title: Clinical and radiological findings suggesting disorders other than tolosa-hunt syndrome among ophthalmoplegic patients: a retrospective analysis.
abstract: OBJECTIVE
  To investigate clinical and radiological features of Tolosa-Hunt syndrome (THS) and examine their diagnostic value, and to propose clinical and radiological features that indicate other symptomatic painful ophthalmoplegias (SPOs) in order to distinguish them from THS.
  
  
  BACKGROUND
  Clinical presentations of THS are nonspecific and may overlap with many etiologies. Therefore, excluding other SPOs is essential for correct diagnosis. At the present time, the predictive value of the current International Classification of Headache Disorders (ICHD) criteria is not well established, and specific imaging markers that can discriminate SPOs from THS are lacking.
  
  
  METHODS
  Patients referred with painful ophthalmoplegia over 12 years were recruited retrospectively and allocated into THS or SPO groups. Typical symptoms (episodic unilateral orbital pain preceding or developing with diplopia) and imaging of THS (inflammatory lesions in the cavernous sinus/orbit by magnetic resonance imaging) were proposed based on ICHD-3 beta criteria and previous literature. Atypical clinical and radiological features suggesting alternative diagnoses were also proposed to predict SPO. Initial presentations and imaging findings were registered and correlated with diagnostic outcomes. The predictive value of clinical and imaging findings was then evaluated.
  
  
  RESULTS
  Of the 61 referred cases, 25 were classified as THS and 36 as SPO. Of the SPO cases, 52.8% manifested typical THS symptoms at onset. Patients with SPOs were prone to have atypical symptoms (47.2%) and radiographical findings (82.1%) in comparison to those with THS (4.0% and 4.2%, respectively; both P < .001). Both typical symptoms and imaging findings predicted a diagnosis of THS with high sensitivity (95.8% and 100%, respectively) but low specificity (47.2% and 28.6%, respectively). High sensitivity (82.1%) and specificity (95.8%) were achieved using atypical imaging features to predict SPO.
  
  
  CONCLUSIONS
  A diagnosis of THS based strictly on clinical presentations or imaging results is not completely reliable. Identification of atypical imaging features may have a useful role in discriminating SPOs and thus avoid erroneous diagnoses of THS. Future studies with larger sample sizes are warranted to evaluate their validity in general population.
authors: Department of Neurology, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan; Department of Neurology, Kaohsiung Medical University Hospital; Kaohsiung Medical University, Kaohsiung, Taiwan; Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan.
authors: Chih-Hsien
authors: CH
authors: Hung
authors: Kuo-Hsuan
authors: KH
authors: Chang
authors: Yao-Liang
authors: YL
authors: Chen
authors: Yi-Ming
authors: YM
authors: Wu
authors: Chiou-Lian
authors: CL
authors: Lai
authors: Hong-Shiu
authors: HS
authors: Chang
authors: Rong-Kuo
authors: RK
authors: Lyu
authors: Yih-Ru
authors: YR
authors: Wu
authors: Chiung-Mei
authors: CM
authors: Chen
authors: Chin-Chang
authors: CC
authors: Huang
authors: Chun-Che
authors: CC
authors: Chu
authors: Chun-Hung
authors: CH
authors: Chen
authors: Long-Sun
authors: LS
authors: Ro
mesh_terms: D000368:Aged; D015901:Angiography, Digital Subtraction; D005260:Female; D006801:Humans; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009886:Ophthalmoplegia / Q000150:complications* / Q000175:diagnosis*; D012189:Retrospective Studies; D020333:Tolosa-Hunt Syndrome / Q000150:complications* / Q000175:diagnosis*; D015898:Tomography Scanners, X-Ray Computed
keywords: Tolosa-Hunt syndrome; diplopia; headache; magnetic resonance imaging; neuro-ophthalmology; painful ophthalmoplegia