LETTER TO THE EDITOR

TolosaHunt syndrome: critical literature review based on IHS 2004 criteria

Dear Sir We carefully read the review article by La Mantia et al. (1); however, we believe that some facts regarding the TolosaHunt syndrome (THS) diagnosis must be taken into account, based on the criteria of the International Classication of Headache Disorders, second edition (ICHD-II) (2). In the rst paragraph, the authors clearly show misunderstanding of the current diagnostic criteria for THS by claiming that the presence of granuloma by magnetic resonance imaging (MRI) or biopsy is essential for diagnosing THS. According to Criterion B (code 13.16: paresis of one or more of the third, fourth and/or sixth cranial nerves and/or demonstration of granuloma by MRI or biopsy) (2), one can conclude that THS diagnosis is possible even in the presence of normal MRI. Also, contrary to the authors suggestion in the last paragraph of the Discussion, THS cases with normal MRI are addressed by ICHD-II (2). We agree with La Mantia et al. that the clinical features suggesting THS are not specic for that syndrome, but are common to several conditions and that their presence alone does not guarantee the correct diagnosis. For this reason, we would like to point out that, in order to diagnose THS, it is necessary to rule out other causes of painful ophthalmoplegia through appropriate investigation, according to Criterion E (code 13.16, ICHDII) (2).

Authors reply
Dear Sir We are very grateful to Dr Dach for her comments on our paper (1); she raises some relevant points. 1 We share the authors opinion that TolosaHunt syndrome (THS) may occur in patients with or without inammatory intracranial lesions, or it may be symptomatic of other diseases, as reported in the subgroups analysis performed in our study (Benign, Inammatory, Symptomatic). 2 Dr Dach comments critically on our interpretation of criterion B of the International Classication of Headache Disorders-II, which, in her opinion, indicates that ophthalmoparesis may or may not be associated with an inammatory 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 ndings to verify the actual relevance of these data. This is why our study was called a critical literature review. 3 However, there is general agreement that THS is a steroid-responsive painful ophthalmoparesis due to an idiopathic granulomatous inammation in the cavernous sinus and that MRI is the most sensitive technique in directly revealing the lesion, although not specic (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 inammatory lesions), although both protocol and follow-up MRI should be better dened, to avoid incorrect diagnosis of THS. 4 We agree that patients with a clinical syndrome suggestive of THS in which the diagnostic work-up shows other possible diagnoses (socalled symptomatic) should be no longer
Blackwell Publishing Ltd Cephalalgia, 2007, 27, 960961

References
1 La Mantia L, Curone M, Rapaport AM, Bussone G. Tolosa Hunt syndrome: critical literature review based on HIS 2004 criteria. Cephalalgia 2006; 26:77281. 2 Headache Subcommittee of the International Headache Society. The International Classication of Headache Disorders, 2nd edition. Cephalalgia 2004;24 (Suppl. 1):1 160. F Dach and J Speciali, Department of Neurology, University of So Paulo, School of Medicine at Ribeiro Preto, Hospital of Clinics, Av. Bandeirantes, 3900 Canpus Universitrio Ribeiro Preto So Paulo 14000-000, Brazil. E-mail fabioladach@yahoo.com.br

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Letter to the Editor diagnosed as THS according to the new IHS criteria.

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3 Gladstone JP, Dodick DW. Painful ophthalmoplegia: overview with a focus on TolosaHunt syndrome. Current Pain Headache Reports 2004; 8:3219. G Bussone and L La Mantia, Headache Unit, Department of Clinical Neurology, Neurological Institute C. Besta, Milan, Italy. E-mail: bussone@istituto-besta.it

References
1 La Mantia L, Curone M, Rapoport AM, Bussone G. Tolosa Hunt sindrome: critical literature review based on IHS 2004 criteria. Cephalalgia 2006; 26:77281. 2 Cakirer S. MRI ndings in TolosaHunt syndrome before and after systemic corticosteroid therapy. Eur J Neurol 2003; 45:8390.

Blackwell Publishing Ltd Cephalalgia, 2007, 27, 960961