Intracavernous Aneurysm Mimicking Tolosa-Hunt Syndrome

Abstract

Introduction: Tolosa-Hunt syndrome (THS) is a disorder related to inflammation of cavernous sinus and superior orbital fissure that usually presents with ophthalmoplegia and oculomotor nerve palsies. The etiology of the syndrome is unknown and the diagnosis is set by exclusion of other clinical conditions that manifest in a similar way. Intracranial aneurysms, such as intracavernous ones, should be included in the differential diagnosis as they can compress cranial nerves leading to similar clinical presentation.

Case report: We present a case of a 51-year-old woman who was referred to our clinic after 24-hour hospitalization in an ophthalmology clinic due to periorbital cellulitis in her right eye. A nose and paranasal sinuses computed tomography (CT) scan with contrast revealed sinusitis affecting the maxillary sinus, the ethmoidal cells and the sphenoid sinus on the right side. The patient underwent endoscopic sinus surgery on the right side, where middle meatal antrostomy, anterior and posterior ethmoidectomy and Draf I frontal sinus drainage were performed. There was an immediate improvement of the orbital edema and the neuro-opthalmologic examination of the right eye was normal. However, on the ninth postoperative day she presented headache, retro-orbital pain and diplopia of her left eye. In 24 hours, the symptoms progressed to ophthalmoplegia and ipsilateral palpebral ptosis. Intravenous treatment with corticosteroids was initiated under the suspicion of Tolosa-Hunt syndrome, without resolution of her symptoms. Emergency CT and CT-angiography scans revealed a possible intracavernous carotid artery aneurysm on the left side. The diagnosis was confirmed by a magnetic resonance imaging (MRI) scan and the patient was referred to neurosurgery department, where a cerebral angiography was performed and the giant intracavernous aneurysm was treated with guglielmi detachable coils.

Conclusion: Our case indicates that an intracavernous aneurysm can present with painful ophthalmoplegia in all directions, mimicking the Tolosa-Hunt syndrome. One must underline the importance of radiological examination focusing on the vascular structures, as it is essential for the differential diagnosis, defining the course of treatment applied in such cases.

FIGURE 1.

Computed tomography scan showing sinusitis and periorbital cellulitis on the right side

FIGURE 2.

Computed tomography scan showing sinusitis and periorbital cellulitis on the right side

FIGURE 3.

Periorbital celullitis preoperatively on the right eye and clinical improvement after the performance of endoscopic sinus surgery

FIGURE 4.

Ninth postoperative day: opthalmoplegia and palpebral ptosis on the left eye

FIGURE 5.

Computed tomography scan showing a possible intracavernous carotid artery aneurysm (ICA) on the left side

FIGURE 6.

Magnetic resonance angiography scan revealing a giant intracavernous carotid artery aneurysm on the left side