title: Steroid-resistant Tolosa-Hunt syndrome with a de novo intracavernous aneurysm: A case report.
abstract: BACKGROUND
  We report a case of steroid-resistant Tolosa-Hunt syndrome (THS) with recurrent bilateral painful ophthalmoplegia, accompanied with sphenoid sinusitis, pituitary abscess, and an aneurysm arising from the cavernous portion of the internal carotid artery.
  
  
  METHODS
  A 53-year-old woman suffered severe left painful ophthalmoplegia. A magnetic resonance image (MRI) revealed thickness of the left cavernous sinus (CS). Steroid was administrated under the diagnosis of THS, and the symptom transiently diminished. However, painful ophthalmoplegia fluctuated bilaterally after tapering the steroid. An MRI showed development of bilateral cavernous lesions associated with sphenoid sinusitis, pituitary abscess, and an aneurysm in the left C4 segment. Biopsy and drainage of the lesions were performed with an endoscopic transsphenoidal procedure. The histological examination showed nonspecific granulomatous inflammation. The methotrexate (MTX) was effective to reduce the CS and pituitary lesions; however, the aneurysm slightly increased and remained unchanged in size thereafter.
  
  
  CONCLUSIONS
  To our knowledge, this is the first report of a growing de novo C4 aneurysm in THS. Surgical intervention and administration of MTX should be attempted in steroid-resistant THS. Careful observation with serial MRI and MR angiography is important to manage the complicated THS.
authors.affiliation: Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Takasuna
authors.affiliation: Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Rie
authors.initials: R
authors.lastname: Sasaki
authors.affiliation: Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Shiraishi
authors.affiliation: Department of Pathology, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Masatomo
authors.initials: M
authors.lastname: Doi
authors.affiliation: Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Wakui
authors.affiliation: Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Hidemichi
authors.initials: H
authors.lastname: Ito
authors.affiliation: Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Kotaro
authors.initials: K
authors.lastname: Oshio
authors.affiliation: Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan.
authors.forename: Yuichiro
authors.initials: Y
authors.lastname: Tanaka
keywords: Aneurysm; Tolosa–Hunt syndrome; cavernous sinus; pituitary abscess; sphenoid sinusitis; steroid