Probable Tolosa-Hunt syndrome with a normal MRI

Abstract

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.

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

“…In this study, normalization of MRI findings occurred within 3 ± 1 months of M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 13 treatment with one study reporting complete normalization of findings after 2 years. These observations support previous recommendations for follow-up MRI studies every 3-6 months after the initial diagnosis for up to 2 years to assess therapy response, follow disease progression, and consider alternative diagnoses in cases of non-resolution [9,10,38].…”

“…However, other conditions such as lymphoma, sarcoidosis, and meningioma can have similar findings and the clinician must keep these in mind when interpreting MRI results [2,5,39,40]. Infrequently, the MRI can be normal in patients with THS [9,12,33,38,[41][42][43]. In this study, MRI demonstrated cavernous sinus enhancement in all patients whose initial MRI was normal.…”

“…Relapses can occur in up to one-half of reported cases of THS (19% in this study) in intervals of months to years and can be ipsilateral, contralateral or bilateral [18,28,38,[46][47][48].…”

“…Specific serologic studies such as antinuclear antibody and anti-dsDNA (lupus), angiotensin converting enzyme (sarcoidosis), anti-neutrophil cytoplasmic antibody (Wegener's granulomatosis), hemoglobin A 1c (diabetic ophthalmoplegia), Borrelia burgdorferi serology (Lyme disease), and HIV testing are recommended if the initial evaluation is unremarkable [10,38]. Surgical biopsy is rarely performed and we suggest that this may not be warranted in many cases if careful observation and appropriate follow-up neuroimaging is performed.…”

“…The ophthalmoparesis typically resolves within weeks to months after the initiation of treatment, but spontaneous resolution can occur when untreated [3,12,13,16,38,45]. Neurological deficits may rarely persist.…”