PO-36 | An atypical presentation of Tolosa-Hunt Syndrome: a case report

Marco Bolchini, Matteo Cortinovis, Paola Zavarise, Giulia Campana, Giorgio Dalla Volta | Neurology Unit and Headache Center, Istituto Clinico Città di Brescia, Brescia, Italy

Background: Tolosa-Hunt syndrome (THS) is a rare, inflammatory condition characterized by painful ophthalmoplegia due to inflammation of the cavernous sinus or superior orbital fissure, most commonly involving the oculomotor, trochlear, and abducens nerves. This case report describes an atypical presentation of Tolosa-Hunt syndrome in a 64-year-old male with sequential involvement of the right abducens (CN VI) and facial (CN VII) nerves, along with persistent right-sided headache unresponsive to anti-inflammatory drugs.

Case presentation: The patient initially presented with diplopia due to right abducens nerve palsy and persistent drug-resistant headache lateralized to the right side of the head (without face involvement or accompanying neuro-vegetative autonomic symptoms), followed months later by facial weakness, involving upper and lower facial muscles. Contrast-enhanced brain MRI revealed inflammation of the right facial nerve, without any other acute lesions. CSF analysis and blood exams were unremarkable, excluding other possible infective or inflammatory causes. Based on the clinical course of the disease and exclusion of other neurological disorders, a diagnosis of Tolosa-Hunt syndrome was made. The patient was treated with high-dose oral corticosteroids, resulting in partial clinical improvement in the next few days and complete resolution of symptoms at 1-month follow-up.

Conclusion: This case report highlights the variability of Tolosa-Hunt syndrome, including its atypical presentation with facial nerve involvement, and underscores the importance of early diagnosis and steroid therapy for favorable outcomes.