The second MRI exam is performed 4 months after steroid treatment, which revealed significant size regression.

The diagnosis in this case is presumptive (by MRI radiological features only), no biopsy was taken.

Tolosa hunt syndrome is a non-specific inflammation of the cavernous sinus and superior orbital fissure.

The  histopathological features of the disease is similar to those of idiopathic orbital pseudotumor; 

Clinical presentation (secondary to cavernous sinus inflammation)

• Recurrent retro-orbital pain,
• Palsy of the third, fourth or sixth cranial nerves as well as the first and second divisions of the trigeminal nerve.

Differential diagnosis includes other pathological processes presenting with similar clinical features like Meningioma, Sarcoidosis, Pituitary tumors, tuberculous meningitis, Lymphoma.

The disease is characterized by immediate dramatic response to steroid therapy.

The case is courtesy of Dr Mohamed Fouad, Mohamed Ibrahim & Bahaa Al Din Mahmoud.