Meningioma presenting as Tolosa-Hunt syndrome

A 23-year-old woman was admitted with headache, nausea, vomiting and blurre d vision on the left side. Neurological examination showed ptosis with a co mplete internal and external ophthalmoplegia and a red fullness around the left orbita. Computed tomographic scanning of the brain revealed no abnorma lities. As she improved on high doses of steroids a diagnosis of Tolosa-Hun t syndrome (THS) seemed to be indicated. However, magnetic resonance imagin g (MRI) showed a lesion with intermediate signal intensity in the left cave rnous sinus. Craniotomy was performed when symptoms of THS recurred. Histop athological examination revealed a meningioma with a papillary aspect and s ome mitoses. This case illustrates that: (1) THS is still a diagnosis by ex clusion; (2) MRI and histopathological examination are important if there i s any doubt about the diagnosis; and (3) also when there is no doubt, impro vement after steroid therapy may be a diagnostic pitfall. Therefore, not on ly MRI but also orbital phlebography and angiography should seriously be co nsidered. (C) 1999 Elsevier Science B.V. All rights reserved.