Tolosa–Hunt syndrome demonstrated by constructive interference steady state magnetic resonance imaging

Wani, Nisar Ahmad; Jehangir, Majid; Lone, Parveen Akhter

doi:10.4103/2008-322x.200171

Cited by 8 publications

(14 citation statements)

References 10 publications

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“… 15 17 Advanced MRI protocols such as constructive interference steady state, selective partial inversion recovery, and three-dimensional fast-imaging employing steady-state acquisition may help in demonstrating the causative lesion. 19 20 21 …”

Section: R Esultsmentioning

confidence: 99%

Tolosa–Hunt syndrome: A review of diagnostic criteria and unresolved issues

Dutta

Anand

2021

J Curr Ophthalmol

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Purpose: To review the diagnostic criteria for Tolosa–Hunt syndrome (THS) and utility of recent modifications. Methods: We searched PubMed for keywords Tolosa Hunt and magnetic resonance imaging. We compared the three editions of International Classification of Headache Disorders and isolated case reports and case series with the assessment of cavernous internal carotid artery (ICA) caliber to find the prevalence of vascular anomalies. We also evaluated cases of THS with the involvement of extracavernous structures and the possible role of idiopathic hypertrophic pachymeningitis (HP). Cases diagnosed falsely as THS were also reviewed for the presence of atypical features and relevance of criterion D. We assessed nonconforming cases (those with normal neuroimaging benign THS) and idiopathic inflammatory orbital pseudotumor (IIPO). Results: Vascular abnormalities were found in 36.36% of THS cases. Benign THS may also show changes in ICA caliber. Evidence suggestive of idiopathic HP could be found in 57% of cases with the involvement of extracavernous structures, such as facial nerve and pituitary gland. Both THS and IIPO are steroid-responsive pathologies with similar clinical and radiological features. False-positive diagnosis of THS results from early labeling, based solely on clinical features and symptom resolution after steroid therapy. Conclusions: Benign THS may be a result of limitation of resolution of available neuroimaging technique or early testing. Early and late vascular changes can be seen in both THS and its benign variant; some of them are not innocuous. THS may be considered a type of focal idiopathic HP. IIPO may represent an anterior variant of THS. In the absence of histopathological diagnosis, steroid-induced resolution of symptoms should be confirmed radiologically and followed-up.

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Section: R Esultsmentioning

confidence: 99%

Tolosa–Hunt syndrome: A review of diagnostic criteria and unresolved issues

Dutta

Anand

2021

J Curr Ophthalmol

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“…Specific clinical diagnostic criteria are delineated; however, literature on the radiological aspect of the diagnosis remains ambiguous [ 2 , 3 , 6 , 9 , 10 ]. This may be due to the rarity of the disease as well as the difficulty in creating detailed images of the cavernous sinus [ 2 , 3 , 9 , 10 , 12 ].…”

Section: Discussionmentioning

confidence: 99%

“…Currently, MRI is the imaging modality of choice for evaluating THS, and to exclude other lesions that can involve the cavernous sinus such as lymphoma [ 1 , 4 , 7 ]. Suggestive findings of THS in MRI include enlargement and dural margin convexity, with or without T1-isointense with gray matter abnormal tissue, and isointense to hypointense on T2 sequences [ 2 , 3 , 6 , 9 , 10 , 12 ]. A limitation, however, is that MRI detects any abnormal tissue, not only granulomatous inflammation [ 2 , 3 , 6 , 9 , 10 ].…”

Section: Discussionmentioning

confidence: 99%

Tolosa Hunt Syndrome: MRI Findings

Ramirez,

Ramirez Marquez,

Torres

et al. 2023

Cureus

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Tolosa-Hunt syndrome (THS) is an idiopathic inflammatory condition involving the cavernous sinus and orbital apex with an incidence of 1 case per million per year. We report on a case of a 70-year-old male with atypical MRI findings, vision loss, and painless ophthalmoplegia.  Ophthalmic evaluation revealed his best-corrected visual acuity was 20/40 in the right eye and counting fingers at a 0.5-foot distance in the left eye. External examination of the left eye revealed limited ocular movement, proptosis, and a positive relative afferent pupillary defect. Complete blood count, inflammatory markers, and full biochemistry tests, including thyroid and liver function tests, were within the normal range. A magnetic resonance imaging of the orbits with and without contrast demonstrated a homogenously enhancing lesion at the posterior intraconal compartment of the left orbit, extending to the orbital apex with the involvement of the adjacent extraocular muscles. The patient was started on intravenous methylprednisolone 60 mg daily and later discharged on prednisone 5 mg daily with partial symptom improvement on follow-up. Resection and biopsy revealed a soft tissue lesion with mixed inflammatory infiltrate. The clinical, pathological, and imaging findings favored the diagnosis of THS.

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“…A combination of diminished tendon reflex and extra-ocular movement disturbance advocate Miller Fisher Syndrome which mimics THS [53]. Persistent ipsilateral somatosensory loss/forehead paresthesia and decreased pinprick sensation owing to the subdivision of trigeminal nerve (ophthalmic) lesion may also be detected on examination [25] [54] [55].…”

Section: Physical Examintion/signsmentioning

confidence: 99%

“…MRI findings of THS may reveal thickening changes of the CS due to the soft tissue abnormality with or without entanglement of the internal carotid(IC) artery, SOF, OA, or optic CN, the granulomatous lesion appears as T1 isointensity sequence and iso hypointensity apperance in T2 sequences with diffusion abnormality and shows significant contrast involvement following contrast injection of the medium intravenously, Figure 1 [ [64]. Recent researches have revealed that restricted diffusion can delineate the extent of THS as precisely as the current cornerstone modality of choice (the Gadolinium-enhanced MRI) in portraying the degree of the lesion and guide treatment response by virtue of intrusion by inflammatory cells makes the inflammatory regions more evident on DWI, hence further studies of these lesions on DWI can pave a way into significant reduction total scan duration, on the side, Constructive interference in steady-state (CISS) MRI has recently been proved to have high sensitivity as well for diagnosing and follow up THS [55] [65].…”

Section: Imaging In Thsmentioning

confidence: 99%

Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment

Msigwa¹,

Li²,

Cheng³

2020

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Tolosa-Hunt syndrome (THS) is an uncommon diagnosis with an incidence of nearly 1 to 2 cases per million hallmarked by the presence of painful ophthalmoplegia (PO) due to a granulomatous inflammation (GI). Diagnostically, the major THS challenges encountered are owing to the exclusion of other GI presenting conditions necessitating multi-specialization consultations. This article presents uniquely advances in diagnosis and challenges encountered attempting to exclude THS mimics, details on physical examination and laboratory investigations have been incorporated. Tolosa Hunt MRI protocol (contrast-enhanced MRI), restricted diffusion and CISS MRI have lately proved to be precise investigations for THS diagnosis and follow up, on the contrary, number of false-negative/positive MRI diagnoses appears to be rising, hence proposed that MRI or biopsy shouldn't be mandatory criteria for diagnosis as opposed to IHS 2018 guidelines. Despite corticosteroids being the cornerstone therapy for THS, there are controversies concerning the better administration route, optimal dosage, and therapy longevity, through case reports, high dose IV mPSL of 500 mg BID for 3 days, followed with maintenance dose of prednisone 60 mg resulted in the earliest recovery, hereafter standardized guidelines are required. Alternatively, infliximab (300 mg infusion), azathioprine, methotrexate, and acupuncture can be used, farther studies are required to appraise the effectiveness and their safety. On the other side, microsurgery can be utilized for GI evacuation however associated risks of permanent CN VI palsy have been stated, nonetheless, GKRS can be employed when contraindication or corticosteroid intolerability exists though the hazard of late malignancy is a drawback.

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Tolosa–Hunt syndrome demonstrated by constructive interference steady state magnetic resonance imaging

Cited by 8 publications

References 10 publications

Tolosa–Hunt syndrome: A review of diagnostic criteria and unresolved issues

Tolosa–Hunt syndrome: A review of diagnostic criteria and unresolved issues

Tolosa Hunt Syndrome: MRI Findings

Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment

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