Painful ophthalmoplegia with normal cranial imaging

Abstract

BackgroundPainful ophthalmoplegia with normal cranial imaging is rare and confined to limited etiologies. In this study, we aimed to elucidate these causes by evaluating clinical presentations and treatment responses.MethodsCases of painful ophthalmoplegia with normal cranial MRI at a single center between January 2001 and June 2011 were retrospectively reviewed. Diagnoses of painful ophthalmoplegia were made according to the recommendations of the International Headache Society.ResultsOf the 58 painful ophthalmoplegia cases (53 patients), 26 (44.8%) were diagnosed as ocular diabetic neuropathy, 27 (46.6%) as benign Tolosa-Hunt syndrome (THS), and 5 (8.6%) as ophthalmoplegic migraine (OM). Patients with ocular diabetic neuropathy were significantly older (62.8 ± 7.8 years) than those with benign THS (56.3 ±12.0 years) or OM (45.8 ± 23.0 years) (p < 0.05). Cranial nerve involvement was similar among groups. Pupil sparing was dominant in each group. Patients with benign THS and OM responded exquisitely to glucocorticoid treatment with resolved diplopia, whereas patients with ocular diabetic neuropathy didn’t (p < 0.05). Patients with OM recovered more rapidly than the other groups did (p < 0.05). Overall, most patients (94.8%) recovered completely during the follow-up period.ConclusionsOcular diabetic neuropathy and benign THS accounted for most of the painful ophthalmoplegias in patients with normal cranial imaging. Patient outcomes were generally good.

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

“…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.…”

Clinical and Radiological Findings Suggesting Disorders Other Than Tolosa–Hunt Syndrome Among Ophthalmoplegic Patients: A Retrospective Analysis

“…4,5,14,15,17 In contrast to SPO, these conditions commonly end with good outcomes. 15 In the latest ICHD criteria, radiographical or histopathological evidence of a granulomatous lesion is an essential condition for the diagnosis of THS. 4 Using cranial imaging as a discriminator, there is no difficulty in differentiating these benign conditions from those with intracranial structurally compressive lesions.…”

“…Dural meningeal enhancement of the lesions and focal narrowing of the intra‐cavernous internal carotid artery are other common findings . Occasionally, patients that manifest THS may develop symptoms despite normal cranial imaging (referred to as “benign THS”), and the official elaboration and definition of these MRI‐negative painful ophthalmoplegias remain to be determined . THS is considered as a benign condition due to a self‐limited disease course and good outcomes .…”

“…[5][6][7][8][9][10][11][12][13] Occasionally, patients that manifest THS may develop symptoms despite normal cranial imaging (referred to as "benign THS"), 5,14,15 and the official elaboration and definition of these MRI-negative painful ophthalmoplegias remain to be determined. 5,14,15 THS is considered as a benign condition due to a self-limited disease course and good outcomes. 1,16 However, clinical presentations of THS are nonspecific and overlap with many other potentially dangerous etiologies, such as nasopharyngeal carcinoma, carotid-cavernous fistula (CCF), and fungal sinusitis.…”

High-Field MRI Contribution in Tolosa-Hunt Syndrome (THS). Report of Two Cases and Review of Literature

“…In the series of Chih-Hseien, et al, causes of painful ophthalmoplegia with normal MRI (examination with gadolinium injection) were ocular diabetic neuropathy (44.8%), THS (46.6%) or ophthalmoplegic migraine (8.6%) [12].…”