Painful ophthalmoplegia with normal cranial imaging

Tolosa-Hunt syndrome: a review of diagnostic criteria based on a case series

Purpose

Tolosa-Hunt syndrome (THS) is a rare cause of painful ophtalmoplegia with different clinical manifestations. It is described as a unilateral periorbital headache with concomitant dysfunction of at least one out of the IIIrd, IVth and VIth cranial nerves due to the granulomatous inflammation of periorbital structures, but no underlying cause has been established.

Case description

We present six patients referred to the Neurology Department due to a unilateral headache with ipsilateral paresis of at least one cranial nerve responsible for eye movements. The THS diagnostic criteria of the International Headache Disorders Classification (ICHD-3) were applied and analysed. Few patients had atypical clinical manifestations according to these criteria.

Comment

Diagnosing THS may prove very challenging. There is a lack of specific markers for the disorder, whereas diagnostic criteria leave a wide area for misdiagnosis. The diagnostic approach should be focused on the exclusion of other pathologies because typical steroid therapy may prove fatal in otherwise benign cases.

Ocular motor nerve palsy in patients with diabetes: High-resolution MR imaging of nerve enhancement

OBJECTIVE

To evaluate the extent of signal abnormality in impaired ocular motor nerves using high signal and spatial resolution MRI sequences and to discuss the involvement of inflammatory or microvascular impairment in patients with diabetic ophthalmoplegia.

METHODS

We conducted a retrospective study of 10 patients referred for acute ocular motor nerve palsy in the context of diabetes mellitus from September 15th, 2021 to April 24th, 2022. 3T MRI evaluation included diffusion, 3D TOF, FLAIR, coronal STIR and post-injection 3D T1 SPACE DANTE sequences.

RESULTS

Ten patients were included: 9 males and 1 female aged from 46 to 79 years. Five patients presented with cranial nerve (CN) III palsy, and 5 presented with CN VI palsy. Third nerve palsy was pupil-sparing in 4 patients and pupil-involved in 1 patient. Pain was associated in all patients with CN III deficiencies and in 2 patients CN VI deficiencies. In all patients, MRI sequences ruled out mass effect and vascular pathology, such as acute stroke or aneurysm. Eight patients presented with STIR hypersignals, some with enlargement of the involved nerve. The diagnosis was confirmed through a post-injection 3D T1 SPACE DANTE sequence, which showed extended enhancement along the abnormal portion of the nerve.

CONCLUSION

High-resolution MRI evaluation of diplopia in diabetic patients is used to rule out a diagnosis of acute stroke and contributes to the positive diagnosis of ocular motor nerve impairment, possibly combining the influences of inflammatory and microvascular phenomena. Dedicated MR imaging should be included in the initial diagnosis and longitudinal follow-up of patients with diabetic ophthalmoplegia.

Research hotspots and trends of oculomotor nerve palsy from 2001 to 2021 based on web of science: A bibliometric analysis

Background

Oculomotor nerve palsy (ONP) is a clinically occurring neurological disorder. Due to the complex anatomy and long travel distances of the oculomotor nerve, the causes of ONP vary and manifest in various ways. With continued interest in this area, it has become necessary to conduct a bibliometric study in ONP. This work aims to synthesize and visually identify current research themes and future trends in ONP through a literature-based analysis.

Method

Articles and reviews on ONP published from 2002 to 2021 were derived from the Web of Science Core Collection (WoSCC) database. We generated visual images and performed quantitative and qualitative analysis through an online bibliometric tool, Citespace and VOSviewer software.

Results

A total of 1,205 published articles were included in this analysis. The annual number of this area's publications is showing an overall upward trend, with the number of citations increasing every year, reaching 2,698 by 2021. The United States (367) and Japan (116) dominated the list with the most numerous articles published. The University of California Los Angeles in the USA is the institution that published the highest number of articles (47). Engle EC (23) and the JOURNAL OF NEUROSURGERY (46) are the most influential authors and journals in this field. The co-occurrence network analysis divided the keywords into five main research themes, which mainly include clinical manifestations of ONP, aneurysms, cerebral neurological symptoms, diseases with ONP as a complication, and other neurological disorders.

Conclusion

This study is the first comprehensive and systematic bibliometric analysis of the current state of global ONP research over the past 20 years. We organized current hotspots and expected trends and provided key information for exploring potential research frontiers in ONP.

Clinical Features of Painful Ophthalmoplegia with a High-Intensity Ring Appearance around the Optic Nerve on MRI: A Case Series

Objective

Painful ophthalmoplegia includes nonspecific magnetic resonance imaging (MRI) manifestations and various clinical features including orbital pain and cranial nerve palsies. Treatment for painful ophthalmoplegia remains controversial. The aim of this report was to describe detailed clinical features, MRI findings, treatments, and prognosis of patients with painful ophthalmoplegia. Patients and Methods. We retrospectively investigated four cases of patients with painful ophthalmoplegia diagnosed using the International Classification of Headache Disorders, 3rd edition.

Results

All patients experienced unilateral orbital pain and oculomotor nerve palsy with diplopia but no vision loss. One of the four patients was diagnosed with Tolosa-Hunt syndrome based on the appearance of a granulomatous inflammation of the cavernous sinus on MRI. No specific lesions were detected on brain MRI for the other three patients; therefore, their headaches were attributed to ischaemic ocular motor nerve palsy. In all patients, a high-intensity ring appearance around the ipsilateral optic nerve was observed on MRI. Steroid therapy was administered to these patients, and good prognoses were anticipated.

Conclusion

These results indicate that prednisolone is a useful treatment for painful ophthalmoplegia that displays ipsilateral hyperintense ring lesions around the optic nerve on MRI, regardless of the presence of granulomatous inflammation of the cavernous sinus.

Quantitative analysis of pupillometry in isolated third nerve palsy

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.

Recurrent painful ophthalmoplegic neuropathy

Recurrent painful ophthalmologic neuropathy (RPON), previously termed ophthalmoplegic migraine, is characterised by repeated attacks of one or more ocular cranial nerve palsies with ipsilateral headache. Its cause remains unclear; it is currently thought to be neuropathic in origin, but there is debate in the literature. In documented cases, a third cranial nerve palsy is by far the most common. Here we present a case of RPON involveing the fourth and sixth cranial nervesonly. Thorough investigation, including MR scan of brain and lumbar puncture, found no alternative explanation. This case adds to the debate over whether the cause of RPON is truly neuropathic or migrainous.

Evaluation and Management of Tolosa-Hunt Syndrome in Children: A Clinical Update

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.

Steroid-responsive painful ophthalmoplegia: Tolosa–Hunt syndrome, Eales disease, or both?

Introduction

Tolosa–Hunt syndrome (THS) is one of the most common ‘benign’ causes of painful ophthalmoplegia. Diagnosis is based on clinical and imaging findings and the exclusion of other causes because there is no specific biomarker for the syndrome. Eales disease, an idiopathic inflammatory venous disease that primarily affects the eye, can also affect the central (as stroke or myelitis) and peripheral nervous system.

Case report

We report the case of a 32-year-old woman with a subacute left ophthalmoplegia and evidence of a gadolinium-enhanced lesion suggesting an inflammatory granuloma that resolved within 48 hours after treatment with steroids. A diagnosis of THS was considered at this time. On a follow-up ophthalmological examination, a diagnosis of Eales disease with involvement of the left eye was made. The patient was treated successfully.

Conclusion

Eales disease could be a cause of painful ophthalmoplegia and may mimic THS. Long-term follow-up of patients diagnosed with THS may be necessary to exclude other diagnoses.

From ophthalmoplegic migraine to cranial neuropathy

Ophthalmoplegic migraine (OM)/recurrent painful ophthalmoplegic neuropathy (RPON) is a rare disease consisting of recurrent unilateral headache accompanied or followed by ipsilateral ophthalmoplegia. Because MRI findings suggest neuropathy and the relationship to typical migraine remains unclear, the disease has been renamed from "ophthalmoplegic migraine" to "recurrent painful oculomotor neuropathy" in the third edition of the International Classification of Headache Disorders (ICHD). However, it remains a fact that most cases of OM/RPON described in the literature have a history of migraine and that the headache during OM/RPON often has migrainous features. A more detailed clinical description of the headache during OM/RPON and additional results from imaging and possibly histology will be needed to better understand the pathophysiology of the disease and its relationship to typical migraine.

Clinical and radiological findings suggesting disorders other than tolosa-hunt syndrome among ophthalmoplegic patients: a retrospective analysis

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.