Inflammatory involvement of the hypophysis in Tolosa-Hunt syndrome

Tolosa-Hunt syndrome presenting with features of a trigeminal autonomic cephalalgias and pituitary enlargement

Tolosa-Hunt syndrome is understood as a steroid-responsive, relapsing-remitting, unilateral headache disorder associated with ipsilateral cranial neuropathies, of a probable granulomatous aetiology. The diagnosis is made clinically from the history and examination, supported by appropriate imaging. Here the authors report a case of Tolosa-Hunt syndrome with a headache phenotype mimicking a trigeminal autonomic cephalalgias (hemicrania continua), and serial MRI studies showing a stable enlarged pituitary. Due to her initial lack of clinical signs, she was diagnosed with chronic migraine, revised to hemicrania continua based on indomethacin response, then revised back to chronic migraine. Her final diagnosis was achieved after she developed a left cavernous sinus syndrome 4 years into her disease course. This case shows that Tolosa-Hunt syndrome may present with a non-side-locked headache and delayed development of clinical signs. Clinicians should also maintain a high degree of suspicion when faced with incidental MRI findings.

Tolosa–Hunt Syndrome: Critical Literature Review Based on IHS 2004 Criteria

In 2004, the International Headache Society (IHS) re-defined the diagnostic criteria of Tolosa–Hunt syndrome (THS) specifying that granuloma, demonstrated by magnetic resonance imaging (MRI) or biopsy, is required for diagnosis. We reviewed the literature on THS published from 1988 (year of publication of first IHS criteria) to 2002, analysing individual cases in relation to the new IHS criteria. One hundred and twenty-four cases were identified. As far as it was possible to discern, clinical presentation was similar in all, but 44 (35±) were reported to have inflammation on MRI or bioptic evidence of granuloma, 41/124 (33±) had normal neuroimaging findings and 39 (31±) had a specific lesion, so the THS was secondary. These data confirm that clinical criteria for THS are common to several conditions and their application alone does not guarantee a correct diagnosis. The requirement for inflammation on MRI will result in better classification of painful ophthalmoplegias; nevertheless, an MRI protocol that best defines inflammation should be specified. The status of cases which fulfil the clinical criteria but have normal MRI remains to be clarified.

Granulomatous Pachymeningitis Around the Sella Turcica (Tolosa-Hunt Syndrome) Involving the Hypophysis-Case Report-

A 50-year-old female presented with right painful abducens nerve palsy persisting for 4 months and mild panhypopituitarism with diabetes insipidus for 6 months. T(1)-weighted magnetic resonance (MR) imaging of the sellar region showed a homogeneously enhanced mass lesion in the right cavernous sinus which seemed to extend from the swollen pituitary gland. T(2)-weighted MR imaging clearly showed the mass in the right cavernous sinus and the thickened dura mater of the sellar floor as hypointense, and the enlarged pituitary gland as isointense. Biopsy of the thickened dura mater and swollen pituitary gland was performed via the transsphenoidal approach. Histological examination revealed inflammation and collagen fiber formation in these regions. The diagnosis was secondary panhypophysitis resulting from granulomatous pachymeningitis involving the cavernous sinus (Tolosa-Hunt syndrome). Corticosteroid therapy was begun after the biopsy. Her periorbital pain and diplopia were relieved, but diabetes insipidus persisted. Follow-up MR imaging showed a decrease in the volumes of the pituitary gland and the mass in the cavernous sinus.

A case of Tolosa-Hunt syndrome affecting both the cavernous sinuses and the hypophysis, and associated with C3 and C4 aneurysms

BACKGROUND

We describe the first case of Tolosa-Hunt syndrome that is associated with C3 and C4 aneurysms.

CASE DESCRIPTION

The patient, a female aged 58 years, had diplopia and right retroorbital pain. Magnetic resonance imaging revealed an enlargement of the hypophysis and bilateral cavernous sinuses, particularly on the right side. Cerebral angiography demonstrated ICA aneurysms of the left C3 and right C4 portions. These symptoms were immediately alleviated after initiation of prednisolone therapy, but recurred after the dose was tapered off. Radiological examination revealed an enlargement of the hypophysis whereas the right C4 aneurysm had decreased in size and no blood flow was apparent in the ipsilateral ophthalmic artery. A biopsy was performed and the results showed a focal inflammatory change. Steroid therapy was represcribed, and after a follow-up period of 10 months without therapy, the patient has been free of symptoms.

CONCLUSION

We conclude that bilateral ICA aneurysms might be directly induced by inflammatory infiltration into intracavernous ICAs.

Lymphocytic hypophysitis: its expanding features

Lymphocytic hypophysitis is classically defined as an inflammatory disorder confined to adenohypophysis. However, it has recently been indicated that infundibuloneurohypophysitis underlies some subsets of central diabetes insipidus (DI). Therefore, lymphocytic hypophysitis can be considered a syndrome including disorders of both the anterior pituitary (lymphocytic adenohypophysitis) and the posterior pituitary (lymphocytic infundibuloneurohypophysitis). We describe a 77-yr-old woman with lymphocytic hypophysitis presenting with headache, diplopia, general malaise and appetite loss. Head magnetic resonance imaging (MRI) demonstrated pituitary swelling and dura mater thickening on the dorsum sella. Endocrinological investigations revealed both anterior and posterior pituitary dysfunction associated with primary hypothyroidism due to Hashimoto's thyroiditis. Headache and diplopia spontaneously disappeared, and anterior pituitary dysfunction, general malaise and appetite loss improved after taking 10 mg hydrocortisone daily, although ACTH hyposecretion persisted. Pituitary swelling was thereafter reduced but the dura mater thickening persisted. We suggest that this case may represent a variant of lymphocytic hypophysitis in which chronic inflammatory process involves both the anterior and the posterior pituitary gland, infundibulum, dura mater on the dorsum sella and cavernous sinus. Regarding expanding features of lymphocytic hypophysitis, it may be considered a syndrome including heterogeneous disorders, of which the pathogenesis remains to be elucidated.