Ipsilateral Cavernous Sinus Research Articles

Carotid Cavernous Fistula – Radiological Features

Carotid cavernous fistula (CCF) is an abnormal vascular shunt from the carotid artery to the cavernous sinus. The characteristic clinical features include chemosis, proptosis, ocular bruit, headache, diplopia, and ophthalmoplegia. The classical radiological features on magnetic resonance imaging (MRI) include proptosis, extraocular muscle enlargement, dilatation of the superior ophthalmic vein, and ipsilateral cavernous sinus enlargement. We report the case of a 66-year-old female who presented with headache, redness of the right eye, and double vision, who had features of CCF on MRI.

Seizure as the first symptom of cavernous sinus dural arteriovenous fistula: A case report and literature review

Cavernous sinus dural arteriovenous fistula (CS-DAVF) is an abnormal arteriovenous communication associated with a variety of clinical manifestations. The previous literature has rarely reported the occurrence of CS-DAVF with seizures and cerebral hemorrhage, signaling the need for more case reports and literature review in this area. A 62-year-old Chinese female presented with a paroxysmal loss of consciousness, accompanied with involuntary eye movement to the left, chewing issues, salivation at the right corner of the mouth, and bit tongue. The brain computed tomography revealed that the left temporal lobe was hemorrhagic. Brain scan and contrast-enhanced magnetic resonance imaging showed diffuse meningeal enhancement and lesions in the left frontoparietal temporal lobe, insular lobe, and hippocampal head region. Electroencephalography demonstrated continuous emission of spike and slow waves in the left hemisphere. With the aid of digital subtraction angiography, the patient was confirmed with a diagnosis of CS-DAVF draining into the ipsilateral cavernous sinus, intercavernous sinus, contralateral cavernous sinus, left superior ophthalmic vein, left lateral fissure vein, and left pterygoid venous plexus. The fistula was closed with interventional embolization through the femoral vein, and immediate angiography showed complete resolution of CS-DAVF after operation. The patient did not manifest any post-operative complications. This case highlights that the prevention of epilepsy, cerebral hemorrhage, and other serious complications is extremely important for good prognosis, especially in some patients presenting with serious clinical symptoms. It also sheds light on the necessity to consider the diagnosis of CS-DAVF if seizures, although extremely rare, are present.

Curious Cases of Painful Ophthalmoplegia (P1-9.012)

<h3>Objective:</h3> Importance of various investigations for diagnoses by exclusion and importance of starting treatment, which might be common for specific pathologies irrespective of different etiologies. (in a resource-limited environment) <h3>Background:</h3> There were two cases of adult women (Patient G and Patient V) residing in the same neighborhood. They presented with similar complaints of right-sided orbital pain, headache, and sixth cranial nerve palsy. <h3>Design/Methods:</h3> On individual evaluation, Patient G had prominent right-sided dull orbital pain for 3 weeks with right-sided headache and diplopia for 1 week. Examination showed ipsilateral sixth nerve paresis. Investigations like Complete Blood Count, Complete Metabolic Panel, Chest X-ray, ANA, CSF Analysis (including Adenosine deaminase), ESR, and CRP were negative. MRI showed a single hypointense extra-axial lesion in right anteromedial temporal region, anterolateral to ipsilateral cavernous sinus. The lesion appeared to partially encase right sixth cranial nerve and approaching right superior orbital fissure. Patient V had similar complaints of right-sided headache for 4 weeks and diplopia for 1 week. Examination showed complete paralysis of ipsilateral sixth nerve palsy. Similarly, investigations were negative (including serum ACE levels). MRI revealed a single extra-axial hypointense lesion along right medial temporal region along with partial invasion of ipsilateral cavernous sinus. Mild asymmetric thickening of right fifth and sixth cranial nerves was seen. <h3>Results:</h3> Investigations were necessary to rule out differential diagnoses like tuberculous meningoencephalitis, thyroid ophthalmopathy, and other infectious, autoimmune, or neoplastic etiologies. By diagnosis of exclusion, patient G was diagnosed with <b>Tolosa-Hunt syndrome</b>. Though biopsy results were unavailable for patient V, she was provisionally diagnosed with <b>Neurosarcoidosis</b>. Both were started on Corticosteroids. On respective follow-up visits, both patients reported significant improvement in their symptoms. This further solidified the respective diagnoses in these patients. <h3>Conclusions:</h3> In a resource-limited environment, response to treatment is as important as other investigations to diagnose rare diseases by exclusion. <b>Disclosure:</b> Mr. Shah has nothing to disclose.

Unraveling the patterns and pathways of local recurrence of nasopharyngeal carcinoma: evidence for individualized clinical target volume delineation

BackgroundsDespite publication of international guidelines, there are notable controversial points of clinical target volume (CTV) delineation in nasopharyngeal carcinoma (NPC). Recently, scholars proposed a novel way of delineation of CTV in NPC—individualization of CTV delineation based on T classification and spread patterns, which yielded excellent long-term local control with limited late toxicities. The aim of this study was to clarify the anatomic patterns and pathways of local recurrence of NPC and provide a clinical reference for the delineation of CTV.MethodsA total of 869 patients with non-metastatic NPC were treated with intensity-modulated radiation therapy (IMRT) at our institution between 2009 and 2010. Among the 57 cases of local/locoregional recurrence, 52 cases with traceable radiotherapy plans and magnetic resonance imaging at the time of the first diagnosis of recurrence were included. Anatomical structures and gross tumor volume of local recurrence were contoured. The incidence of relapse of each anatomic structure, route of local recurrence, and their correlation were analyzed.ResultsLocally advanced disease had a significantly increased risk of recurrence in the posterior nasal cavity and a trend towards higher risk of recurrence in the clivus, lateral pterygoid muscle, and hypoglossal canal. Based on the incidence of local recurrence, we constructed a high-risk map for the early and locally advanced stages. Local recurrences were classified into five routes, where anterior extension accounted for the majority (30.8%), and caudal tumor extension pathway had the lowest incidence (5.8%). There was a significant correlation between the local recurrences of neural foramina and neighboring anatomical structures along each pathway. All cases relapsed at unilateral cavernous sinus, most at the same side of primary tumor. Based on our findings, we proposed some suggestions on delineations of CTV, based on T classification and local extension pattern.ConclusionsLocal recurrence of NPC varied according to T classification, followed a stepwise pattern, spread via neural foramina, and recurred at ipsilateral cavernous sinus. This provides meaningful clinical evidence for delineation of CTV, especially individualized delineation.

Gastrointestinal carcinoma first presenting as pituitary mass: recognition of a rare case and multidisciplinary approach for the management of pituitary metastases

Abstract Introduction PMs (pituitary metastases) are rare and only a few cases are reported in the literature. In half of the documented cases, PMs originate from breast and lung cancers, rarely from other sites. They can grow rapidly and present local invasiveness, leading to acute onset of neurological symptoms, such as headache, visual and oculomotor disturbances, or endocrinological signs, such as diabetes insipidus and hypopituitarism. Their rarity and the lack of specific clinical and radiological features often impede their differentiation from other more common sellar area lesions, particularly when history of malignancy is absent. As PMs can be life-threatening, they must be recognized and treated promptly. Management of PMs may also be difficult because the prognosis depends on the course of the primary neoplasm. The case presented below is one of the few documented cases in the world of a pituitary metastasis from a primary gastrointestinal carcinoma. Clinical Case A 76-year-old woman, with no history of malignancy, presented with headache, dizziness and diplopia. Neurologic examination was remarkable for complete left ophthalmoplegia associated with sensitivity deficit in the left half face. Radiologic investigations documented a voluminous sellar and suprasellar formation, with extension in the ipsilateral cavernous sinus, compressing the optic chiasm and ipsilateral temporal lobe. The mass appeared heterogeneous as component of apoplectic infarction. Left cavernous sinus syndrome in apoplectic macroadenoma was diagnosed. Surgical removal of the lesion was performed through a transsphenoidal endoscopic endonasal approach. The histological exam disclosed a metastasis of adenocarcinoma with widespread necrotic-haemorrhagic elements. The immunohistochemical profile suggested an origin from a primary gastrointestinal carcinoma. Hormone replacement therapy and adjuvant therapy were instituted, although radiological investigations failed to identify the site of the primary gastrointestinal carcinoma. Postoperative MRI showed a parasellar residual tumor, which was radiologically stable at 6-month follow-up. The patient will undergo a radiotherapy and neurosurgical evaluation. Conclusions Clinicians should consider the possibility of PMs in patients with symptoms and signs that may suggest the presence of a pituitary mass. Since PMs can be cancer first manifestation, the recognition of PMs determines the referral to adequate oncological therapy. Prognosis is usually poor and it's difficult to estimate as it varies significantly depending on the systemic disease and the primary histology. Recognition and management of PMs remain complex and require a multidisciplinary team of endocrinologists, oncologists, neurosurgeons and neuroradiologists.

Clinico-Radiological-Pathological Correlation of Visual Loss in COVID-Associated Rhino-Orbito-Cerebral Mucormycosis.

Purpose:To correlate the clinical, radiological, and histopathological features in Covid-associated Rhino-orbito-cerebral mucormycosis cases presenting with acute visual loss.Design:Cross-sectional study.Methods:Covid-associated Rhino-orbito-cerebral mucormycosis cases with unilateral visual loss, planned for exenteration, underwent orbital and ophthalmological ocular examination. The available radiological sequences, doppler ultrasonography and histopathology findings were correlated with clinical manifestations.Results:The median age was 51 years and the male: female ratio was 3:1. All except one presented with unilateral ophthalmoplegia. The ocular media were hazy in 2 eyes. In 8 eyes, retinal changes were suggestive of occlusion of CRA (6), combined occlusion of CRA and central retinal vein (1), and myopic degeneration with hypertensive retinopathy (1). The contralateral eye showed retinal ischemic changes in one patient. Radiological imaging showed orbital apex involvement in the 10 affected eyes and one contralateral eye. Ipsilateral cavernous sinus thrombosis, diffusion restriction on MRI of optic nerve, internal carotid artery narrowing/thrombosis, and cortical watershed infarcts were seen in 8, 4, 4, and 2 cases, respectively. The blood flow in CRA and ophthalmic artery was absent or reduced in all the 10 affected eyes and in 1 contralateral eye. On histopathology, orbital fat necrosis, fungal hyphae, acute inflammation, granuloma formation, ischemic thrombosis of ophthalmic artery was observed in 10 specimens. CRA was patent in 9 and thrombosed in 1 eye. Optic nerve was ischemic in 8 and viable in 2 eyes.Conclusion:Acute visual loss in ROCM cases is associated with orbital apex involvement and thrombotic ischemia of ophthalmic artery. Cessation of flow in CRA possibly occurs secondary to ophthalmic artery thrombosis.

Tolosa-Hunt syndrome after COVID-19 infection

Tolosa-Hunt syndrome (THS) is a rare, idiopathic, non-specific inflammation within the cavernous sinus and/or superior orbital fissure leading to painful ophthalmoplegia. The authors describe the first case of a 12-year-old otherwise healthy girl who presented with painful ophthalmoplegia after a documented COVID-19 infection. Neuroimaging revealed inflammation within the ipsilateral cavernous sinus, Meckel’s cave, and orbital apex. After a comprehensive work-up was negative, the patient experienced prompt clinical and radiographic improvement with high-dose corticosteroids, and a diagnosis of THS was made.

Successful Endovascular Treatment for Recanalized Post-Traumatic Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are spontaneous or acquired communications between the internal carotid artery (ICA) and the cavernous sinus, which can be classified as direct or indirect. Direct fistulas between the ICA and the cavernous sinus can arise from injury, rupture of intracavernous carotid aneurysm, collagen deficiency syndrome, artery dissection, fibromuscular dysplasia, and direct surgical trauma. The symptoms caused by CCF are related to their size, duration, location, the direction of venous outflow, and the presence of arterial and venous collaterals. The goal of treatment for direct CCFs is to close the defect between the ICA and the cavernous sinus while maintaining the patency of the ICA. This goal can be achieved either by transarterial fistula occlusion using a removable balloon, transarterial or transvenous occlusion of the ipsilateral cavernous sinus with coils or other embolic material, or by implanting a covered stent in the fistula area. The choice of a method for CCF treatment remains relevant. The paper describes a clinical case of successful endovascular treatment for post-traumatic recanalized CCF in a patient with obvious ophthalmic manifestations as pulsating exophthalmos, conjunctival chemosis, and ischemic optic neuropathy of the right eye. Previously, the patient had undergone endovascular CCF embolization with coils and ICA reconstruction with flow diverting stents. Fistula embolization was performed with coils via transvenous access. In the opinion of the authors, the use of venous access in this case allowed them to perform total occlusion of the recanalized fistula and to achieve good angiographic and clinical results in the long-term period.

Efficiency of Endovascular Therapy for Bilateral Cavernous Sinus Dural Arteriovenous Fistula

The principles of endovascular treatment of bilateral cavernous sinus dural arteriovenous fistula (CS-dAVF) are not well established because of the complexity in the number of fistula tracts and their behavior, which seems to be more aggressive. We aimed to determine an efficient technique for endovascular treatment of bilateral CS-dAVF and the associated factors to achieve good clinical and angiographic outcomes. The data were analyzed from 165 consecutive patients diagnosed with CS-dAVF from January 2005 to September 2018. The demographic data included approaching route, embolization times, embolization material, sequence of embolization, number of embolization sessions, and angiographic and clinical outcomes. Interrater agreement of bilateral CS-dAVF diagnosis was performed using the κ coefficient. The factors associated with treatment outcome were analyzed using a Pearson χ2 test. Bilateral CS-dAVF was detected in 43 patients (26%). Angiographic presentations that showed evidence of sinus thrombosis, dangerous venous drainage, and higher Satomi classification were more commonly found in bilateral CS-dAVF than in unilateral CS-dAVF. Good clinical outcome and cure from angiography were obtained in 90% and 74%, respectively. Ipsilateral inferior petrosal sinus-intercavernous sinus-contralateral cavernous sinus catheterization was the major approach route of treatment. The factors associated with improved clinical outcome were transvenous approach, shunt closure, coil embolization, and sequencing the embolization (P < 0.001). Dangerous venous drainage tends to increase in bilateral CS-dAVF. Retrograde ipsilateral inferior petrosal sinus catheterization using coil embolization and sequencing the embolization are the major concerns for treatment.

Infarto cerebral limítrofe secundario a enfermedad inflamatoria orbitaria idiopática

Los infartos limítrofes son aquellos ubicados en regiones entre dos territorios vasculares contiguos y la enfermedad inflamatoria orbitaria idiopática es un proceso inflamatorio orbitario inespecífico. Presentamos el caso de un varón de 60 años con exoftalmos, ptosis palpebral, disminución de agudeza visual derecha y afección de los nervios oculomotores derechos. Los estudios de imágenes mostraron una masa retro ocular derecha con invasión de los senos cavernosos y esfenoidal. Durante la hospitalización, el paciente sufrió un infarto cerebral limítrofe por compresión de la arteria carótida interna derecha en su segmento intracavernoso. La exéresis y la anatomía patológica de la lesión orbitaria fueron compatibles con la enfermedad inflamatoria orbitaria idiopática. Nuestro caso muestra a la enfermedad inflamatoria orbitaria idiopática como una causa inhabitual de infarto cerebral limítrofe.

Pituitary Adenoma Presenting As Trigeminal Neuralgia

AbstractCompression of trigeminal nerve in cavernous sinus leading to trigeminal neuralgia is one of the rare presentations of pituitary tumor. We report a patient whose presenting complaint was trigeminal neuralgia in V1, V2 distribution and he had pituitary macroadenoma invading ipsilateral cavernous sinus. After surgery, the neuralgia disappeared completely.

Bilateral Persistent Trigeminal Arteries with Unilateral Trigeminal Artery to Cavernous Sinus Fistula

A 59-year-old man who denied a history of trauma presented with left pulsatile tinnitus and left orbital swelling for six months. Digital subtraction angiography showed a left persistent trigeminal artery (PTA) with a trigeminal artery to cavernous sinus (trigeminal-cavernous sinus) fistula and a right PTA. Transarterial detachable coil embolization of the left trigeminal-cavernous sinus fistula was performed, and the symptoms subsided. There has been no report of bilateral PTAs with a spontaneous fistula connected from one PTA to the ipsilateral cavernous sinus. This paper reports such a rare circumstance.

Diagnosis and treatment of carotid-cavernous fistula: analysis of 28 patients

To evaluate the feasibility and efficacy of endovascular treatment for different types of carotid cavernous fistula (CCF) via the approach of internal carotid artery (ICA) or inferior petrosal sinus (IPS). From April 2005 to June 2010, 28 CCF patients underwent endovascular treatment at our institution. There were 13 males and 15 females with a mean age of 39 years (range: 21 - 71). According to the Barrow's classification, they were classified into type A (n = 21), type B (n = 2) and type D (n = 5). Patients of type A underwent detachable balloon embolization of ipsilateral cavernous sinus or stent-graft placement via the ICA approach. Patients of types B and D received detachable coil plus n-BCA (n-butyl-2-cyanoacrylate) embolization of ipsilateral cavernous sinus via the IPS approach. The technical results, complications and therapeutic outcomes were reviewed. Detachable balloons (number: 1 - 4) were used in 16 patients of type A. Angiography at immediate postembolization showed a complete occlusion of fistula in 15 patients and a small residual fistula (< 20%) in 1 patient. Five patients of type A received stent-graft placement. One stent was placed in 4 patients and 2 stents in 1 patient. Complete fistula closures with preserved ICA were documented on immediate angiogram in 3 patients whereas a large residual flow (> 50%) persisted in 1. The fistula was completely occluded after 3 detachable balloons were deployed in affected cavernous sinus through a gap between stent and vascular wall. Both fistula and ICA were occluded in 1 patient after stenting. No cerebral infarction was observed due to the adequate collateral blood flow from contralateral ICA. Complete closures of affected cavernous sinus were achieved in 6 patients of types B and D while residual flow (< 50%) persisted in 1. The number of detachable coils for each embolization ranged from 3 to 8 (mean: 6.0). The volume of n-BCA mixture varied from 1.0 to 2.1 ml (mean: 1.3). The mean duration of n-BCA injection was 65 s (range: 45 - 90). Clinical symptoms were completely relieved in 26 patients. During the mean follow-up period of 30 months (range: 12 - 60), no recurrence of clinical symptoms was observed. No thrombosis or stenosis was found in the lumina of stents. Detachable balloon embolization is the preferential treatment for direct CCF. Detachable coil plus n-BCA embolization of cavernous sinus via the IPS approach is an efficient and safe treatment for indirect CCF.

Pre- and postoperative magnetic resonance imaging appearance of the normal residual pituitary gland following macroadenoma resection: Clinical implications

Background:To assess the relationship between the preoperative magnetic resonance imaging (MRI) appearance of the normal residual pituitary gland (NRPG) and pituitary functional outcome following transsphenoidal resection of pituitary macroadenomas.Methods:We retrospectively reviewed the medical records of 100 consecutive patients with a pituitary macroadenoma, who underwent transsphenoidal resection. The preoperative configuration of the displaced NRPG was stratified as superior, superolateral or lateral. The extent of postoperative restitution of the NRPG was divided into four groups: Group 1 — normal residual gland or almost normal; Group 2 — more than 50% restitution; Group 3 — less than 50% of the normal residual gland; and Group 4 — barely visible or absent residual gland. The pre- and postoperative NRPG appearance was correlated with pituitary functional status.Results:Preoperatively, the NRPG was identifiable in 79 patients, with extrasellar displacement in 53%. The displacement pattern was superior in 8%, superolateral in 32%, and lateral in 58% of the patients. If the NRPG was displaced laterally, the ipsilateral cavernous sinus was not invaded by the pituitary macroadenoma. Partial or complete pituitary function was lost in 6 / 23 (26.1%) patients with superior or superolateral displacement of the NRPG, compared to only 1 / 36 (2.8%) patients without superior displacement of the NRPG (P = 0.025). Progressive postoperative reconstitution of the NRPG was related to the preservation of the pituitary hormonal axis (Pearson Chi-Square P < 0.001).Conclusions:Progressive displacement of the NRPG preoperatively, and lack of restitution of the NRPG on postoperative MRI appeared to correlate with the postoperative pituitary functional loss.

Cluster Headache Secondary to Macroprolactinoma with Ipsilateral Cavernous Sinus Invasion

We present a 25 year-old man with episodic cluster headache that was refractory to all standard pharmacological prophylactic and abortive treatments. Because of the lack of response, an MRI brain was performed which showed a large pituitary tumour with ipsilateral cavernous sinus invasion. The serum prolactin was significantly elevated at 54,700 miU/L (50–400) confirming a macro-prolactinoma. Within a few days of cabergoline therapy the headache resolved. He continues to be headache free several years after starting the dopamine agonist. This case highlights the importance of imaging the pituitary fossa in patients with refractory cluster headache, It also raises the potential anatomical importance of the cavernous sinus in pituitary-associated headache.

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Ocular pulse amplitude measured by PASCAL dynamic contour tonometry in patients with a cavernous sinus dural arteriovenous fistula

Orbital nocardiosis

Dear Editor, We read with interest the rare case of disseminated orbital actinomycetoma reported by Shanbagh et al.[1] The authors have crafted a good report highlighting the clinical features, radiological findings, and management of orbital actinomycetoma caused by Nocardia brasiliensisbrazilienses / Nocardia asteroides.[1] We would, however, like to bring to the fore a few issues not addressed by the authors. The authors’ claim to be the first in reporting orbital invasion of actinomycetoma is misplaced. A quick literature search revealed a report by Patil et al., which described a 26-year-old male who was found to have multiple discharging sinuses on the scalp, with orbital and intracranial invasion.[2] Interestingly the presentation, clinical features, imaging, and histopathological details of the two patients have an uncanny resemblance and the ‘patients’ and authors are from the same hospital.[12] Figure 3 in the article is wrongly labelled as computed tomography (CT) scan of orbit while it shows pictures of magnetic resonance imaging (MRI). The authors have described the osteolytic changes seen in longstanding undiagnosed cases of actinomycosis.[1] However, in the interest of the readers, this needs further emphasis and documentation. Patil et al. have described the characteristic moth-eaten appearance of the frontal bone along with orbital and intracranial invasion, in the case reported by them.[2] It may be of interest to note that orbital actinomycosis has been also reported by Pagliani and Sullivan et al.[34] Pagliani et al. described a case of orbital actinomycosis in a patient with a history of carcinomas of the breast and kidney.[3] A CT scan of brain and orbit in this patient showed multiple orbital lesions and widening of the ipsilateral cavernous sinus.[3] Sullivan et al. described a case of orbital actinomycosis with a small ill-defined lesion in the posterolateral orbit.[4] The significant difference was that the periocular skin was uninvolved in both the above-mentioned cases.

TMJ arthroscopy: rare neurological complications associated with breach of the skull base

We report an interesting case of vertigo and palsies of the right oculomotor and trochlear nerves associated with fluid collection in the region of the ipsilateral temporal lobe and cavernous sinus after bilateral arthroscopy of the temporomandibular joint (TMJ).

Intraosseous Cranial Dural Arteriovenous Fistula Treated with Transvenous Embolization

We analyzed the angiographic architecture of intraosseous dural arteriovenous fistulas (DAVFs) and evaluated the use of transvenous embolization for curative treatment. The study population consisted of 6 patients with intraosseous DAVFs from 3 hospitals. In all of these patients, we retrospectively reviewed the medical records and images, and we were able to confirm the lesions in all patients from CT, MR imaging, and angiographic images. 3D rotational angiographic coronal source images clearly demonstrated the presence of an intraosseous DAVF in 2 patients. An intraosseous DAVF was located at the upper clivus in 1, the petrous apex in 1, and the lower clivus adjacent to the hypoglossal canal in 4 cases. All of the cases showed the presence of a dilated venous pouch, manifest as an osteolytic lesion on CT and as an intraosseous signal-intensity void on MR images. All patients were treated with transvenous embolization by targeting the dilated venous pouch and its connecting tributaries. Four intraosseous DAVFs were immediately completely embolized. One patient had a residual shunt, but the shunt disappeared 1 month later. One patient presented with a simultaneous DAVF in the ipsilateral cavernous sinus without a significant amount of shunt. None of the patients had procedural complications, and 5 patients recovered from the presenting symptoms. An intraosseous DAVF could be completely cured with transvenous embolization. For curative treatment, the intraosseous dilated venous pouch can be the target lesion for endovascular treatment.

Tolosa–Hunt syndrome: MRI appearances

A review of MRI findings in seven patients with Tolosa-Hunt syndrome was carried out. Seven patients presented with unilateral painful ophthalmoplegia. Magnetic resonance imaging studies were carried out to evaluate the cavernous sinuses and orbits. Coronal fast spin-echo T2-weighted images and fat-saturated T1-weighted coronal and transverse images with and without contrast enhancement were obtained for the cavernous sinuses and orbits. All patients showed focal-enhancing masses expanding the ipsilateral cavernous sinus. In one patient the mass was extending to the orbital apex and intraorbitally. All patients recovered on corticosteroid therapy and resolution of the masses was documented on follow-up MRI studies in five patients. One patient had a relapse of symptoms after discontinuing therapy. Magnetic resonance imaging studies of the cavernous sinus and orbital apex show high sensitivity for the detection and follow up of inflammatory mass lesions in Tolosa-Hunt syndrome. Magnetic resonance imaging should be the initial screening study in these patients.