhancement of cranial nerves in Tolosa-Hunt syndrome, these MRI findings may be a specific indicator of the pathological process.
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Affiliation(s)
- Daisuke Yamamoto
- Department of Neurology, Sapporo Medical University School of Medicine
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Affiliation(s)
- H U Rehman
- From the University of Saskatchewan, Regina Qu'Appelle Health Region, Regina, SK, S4P 3X1, Canada
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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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Menjot de Champfleur N, Leboucq N, Menjot de Champfleur S, Bonafé A. Imaging of the pre-chiasmatic optic nerve. Diagn Interv Imaging 2013; 94:973-84. [DOI: 10.1016/j.diii.2013.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Jonathan Zurawski
- Medstar Washington Hospital Center Department of Medicine, Washington, DC 20010, USA.
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Hung CH, Chang KH, Wu YM, Chen YL, Lyu RK, Chang HS, Wu YR, Chen CM, Huang CC, Chu CC, Liao MF, Wai YY, Hsu SP, Ro LS. A comparison of benign and inflammatory manifestations of Tolosa-Hunt syndrome. Cephalalgia 2013; 33:842-52. [PMID: 23475292 DOI: 10.1177/0333102412475238] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Tolosa-Hunt syndrome (THS) manifests as a benign or an inflammatory type disease. The nosography differences between these types remain to be elucidated. We aimed to analyze and compare the clinical presentations of benign and inflammatory THS. METHODS The ward patients who presented with THS from January 1990 to May 2011 were retrospectively reviewed. THS was diagnosed according to the recommendations of the International Headache Society. RESULTS Of the 53 THS cases (49 patients), 30 (56.6%) were classified as benign and 23 (43.4%) as inflammatory THS. There were strong similarities between the groups in terms of clinical manifestations, laboratory findings, responses to glucocorticoid treatment, and outcomes. However, patients with inflammatory THS tended to be younger (mean age, 43.4 years; P 0.05) and have optic nerve dysfunction (56.5%; P 0.05) and longer disease duration (2.3 ± 1.0 months; P 0.05) compared to those with benign THS (mean age, 56.4 years; mean disease duration, 1.6 ± 0.7 months). The patients with additional involvement of both the optic nerve and the second division of the trigeminal nerve experienced a longer disease duration ( P 0.05). Additionally, patients with orbital pseudotumors had diplopia that responded poorly to treatment with glucocorticoids ( P 0.05). High-dose (>0.5 mg/kg/day) and low-dose (≤0.5 mg/kg/day) prednisolone were equally effective in relieving symptoms in both groups ( P > 0.05). CONCLUSION Benign and inflammatory THS were highly similar in terms of nosography. The responses to glucocorticoid treatment were generally good except in patients with orbital pseudotumors.
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Affiliation(s)
- Chih-Hsien Hung
- Department of Neurology, E-Da Hospital, I-Shou University, Taiwan
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Serralta San Martín G, Torrecillas Narváez D, Soler Rangel L, Ibáñez Sanz L, Gómez Cerezo J. Síndrome de Tolosa-Hunt. Rev Clin Esp 2013; 213:e11-2. [DOI: 10.1016/j.rce.2012.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/24/2012] [Accepted: 10/30/2012] [Indexed: 11/15/2022]
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Okawa S, Sugawara M, Takahashi S, Otani T, Hashimoto M, Kusunoki S, Ohnishi H. Tolosa-hunt syndrome associated with cytomegalovirus infection. Intern Med 2013; 52:1121-4. [PMID: 23676602 DOI: 10.2169/internalmedicine.52.0084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein present the case of a 38-year-old woman with left-sided oculomotor paralysis with ocular pain that developed after a respiratory infection. Her serum was positive for IgM against GM2 and GalNAc-GD1a gangliosides and cytomegalovirus. Thin-slice magnetic resonance imaging revealed enhanced abnormal tissue located primarily in the superolateral part of the left-sided cavernous sinus, which corticosteroids subsequently obscured with immediate resolution of the patient's ocular symptoms. These clinical features were consistent with those of Tolosa-Hunt syndrome (THS). Our findings in the present patient suggest that cytomegalovirus may provoke granuloma formation in the cavernous sinus, as reported in other various organs, thereby leading to the development of THS.
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Affiliation(s)
- Satoshi Okawa
- Department of Neurology, Akita University Graduate School of Medicine, Japan.
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Kakisaka Y, Kobayashi T, Uematsu M, Numata Y, Hirose M, Hino-Fukuyo N, Tsuchiya S, Doi H, Fukuda H, Kure S. Utility of Thallium-201 Scintigraphy in Tolosa-Hunt Syndrome. TOHOKU J EXP MED 2013; 229:83-6. [DOI: 10.1620/tjem.229.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yosuke Kakisaka
- Department of Pediatrics, Tohoku University School of Medicine
| | | | - Mitsugu Uematsu
- Department of Pediatrics, Tohoku University School of Medicine
| | - Yurika Numata
- Department of Pediatrics, Tohoku University School of Medicine
| | - Mieko Hirose
- Department of Pediatrics, Tohoku University School of Medicine
| | | | | | - Hiroshi Doi
- Department of Ophthalmology, Tohoku University School of Medicine
| | - Hiroshi Fukuda
- Department of Nuclear Medicine and Radiology, Institute of Development, Aging and Cancer, Tohoku University
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine
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Beckham S, Kim H, Truong A. Painful ophthalmoplegia of the right eye in a 20-year-old man. J Emerg Med 2012; 44:e231-4. [PMID: 22981660 DOI: 10.1016/j.jemermed.2012.07.049] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Revised: 03/22/2012] [Accepted: 07/01/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Painful ophthalmoplegia is an infrequent but very important presentation in the acute care setting and requires a thorough neurologic evaluation to determine its cause. This clinical sign has a large differential and generally indicates a serious cerebrovascular process. CASE REPORT We describe a patient with a subacute presentation of painful ophthalmoplegia, ultimately diagnosed as Tolosa-Hunt syndrome, a rare inflammatory process of the cavernous sinus. CONCLUSION This case highlights the importance for the Emergency Physician to quickly recognize painful ophthalmoplegia and rapidly elucidate the cause to prevent further complications for the patient.
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Affiliation(s)
- Stephen Beckham
- Department of Emergency Medicine, Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA 90033, USA
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Chakravarty A, Mukherjee A. Ophthalmoplegic migraine: A critical analysis and a new proposal. Ann Indian Acad Neurol 2012; 15:S2-6. [PMID: 23024560 PMCID: PMC3444213 DOI: 10.4103/0972-2327.99985] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/23/2011] [Accepted: 01/15/2012] [Indexed: 11/04/2022] Open
Abstract
The nosology, classification and pathophysiology of ophthalmoplegic migraine (OM) remains complex and debatable. A recently proposed classification of OM leaves several caveats. A critical analysis of all reported cases of OM (1993-2010) has been made incorporating the authors' own experience to arrive at a simple, unambiguous and easy to use diagnostic criteria and classification of OM. Between 2005 and 2010, 18 adult cases of OM had been seen whose clinical details are summarized. Most had sixth nerve palsies associated with migraine-like headaches lasting more than 4 days. Other possibilities were carefully excluded. All subjects responded to corticosteroids favorably. We prefer using the term ophthalmoplegia with migraine-like headache (OMLH) rather than OM. We classify OMLH as a migraine subtype (1.7) and into two groups-childhood-onset type (where third nerve palsies and nerve enhancement are common) and adult-onset type (where sixth nerve palsies are more common and nerve enhancement unusual). This clinico-radiological classification does not in any way hint at any difference in pathophysiology between the two groups.
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Affiliation(s)
- Ambar Chakravarty
- Department of Neurology, Vivekananda Institute of Medical Science, Kolkatta, West Bengal, India
| | - Angshuman Mukherjee
- Department of Neurology, Vivekananda Institute of Medical Science, Kolkatta, West Bengal, India
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Choi KD, Choi JH, Choi HY, Huh YE, Kim HJ, Oh SY, Jeong SH, Hwang JM, Kim JS. Inferior rectus palsy as an isolated ocular motor sign: acquired etiologies and outcome. J Neurol 2012; 260:47-54. [PMID: 22743791 DOI: 10.1007/s00415-012-6582-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/07/2012] [Accepted: 06/09/2012] [Indexed: 11/26/2022]
Abstract
The aim of this work is to elucidate underlying etiologies, lesion locations, and outcomes of inferior rectus (IR) palsy of acquired origin. Retrospective search identified 44 patients with acquired IR palsy between April 2006 and May 2011 from four Neurology and two Ophthalmology Clinics in Korea. We analyzed clinical features, the results of radiological and laboratory evaluation, and prognosis. The most common causes were vascular (n = 16, 36 %) and trauma (n = 12, 27 %). Vascular disorders included microvascular ischemia (n = 10, 23 %), cerebral infarction (n = 5, 11 %), and dural arterio-venous fistula (n = 1, 2 %). Other causes were inflammation (n = 7, 16 %), myasthenia gravis (n = 5, 11 %), and thyroid ophthalmopathy (n = 1, 2 %). We were unable to determine the etiology in the remaining three patients (7 %). Most patients (95 %) showed a complete recovery with or without treatment. Acquired IR palsy mostly occurs with brainstem or orbital lesions, and has an excellent prognosis.
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Affiliation(s)
- Kwang-Dong Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
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Shimizu Y, Tsutsumi S, Yasumoto Y, Ito M. Carotid cavernous sinus fistula caused by dental implant-associated infection. Am J Otolaryngol 2012; 33:352-5. [PMID: 21924520 DOI: 10.1016/j.amjoto.2011.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 08/03/2011] [Indexed: 10/17/2022]
Abstract
A 61-year-old woman presented with painful ophthalmoplegia, Tolosa-Hunt syndrome. The patient had undergone a placement of dental implant 5 months before the presentation and had a local maxillary sinusitis 1 month later. She had not been aware of any preceding head trauma or infection. On examination, the patient showed serious right oculomotor nerve paresis and retro-orbital pain. Blood examination showed normal findings. Magnetic resonance imaging identified abnormal structure in the right cavernous sinus with flow void signals. Angiography revealed a carotid cavernous sinus fistula fed by the intracavernous branches of the internal carotid artery on both sides, right internal maxillary and middle meningeal arteries, and left ascending pharyngeal artery. The patient underwent coil embolization via both external carotid arteries. We assumed that local maxillary sinusitis caused by dental implant might spread hematogenously into the sphenoid and cavernous sinuses and formed a carotid cavernous sinus fistula, which presented with Tolosa-Hunt syndrome. Implant-associated infection has to be managed promptly with adequate manner before it spreads.
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Camargo JF, Seriburi V, Tenner M, El Khoury MY. Aspergillus osteomyelitis of the lumbar spine complicated with orbital apex syndrome: A potential role of the Batson's plexus in disease propagation. Med Mycol Case Rep 2012; 1:9-12. [PMID: 24371725 DOI: 10.1016/j.mmcr.2012.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/29/2012] [Indexed: 11/29/2022] Open
Abstract
We report a rare case of orbital apex syndrome following epidural steroid injections of the lumbar spine in an immunocompetent individual with osteomyelitis and discitis caused by Aspergillus fumigatus. We suspect that the craniospinal venous system, also known as the Batson's plexus, was the main route for steroid-facilitated disease propagation from the spine to intracranial structures.
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Affiliation(s)
- Jose F Camargo
- Department of Medicine, Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595, USA
| | - Vimon Seriburi
- Department of Medicine, Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595, USA
| | - Michael Tenner
- Department of Radiology, New York Medical College, Valhalla, NY 10595, USA
| | - Marc Y El Khoury
- Department of Medicine, Division of Infectious Diseases, New York Medical College, Valhalla, NY 10595, USA
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Abstract
A 67-year-old Japanese woman without contributory medical history developed acute onset of left-sided trochlear nerve palsy (TNP) with persistent and severe periorbital pain. There were no other neurological abnormalities. Funduscopic findings were normal. Cranial and orbital magnetic resonance (MR) imaging, and cranial MR angiography demonstrated no abnormalities. By administration of prednisolone 40 mg/day from the day after onset, periorbital pain was resolved within 24 hours, and TNP within 5 days. Thereafter, prednisolone was gradually tapered off. She remained asymptomatic under no medication. In the English language literature, this is the first reported case of Tolosa-Hunt syndrome presenting with isolated TNP.
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Affiliation(s)
- Hiromasa Tsuda
- Department of Neurology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan
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Abstract
Head and facial pain are common in neurological practice and the pain often arises in the orbit or is referred into the eye. This is due to the autonomic innervation of the eye and orbit. There are acute and chronic pain syndromes. This review gives an overview of the differential diagnosis and treatment. Idiopathic headache syndromes, such as migraine and cluster headache are the most frequent and are often debilitating conditions. Trigemino-autonomic cephalalgias (SUNCT and SUNA) have to be taken into account, as well as trigeminal neuralgia. Trigemino-autonomic headache after eye operations can be puzzling and often responds well to triptans. Every new facial pain not fitting these categories must be considered symptomatic and a thorough investigation is mandatory including magnetic resonance imaging. Infiltrative and neoplastic conditions frequently lead to orbital pain. As a differential diagnosis Tolosa-Hunt syndrome and Raeder syndrome are inflammatory conditions sometimes mimicking neoplasms. Infections, such as herpes zoster ophthalmicus are extremely painful and require rapid therapy. It is important to consider carotid artery dissection as a cause for acute eye and neck pain in conjunction with Horner's syndrome and bear in mind that vascular oculomotor palsy is often painful. All of the above named conditions should be diagnosed by a neurologist with special experience in pain syndromes and many require an interdisciplinary approach.
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Affiliation(s)
- O Kastrup
- Neurologische Universitätsklinik Essen, Hufelandstr. 55, 45122, Essen, Deutschland.
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Abstract
We report on the imaging findings of Tolosa-Hunt syndrome in a 59-year-old patient. Clinical findings included periorbital pain, ptosis, disordered eye movements, and blurred vision. Treatment with intravenous administration of steroid resolved all symptoms. Currently, magnetic resonance imaging plays a key role in the diagnosis of Tolosa-Hunter syndrome for locating the inflammatory tissue and follow-up. This case of Tolosa-Hunter syndrome with representative (FDG PET/CT) images may imply that FDG PET/CT is a useful tool in detecting and monitoring of this disease.
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Kang CH, Huang YC, Lui CC, Chang YC, Hung PL. Unusual clinical course in pediatric Tolosa-Hunt syndrome. Pediatr Neurol 2011; 44:471-4. [PMID: 21555061 DOI: 10.1016/j.pediatrneurol.2011.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 12/16/2010] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
We report on a 7-year-old immunocompetent boy initially presenting with right-sided frontal cephalalgia, painful ophthalmoplegia, and ptosis for 1 month. Initial cerebrospinal fluid analysis produced normal results. Magnetic resonance imaging revealed an inflammatory pseudotumor of the right cavernous sinus after intravenous gadolinium administration, indicating a rare idiopathic inflammatory disorder of the cavernous sinus, i.e., Tolosa-Hunt syndrome. Ptosis and cephalalgia resolved after steroid treatment, although right-sided ophthalmoplegia remained. Breakthrough headache, associated with signs of meningeal irritation, developed 6 weeks later. Follow-up contrast-enhanced computed tomography revealed no enhancing cavernous soft tissue mass. A further lumbar puncture disclosed central nervous system infection with Staphylococcus saprophyticus. After 6 weeks of vancomycin, the headache resolved completely, and neuroimaging produced normal results. A diagnosis of Tolosa-Hunt syndrome should be rendered cautiously, because the etiology may involve a rare but not "idiopathic" infection. Moreover, if clinical signs are not fully responsive to steroid treatment, the underlying problems should receive careful investigation.
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Affiliation(s)
- Chia-Hao Kang
- Department of Pediatrics, Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan, Republic of China
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The imaging of conditions affecting the cavernous sinus. Clin Radiol 2010; 65:937-45. [DOI: 10.1016/j.crad.2010.06.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 06/11/2010] [Accepted: 06/23/2010] [Indexed: 11/16/2022]
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