Pediatric Tolosa–Hunt Syndrome with Ptosis and Transient Periorbital Headache

An 8-year-old girl with left ptosis and diplopia for 1 day presented with a history of transient left periorbital headache 3 days before her visit. In the left eye, elevation, depression, and adduction movements were impaired ([Fig. 1]) and diplopia was omnidirectional, indicating oculomotor and abducens nerve palsy. Contrast-enhanced magnetic resonance imaging (MRI) revealed an abnormal contrast effect within the left cavernous sinus ([Fig. 2A–D]). Blood tests and cerebrospinal fluid examination showed no abnormalities; infection, tumor markers, and autoantibodies were negative. Based on the International Classification of Headache Disorders (3rd edition, β version) diagnostic criteria for Tolosa–Hunt syndrome (THS),[1] the patient was diagnosed with THS ([Table 1]). Methylprednisolone therapy was administered 7 days after disease onset, causing rapid paralytic improvement. One year after onset, contrast-enhanced MRI revealed a reduced abnormal contrast effect ([Fig. 2E, F]), with no disease recurrence for >3 years.