Abstract
Dear Sir We are very grateful to Dr Dach for her comments on our paper (1); she raises some relevant points.
We share the author's opinion that Tolosa–Hunt syndrome (THS) may occur in patients with or without inflammatory intracranial lesions, or it may be symptomatic of other diseases, as reported in the subgroups analysis performed in our study (Benign, Inflammatory, Symptomatic).
Dr Dach comments critically on our interpretation of criterion B of the International Classification of Headache Disorders-II, which, in her opinion, indicates that ophthalmoparesis may or may not be associated with an inflammatory lesion. We think that she has misinterpreted our analysis. Criterion B clearly indicates that magnetic resonance imaging (MRI) should demonstrate the presence of granuloma in these patients. We have accepted this statement and re-analysed the published cases according to neuroimaging findings to verify the actual relevance of these data. This is why our study was called ‘a critical literature review’.
However, there is general agreement that THS is a steroid-responsive painful ophthalmoparesis due to an idiopathic granulomatous inflammation in the cavernous sinus and that MRI is the most sensitive technique in directly revealing the lesion, although not specific (2, 3): these data led the International Headache Society (IHS) to the sensible inclusion of MRI in the criteria for THS in 2004. This will promote general agreement to make the diagnosis of THS using MRI. We think that its application will allow a clear separation of the two groups of patients (with and without inflammatory lesions), although both protocol and follow-up MRI should be better defined, to avoid incorrect diagnosis of THS.
We agree that patients with a clinical syndrome suggestive of THS in which the diagnostic work-up shows other possible diagnoses (so-called symptomatic) should be no longer diagnosed as THS according to the new IHS criteria.