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Tolosa-Hun synd ome e ealed by MRI: A adiological pe spec i e on pain ul
oph halmoplegia
HAJAR DAHMAN *, IHSANE MANSIR, YOUSSEF BOUKTIB, AYOUB ELHAJJAMI, BADR BOUTAKIOUTE, MERIAM
OUALI IDRISSI and NAJAT IDRISSI EL GANOUNI
Depa men o Radiology, ARRAZI Hospi al, Mohammed VI Uni e si y hospi al, FMPM, Ma akech, Mo occo.
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1739-1741
Publica ion his o y: Recei ed on 03 Ap il 2025; e ised on 11 May 2025; accep ed on 13 May 2025
A icle DOI: h ps://doi.o g/10.30574/wja .2025.26.2.1615
Abs ac
Tolosa-Hun synd ome (THS) is a a e and idiopa hic g anuloma ous in lamma ion o he ca e nous sinus and adjacen
s uc u es, classically p esen ing as pain ul oph halmoplegia. We epo a case o a 53-yea -old woman who p esen ed
wi h igh pe io bi al headache and an incomple e ca e nous sinus synd ome a ec ing c anial ne es III, IV, V1, and V2.
MRI demons a ed a s ongly enhancing lesion in he igh ca e nous sinus wi hou e idence o h ombosis o o bi al
in asion. The pa ien showed apid clinical imp o emen ollowing co icos e oid he apy. This case highligh s he
c i ical ole o MRI in he diagnosis, exclusion o mimicke s, and moni o ing o ea men esponse in THS.
Keywo ds: Tolosa-Hun synd ome; Ca e nous sinus synd ome; Pain ul oph halmoplegia; MRI; Neu oimaging
1. In oduc ion
Tolosa-Hun synd ome (THS) is a a e neu ological diso de cha ac e ized by unila e al o bi al pain associa ed wi h
pa esis o one o mo e o he c anial ne es passing h ough he ca e nous sinus. The pa hogenesis is belie ed o be a
non-speci ic g anuloma ous in lamma ion, al hough he exac cause emains unknown. Imaging, pa icula ly magne ic
esonance imaging (MRI), plays a key ole in con i ming he p esence o in lamma o y lesions and excluding o he
se ious condi ions such as neoplasms o in ec ions. Acco ding o he In e na ional Classi ica ion o Headache Diso de s
(ICHD-3), THS emains a diagnosis o exclusion (1).
2. Case P esen a ion
A 53-yea -old woman p esen ed wi h subacu e onse o igh -sided pe io bi al headache and p og essi e diplopia.
Neu ological examina ion e ealed an incomple e igh ca e nous sinus synd ome wi h in ol emen o c anial ne es
III, IV, V1, and V2. The e we e no sys emic symp oms, and oph halmological examina ion showed no signs o isual
acui y loss o papilledema.
B ain and o bi al MRI was pe o med using T1-weigh ed p e- and pos -con as sequences wi h a supp ession, T2-
weigh ed sequences, FLAIR, and DWI. The pos -con as T1-weigh ed images e ealed a homogeneously enhancing
lesion in he igh ca e nous sinus. The lesion appea ed sligh ly hype in ense on T2-weigh ed images and showed no
es ic ed di usion. The in e nal ca o id a e y was su ounded bu no na owed o displaced. No o bi al apex
in ol emen o op ic ne e comp ession was seen.
Ex ensi e labo a o y es ing was pe o med o ule ou al e na i e diagnoses. Comple e blood coun , C- eac i e p o ein,
e y h ocy e sedimen a ion a e, ANA, ANCA, se um ACE, and in ec ious se ologies (HIV, syphilis, ube culosis) we e all
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1739-1741
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wi hin no mal limi s o nega i e. Ches X- ay and CT scans excluded sys emic in lamma o y o neoplas ic condi ions.
Ce eb ospinal luid analysis was no sugges i e o in ec ion o malignancy. Based on clinical p esen a ion, imaging, and
nega i e sys emic wo k-up, a diagnosis o Tolosa-Hun synd ome was e ained.
Figu e 1 Sagi al and axial magne ic esonance imaging (MRI) wi hou con as e ealed igh ca e nous sinus
enla gemen sligh ly hype in ense on T2 and FLAIR and isoin ense on T1 weigh ed images. (A :T2 weigh ed sagi al
images, B: FLAIR axial images, C: T1 weigh ed axial images)
Figu e 2 Co onal (A)and axial (B) magne ic esonance imaging (MRI) T1 weigh ed images wi h con as e ealed a
homogeneously enhancing lesion in he igh ca e nous sinus su ounding he in e nal ca o id a e y wi hou s enosis
o displacemen
3. Discussion
Tolosa-Hun synd ome (THS) is a a e diso de cha ac e ized by unila e al o bi al o pe io bi al pain associa ed wi h
c anial ne e palsies, mos equen ly in ol ing he oculomo o (III), ochlea (IV), and abducens (VI) ne es. In some
cases, he oph halmic (V1) and maxilla y (V2) b anches o he igeminal ne e may also be a ec ed, e lec ing he
ana omical p oximi y o hese s uc u es wi hin he ca e nous sinus (2,3).
The unde lying pa hophysiology o THS in ol es a g anuloma ous in lamma o y p ocess cen e ed on he ca e nous
sinus, wi h po en ial ex ension in o adjacen egions such as he supe io o bi al issu e and he o bi al apex. This
localized in lamma ion esul s in he comp ession and dys unc ion o he c anial ne es a e sing hese compa men s.
Magne ic esonance imaging (MRI) plays a c ucial ole in he e alua ion o suspec ed THS. Typical imaging indings
include a so issue lesion wi h isoin ense signal ela i e o muscle on T1-weigh ed sequences, sligh hype in ensi y on
T2-weigh ed images, and a id enhancemen ollowing gadolinium adminis a ion (1,6). Ne e heless, while MRI
indings can be highly sugges i e, hey a e no pa hognomonic and mus be in e p e ed wi hin he app op ia e clinical
con ex .
Wo ld Jou nal o Ad anced Resea ch and Re iews, 2025, 26(02), 1739-1741
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The di e en ial diagnosis o lesions in ol ing he ca e nous sinus is b oad and encompasses neoplas ic, in ec ious,
ascula , and in lamma o y condi ions. Neoplas ic e iologies include lymphoma, me as ases, and meningioma, while
in ec ious causes may in ol e ungal o bac e ial pa hogens. Vascula conside a ions p ima ily include ca e nous sinus
h ombosis, and in lamma o y mimics encompass sa coidosis and g anuloma osis wi h polyangii is (3,4,5). Ca e ul
clinical assessmen , labo a o y wo kup, and imaging a e he e o e essen ial o exclude hese al e na i e diagnoses.
A hallma k ea u e o THS is i s d ama ic esponse o co icos e oid he apy, wi h signi ican imp o emen ypically
obse ed wi hin 48 o 72 hou s a e ini ia ion (7). This he apeu ic esponse se es bo h as a key diagnos ic c i e ion
and as con i ma ion o he in lamma o y na u e o he lesion. In ou case, he clinical p esen a ion ul illed he
In e na ional Classi ica ion o Headache Diso de s (ICHD-3) diagnos ic c i e ia o THS, which include cha ac e is ic
o bi al pain, e idence o g anuloma ous in lamma ion on imaging, exclusion o al e na i e diagnoses, and a posi i e
esponse o co icos e oids (1).
Fu he mo e, ollow-up MRI in ou pa ien demons a ed eg ession o he p e iously obse ed lesion, he eby
ein o cing he diagnosis o THS. Despi e he gene ally a o able esponse o he apy, i is impo an o no e ha
ecu ence occu s in app oxima ely 30–40% o cases, o en necessi a ing p olonged clinical and adiological
su eillance (8). Ea ly ecogni ion o elapse is c i ical o p omp managemen and o p e en po en ial long- e m
neu ological sequelae
4. Conclusion
Tolosa-Hun synd ome is a a e bu ea able cause o pain ul oph halmoplegia. MRI plays an essen ial ole in diagnosis
and ollow-up, allowing exclusion o mo e se ious e iologies. Radiologis s a e cen al o pa ien managemen by
iden i ying ypical imaging indings, guiding diagnosis, and moni o ing he apeu ic esponse.
Re e ences
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