Avaliação da flebografia orbitária em oito casos de síndrome de Tolosa-Hunt

Nalli, D.R.; Malheiros, S.M.F.; Nogueira, R.G.; Abdala, N.; Caldas, J.G.P.; Carrete Jr, H.; Massaro, A.R.

doi:10.1590/S0004-282X1994000200014

Resumos

A Síndrome de Tolosa-Hunt (STH) ou oftalmoplegia dolorosa é associada a granulomatose inespecifica de etiologia desconhecida que acomete a fissura orbitária superior. Compromete estruturas nervosas e vasculares causando quadro clínico variável que sempre se associa a dor e apresenta resposta favorável à corticoterapia. Processos inflamatórios, tumores e aneurismas dessa região podem causar sintomas semelhantes. A tomografia computadorizada, a angiografia cerebral e a flebografia orbitária são métodos de imagem indicados para orientar o diagnóstico. Revisamos os resultados destes exames radiológicos de oito pacientes atendidos no Hospital São Paulo no período 1989 a 1991, com diagnóstico de STH segundo os critérios de Hunt e Hannerz. A análise das alterações da flebografia orbitária, de acordo com a sistematização feita por Hannerz e col. mostrou ser este exame inespecífico, porém capaz de orientar melhor o diagnóstico.

síndrome de Tolosa-Hunt; oftalmoplegia dolorosa; flebografia orbitária; veia oftálmica superior; seio cavernoso

Tolosa-Hunt syndrome (THS), or painful ophthalmoplegia is associated to a non-specific granulomatosis of unknown etiology, that involves the superior orbital fissure and its nervous and vascular structures. The clinical picture that responds to steroid therapy, is variable and is always associated with pain. Inflammatory conditions, tumors and aneurysms can produce similar symptoms. Computed tomography, cerebral angiography and orbital phlebography are the imaging methods of choice for making the diagnosis. We revised the results of these radiological examinations of eight patients seen at the Hospital São Paulo from 1989 to 1991, with the diagnosis of THS according to Hunt and Hannerz criteria. The analysis of orbital phlebography changes based upon Hannerz et al. systematization showed non-specific features, but those were able to help the diagnosis.

Tolosa-Hunt; painful ophthalmoplegia; orbital phlebography; superior ophthalmic vein; cavernous sinus

Avaliação da flebografia orbitária em oito casos de síndrome de Tolosa-Hunt

Orbital phlebography evaluation in eight cases of Tolosa-Hunt syndrome

D.R. Nalli^I; S.M.F. Malheiros^II; R.G. Nogueira^IV; N. Abdala^I; J.G.P. Caldas^III; H. Carrete Jr.^I; A.R. Massaro^II

^IHospital São Paulo, Escola Paulista de Medicina (EPM): Pós-Graduando de Neurorradiologia, EPM

^IIHospital São Paulo, Escola Paulista de Medicina (EPM): Mestre em Neurologia EPM

^IIIHospital São Paulo, Escola Paulista de Medicina (EPM): Mestre em Neurorradiologia, EPM

^IVHospital São Paulo, Escola Paulista de Medicina (EPM): Prof. Assistente de Neurorradiologia EPM

RESUMO

A Síndrome de Tolosa-Hunt (STH) ou oftalmoplegia dolorosa é associada a granulomatose inespecifica de etiologia desconhecida que acomete a fissura orbitária superior. Compromete estruturas nervosas e vasculares causando quadro clínico variável que sempre se associa a dor e apresenta resposta favorável à corticoterapia. Processos inflamatórios, tumores e aneurismas dessa região podem causar sintomas semelhantes. A tomografia computadorizada, a angiografia cerebral e a flebografia orbitária são métodos de imagem indicados para orientar o diagnóstico. Revisamos os resultados destes exames radiológicos de oito pacientes atendidos no Hospital São Paulo no período 1989 a 1991, com diagnóstico de STH segundo os critérios de Hunt e Hannerz. A análise das alterações da flebografia orbitária, de acordo com a sistematização feita por Hannerz e col. mostrou ser este exame inespecífico, porém capaz de orientar melhor o diagnóstico.

Palavras-chave: síndrome de Tolosa-Hunt, oftalmoplegia dolorosa, flebografia orbitária, veia oftálmica superior, seio cavernoso.

SUMMARY

Tolosa-Hunt syndrome (THS), or painful ophthalmoplegia is associated to a non-specific granulomatosis of unknown etiology, that involves the superior orbital fissure and its nervous and vascular structures. The clinical picture that responds to steroid therapy, is variable and is always associated with pain. Inflammatory conditions, tumors and aneurysms can produce similar symptoms. Computed tomography, cerebral angiography and orbital phlebography are the imaging methods of choice for making the diagnosis. We revised the results of these radiological examinations of eight patients seen at the Hospital São Paulo from 1989 to 1991, with the diagnosis of THS according to Hunt and Hannerz criteria. The analysis of orbital phlebography changes based upon Hannerz et al. systematization showed non-specific features, but those were able to help the diagnosis.

Key words: Tolosa-Hunt, painful ophthalmoplegia, orbital phlebography, superior ophthalmic vein, cavernous sinus.

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Aceite: 12-outubro-1993.

Dr. Roberto Gomes Nogueira - Departamento de Diagnóstico por Imagem (DDI), Escola Paulista de Medicina - Rua Botucatu 740 - 04023-900 São Paulo SP - Brasil.

1. Brismar J. Orbital phlebography: II Anatomy of superior ophthalmic vein and its tributaries. Acta Radiol Diagn 1974, 15: 481-593.
2. Desai SP, Carter J, Jinkins JR. Contrast-enhanced MR imaging of Tolosa-Hunt syndrome: case report. AJNR 1991, 12: 182-183.
3. Fowler TJ, Earl CJ, McAllister VL, McDonald WI. Tolosa-Hunt Syndrome. The dangers of an eponym. Br J Ophthalmol 1975, 59: 149-154.
4. Hallpike JF. Superior orbital fissure syndrome. J Neurosurg Psych 1973, 36: 486-490.
5. Hannerz J, Ericson K, Bergstrand G. Orbital phlebography in patients with Tolosa-Hunt's sydrome in comparison with normal subjects. Acta Radiol Diagn 1984, 25: 457-463.
6. Hunt WE, Meagher JN, Lefever HE, Zeman W. Painful ophthalmoplegia: its relatioship to indolent inflammation of the cavernous sinus. Neurology 1961 11:56-62.
7. Hunt WE. Tolosa-Hunt syndrome: one cause of painful ophthalmoplegia. J Neurosurg 1976,44:544-549.
8. Kettler HL, Martin JD. Arterial stationary wave phenomenon in Tolosa-Hunt syndrome. Neurology 1975, 25: 765-770.
9. Kline LB. The Tolosa-Hunt syndrome. Surv Ophthalmol 1982, 27: 79-95.
10. Kwan ESK, Wolpert SM, Hedges TR III. Tolosa-Hunt revisited: not necessary a diagnosis of exclusion. AJR 1988,150:413-418.
11. Mathew NT, Chandy J. Painful ophthalmoplegia. J Neurol Sci 1970, 11: 243-256.
12. McNulty JG - Phlebography of the orbital venous system and the cavernous sinus. Br J Radiol 1969, 42: 113-121.
13. Milstein BA, Morretin LB. Report of a case of sphenoid fissure syndrome studied by orbital venography. Am J Ophthalmol 1971, 72: 600-603.
14. Muhletaler CA, Gerlock AJ. Orbital phlebography in painful ophthalmoplegia (Tolosa-Hunt). Am J Roentgenol 1979, 72: 600-616.
15. Neigel JM, Rootman J, Robinson RG, Durity FA, Nugent RA. The Tolosa-Hunt syndrome: computed tomographic changes and reversal after steroid therapy. Can J Ophthalmol 1986, 21: 287-290.
16. Russel DB, Miller JDR. Orbital venography. Radiology 1972, 103: 267-273.
17. Smith JL, Taxdal DSR. Painful opfthalmoplegia. The Tolosa-Hunt syndrome. Am J Ophthalmol 1966, 61: 1466-1472.
18. Sounheimer FK, Knapp J. Angiographic findings in the Tolosa-Hunt syndrome: painful ophthalmoplegia. Radiology 1973,106:105-112.
19. Thomas JE, Yoss RE. The parasellar syndrome: problems in determining etiology. Mayo Clin Proc 1978, 45: 617-623.
20. Tolosa E. Periarteritic lesions of the carotid syphon with clinical features of carotid infraclinoid aneurywsm. J Neurol Neurosurg Psychiatry 1954, 17: 300-302.
21. Vignaud J, Clay C, Bilaniuk I. Venography of the orbit: an analytical report of 413 cases. Radiology 1974, 110:373-381.
22. Vritsos A. A new method for demonstrating ophthalmic veins, facial veins and superficial venous system of the head. Arch Soc Opfthalmol (Grecia) 1961, 12: 223-232.
23. Yousem DM, Atlas SW, Grossman RI, Sergot RC, Savino PJ, Bosley TM. MR imaging of Tolosa-Hunt syndrome. AJNR 1989, 10: 1181-1184.

Datas de Publicação

Publicação nesta coleção
19 Jan 2011
Data do Fascículo
Jun 1994

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Brismar J. Orbital phlebography: II Anatomy of superior ophthalmic vein and its tributaries. Acta Radiol Diagn 1974, 15: 481-593.

[2] 2. Desai SP, Carter J, Jinkins JR. Contrast-enhanced MR imaging of Tolosa-Hunt syndrome: case report. AJNR 1991, 12: 182-183.

[3] 3. Fowler TJ, Earl CJ, McAllister VL, McDonald WI. Tolosa-Hunt Syndrome. The dangers of an eponym. Br J Ophthalmol 1975, 59: 149-154.

[4] 4. Hallpike JF. Superior orbital fissure syndrome. J Neurosurg Psych 1973, 36: 486-490.

[5] 5. Hannerz J, Ericson K, Bergstrand G. Orbital phlebography in patients with Tolosa-Hunt's sydrome in comparison with normal subjects. Acta Radiol Diagn 1984, 25: 457-463.

[6] 6. Hunt WE, Meagher JN, Lefever HE, Zeman W. Painful ophthalmoplegia: its relatioship to indolent inflammation of the cavernous sinus. Neurology 1961 11:56-62.

[7] 7. Hunt WE. Tolosa-Hunt syndrome: one cause of painful ophthalmoplegia. J Neurosurg 1976,44:544-549.

[8] 8. Kettler HL, Martin JD. Arterial stationary wave phenomenon in Tolosa-Hunt syndrome. Neurology 1975, 25: 765-770.

[9] 9. Kline LB. The Tolosa-Hunt syndrome. Surv Ophthalmol 1982, 27: 79-95.

[10] 10. Kwan ESK, Wolpert SM, Hedges TR III. Tolosa-Hunt revisited: not necessary a diagnosis of exclusion. AJR 1988,150:413-418.

[11] 11. Mathew NT, Chandy J. Painful ophthalmoplegia. J Neurol Sci 1970, 11: 243-256.

[12] 12. McNulty JG - Phlebography of the orbital venous system and the cavernous sinus. Br J Radiol 1969, 42: 113-121.

[13] 13. Milstein BA, Morretin LB. Report of a case of sphenoid fissure syndrome studied by orbital venography. Am J Ophthalmol 1971, 72: 600-603.

[14] 14. Muhletaler CA, Gerlock AJ. Orbital phlebography in painful ophthalmoplegia (Tolosa-Hunt). Am J Roentgenol 1979, 72: 600-616.

[15] 15. Neigel JM, Rootman J, Robinson RG, Durity FA, Nugent RA. The Tolosa-Hunt syndrome: computed tomographic changes and reversal after steroid therapy. Can J Ophthalmol 1986, 21: 287-290.

[16] 16. Russel DB, Miller JDR. Orbital venography. Radiology 1972, 103: 267-273.

[17] 17. Smith JL, Taxdal DSR. Painful opfthalmoplegia. The Tolosa-Hunt syndrome. Am J Ophthalmol 1966, 61: 1466-1472.

[18] 18. Sounheimer FK, Knapp J. Angiographic findings in the Tolosa-Hunt syndrome: painful ophthalmoplegia. Radiology 1973,106:105-112.

[19] 19. Thomas JE, Yoss RE. The parasellar syndrome: problems in determining etiology. Mayo Clin Proc 1978, 45: 617-623.

[20] 20. Tolosa E. Periarteritic lesions of the carotid syphon with clinical features of carotid infraclinoid aneurywsm. J Neurol Neurosurg Psychiatry 1954, 17: 300-302.

[21] 21. Vignaud J, Clay C, Bilaniuk I. Venography of the orbit: an analytical report of 413 cases. Radiology 1974, 110:373-381.

[22] 22. Vritsos A. A new method for demonstrating ophthalmic veins, facial veins and superficial venous system of the head. Arch Soc Opfthalmol (Grecia) 1961, 12: 223-232.

[23] 23. Yousem DM, Atlas SW, Grossman RI, Sergot RC, Savino PJ, Bosley TM. MR imaging of Tolosa-Hunt syndrome. AJNR 1989, 10: 1181-1184.