Tolosa-Hunt syndrome

Case contributed by Dalia Ibrahim
Diagnosis almost certain

Presentation

Left painful ophthalmoplegia.

Patient Data

Age: 40 years
Gender: Male
mri
This study is a stack
Axial T1
C+ fat sat
This study is a stack
Sagittal T1
C+ fat sat
This study is a stack
Axial
T1 C+
This study is a stack
Coronal
T1 C+
This study is a stack
Axial
T1
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Axial
T2
This study is a stack
Axial
FLAIR
This study is a stack
Coronal
T1
This study is a stack
Coronal
T2
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Info

Intense homogeneously enhancing soft tissue mass lesion is seen at the left anterior cavernous sinus, orbital apex, and superior orbital fissure.

4 months post steroid therapy

mri
This study is a stack
Axial T1
C+ fat sat
This study is a stack
Sagittal
T1 C+
This study is a stack
Axial
T1 C+
This study is a stack
Coronal
T1 C+
This study is a stack
Axial
T1
This study is a stack
Axial
T2
This study is a stack
Coronal
T1
This study is a stack
Sagittal
T2
Download
Info

Significant size regression with near total resolution regarding the previously noted left anterior cavernous sinus, and orbital apex soft tissue mass.

4 months post steroid therapy

Annotated image
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Info

Significant size regression with near total resolution regarding the previously noted left cavernous sinus and orbital apex soft tissue mass.

Case Discussion

The second MRI exam was performed 4 months after steroid treatment, which revealed significant size regression. The diagnosis in this case is presumptive (by MRI radiological features only), no biopsy was taken.

Tolosa hunt syndrome is a non-specific inflammation of the cavernous sinus and superior orbital fissure. The histopathological features of the disease are similar to those of idiopathic orbital pseudotumor; 

Clinical presentation (secondary to cavernous sinus inflammation)

  • recurrent retro-orbital pain

  • palsy of the third, fourth or sixth cranial nerves as well as the first and second divisions of the trigeminal nerve

Differential diagnosis includes other pathological processes presenting with similar clinical features like meningioma, sarcoidosis, pituitary tumors, tuberculous meningitis, and lymphoma.

The disease is characterized by immediate dramatic response to steroid therapy.

The case is courtesy of Dr Mohamed Fouad, Mohamed Ibrahim & Bahaa Al Din Mahmoud.

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