Presentation
New onset gaze-dependent diplopia. History of recent upper respiratory infection and minor head trauma.
Patient Data
Several sequences are degraded by motion artifacts (examination was done without sedation), but overall the study is of diagnostic quality.
Focal thickening of the ethmoid air cells and sphenoid sinus mucosa. Striking enhancement of the right orbital apex, and relative hyperenhancement and widening of the right cavernous sinus best seen on the postcontrast FLAIR sequence.
Case Discussion
The unilateral hyperenhancement and thickening of the orbital apex and ipsilateral cavernous sinus is suggestive of Tolosa-Hunt syndrome. Note that changes are hard to appreciate on a T1W contrast-enhanced study, but stand out on the postcontrast FLAIR. It is prudent to include postcontrast FLAIR imaging in all contrast-enhanced brain MRI studies, as it can be a cirtical problem solving tool, and makes leptomeningeal contrast enhancement more easier to appreciate. Prompt steroid therapy resulted in gradual improvement of the symptoms.
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