Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia

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Abass" }, { "@type": "Person", "name": "Isra Babiker" }, { "@type": "Person", "name": "Gufran Algaly" }, { "@type": "Person", "name": "Khalid Y. Fadul" }, { "@type": "Person", "name": "Sara M.I. Ahmed" }, { "@type": "Person", "name": "Fajr Jamal A. Bagi" }, { "@type": "Person", "name": "Muhammad Abugabala" }, { "@type": "Person", "name": "Amin Saied" }, { "@type": "Person", "name": "Mohamed Elgassim" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Background Tolosa-Hunt syndrome is a rare neuroinflammatory disease that affects the cavernous sinus and superior orbital fissure, resulting in symptoms of neuropathy. Case presentation We report a case of a 35-year-old male patient with no past medical history who presented to the emergency department (ED) complaining of a four-day history of progressively increasing headaches associated with right eye pain and double vision. A physical examination showed findings suggestive of abducens nerve palsy. A computed tomography (CT) scan showed subtle asymmetric thickening of the right cavernous sinus, which prompted further investigation by magnetic resonance imaging (MRI) scan. The MRI scan showed intensely enhanced soft tissue thickening in the right cavernous sinus region, slightly extending to the right orbital apex, which caused enlargement of the cavernous sinus and appeared isointense to the adjacent muscles on T1 and T2. The diagnosis of Tolosa-Hunt syndrome was made after the exclusion of all other possible pathologies. The patient received prednisolone therapy; his symptoms improved, and he was discharged after three days. Two weeks later, the patient presented again to the ED with the same symptoms and was treated symptomatically. Conclusions This case highlights a very rare etiology for painful ophthalmoplegia, which is Tolosa-Hunt syndrome. Thickening of the cavernous sinus on MRI images with a background history of painful ophthalmoplegia and headache should raise clinician’s suspicion towards the disease. In addition, exclusion of other possible causes is very important, as Tolosa-Hunt syndrome is a diagnosis of exclusion. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-1594/v2", "name": "Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful..." } } ] } Home Browse Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Abdelrahman A, Elgassim M, Abdalkarim A et al. Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.12688/f1000research.142749.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Case Report Revised Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] Amro Abdelrahman https://orcid.org/0009-0009-7983-422X 1 , Moayad Elgassim 1 , Asmaa Abdalkarim https://orcid.org/0009-0008-5999-7948 1 , [...] Anas Mohamed Babiker 1 , Muhnad Abdeen https://orcid.org/0009-0008-4645-2455 1 , Shahd M. Abass 1 , Isra Babiker 1 , Gufran Algaly 1 , Khalid Y. Fadul https://orcid.org/0000-0001-8057-0182 1 , Sara M.I. Ahmed 1 , Fajr Jamal A. Bagi https://orcid.org/0009-0007-9643-5381 1 , Muhammad Abugabala https://orcid.org/0009-0004-7062-5935 2 , Amin Saied 1 , Mohamed Elgassim https://orcid.org/0009-0000-8454-132X 1 Amro Abdelrahman https://orcid.org/0009-0009-7983-422X 1 , Moayad Elgassim 1 , [...] Asmaa Abdalkarim https://orcid.org/0009-0008-5999-7948 1 , Anas Mohamed Babiker 1 , Muhnad Abdeen https://orcid.org/0009-0008-4645-2455 1 , Shahd M. Abass 1 , Isra Babiker 1 , Gufran Algaly 1 , Khalid Y. Fadul https://orcid.org/0000-0001-8057-0182 1 , Sara M.I. Ahmed 1 , Fajr Jamal A. Bagi https://orcid.org/0009-0007-9643-5381 1 , Muhammad Abugabala https://orcid.org/0009-0004-7062-5935 2 , Amin Saied 1 , Mohamed Elgassim https://orcid.org/0009-0000-8454-132X 1 PUBLISHED 20 Aug 2024 Author details Author details 1 Medical Education Department, Hamad Medical Corporation, Doha, Doha, Qatar 2 Medicine Department, University of Khartoum, Khartoum, Khartoum, Sudan Amro Abdelrahman Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Moayad Elgassim Roles: Writing – Original Draft Preparation Asmaa Abdalkarim Roles: Writing – Original Draft Preparation Anas Mohamed Babiker Roles: Conceptualization, Writing – Original Draft Preparation Muhnad Abdeen Roles: Writing – Original Draft Preparation Shahd M. Abass Roles: Writing – Original Draft Preparation Isra Babiker Roles: Writing – Original Draft Preparation Gufran Algaly Roles: Writing – Original Draft Preparation Khalid Y. Fadul Roles: Supervision, Writing – Review & Editing Sara M.I. Ahmed Roles: Writing – Review & Editing Fajr Jamal A. Bagi Roles: Writing – Original Draft Preparation Muhammad Abugabala Roles: Writing – Original Draft Preparation Amin Saied Roles: Supervision, Validation, Writing – Review & Editing Mohamed Elgassim Roles: Conceptualization, Supervision OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Tolosa-Hunt syndrome is a rare neuroinflammatory disease that affects the cavernous sinus and superior orbital fissure, resulting in symptoms of neuropathy. Case presentation We report a case of a 35-year-old male patient with no past medical history who presented to the emergency department (ED) complaining of a four-day history of progressively increasing headaches associated with right eye pain and double vision. A physical examination showed findings suggestive of abducens nerve palsy. A computed tomography (CT) scan showed subtle asymmetric thickening of the right cavernous sinus, which prompted further investigation by magnetic resonance imaging (MRI) scan. The MRI scan showed intensely enhanced soft tissue thickening in the right cavernous sinus region, slightly extending to the right orbital apex, which caused enlargement of the cavernous sinus and appeared isointense to the adjacent muscles on T1 and T2. The diagnosis of Tolosa-Hunt syndrome was made after the exclusion of all other possible pathologies. The patient received prednisolone therapy; his symptoms improved, and he was discharged after three days. Two weeks later, the patient presented again to the ED with the same symptoms and was treated symptomatically. Conclusions This case highlights a very rare etiology for painful ophthalmoplegia, which is Tolosa-Hunt syndrome. Thickening of the cavernous sinus on MRI images with a background history of painful ophthalmoplegia and headache should raise clinician’s suspicion towards the disease. In addition, exclusion of other possible causes is very important, as Tolosa-Hunt syndrome is a diagnosis of exclusion. READ ALL READ LESS Keywords Tolosa Hunt syndrome, Painful ophthalmoplegia, Headache, Cavernous sinus, Neurology, Ophthalmology Corresponding Author(s) Mohamed Elgassim ( [email protected] ) Close Corresponding author: Mohamed Elgassim Competing interests: No competing interests were disclosed. Grant information: Open Access funding provided by the Qatar National Library. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2024 Abdelrahman A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Abdelrahman A, Elgassim M, Abdalkarim A et al. Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.12688/f1000research.142749.2 ) First published: 14 Dec 2023, 12 :1594 ( https://doi.org/10.12688/f1000research.142749.1 ) Latest published: 20 Aug 2024, 12 :1594 ( https://doi.org/10.12688/f1000research.142749.2 ) Revised Amendments from Version 1 Points added: Other neurons that could be affected in the introduction Differential diagnosis in case presentation CT image added in the case presentation Opening pressure added in the case presentation Points added: Other neurons that could be affected in the introduction Differential diagnosis in case presentation CT image added in the case presentation Opening pressure added in the case presentation See the authors' detailed response to the review by Sanjay Mhalasakant Khaladkar See the authors' detailed response to the review by Shreyashi Jha READ REVIEWER RESPONSES Introduction Tolosa-Hunt syndrome is a disease characterized by granulomatous inflammation affecting the cavernous sinus and/or superior orbital fissure. This inflammation leads to the compression of various cranial nerves and subsequent neuropathic symptoms. This condition was originally documented in 1954. 1 Tolosa-Hunt syndrome manifests as ptosis, discomfort in the orbital, periorbital, or hemicrania areas, and ophthalmoplegia (partial or full). 2 Typically, inflammation originates in the cavernous sinus and then extends towards the superior orbital fissure and orbital cavity. This condition presents as recurring episodic attacks, following a pattern of relapsing and remitting. According to reports, there are about one in a million cases affected by this disease annually. 1 Tolosa-Hunt Syndrome (THS) primarily affects the cavernous sinus and its nerves. The most commonly involved nerve is the oculomotor nerve (CN III), seen in about 80% of cases. The abducens nerve (CN VI) is affected in about 70% of cases. The trochlear nerve (CN IV) and branches of the trigeminal nerve (V1 and V2) can also be affected. If inflammation spreads to the orbital apex, it can impact the optic nerve (CN II), leading to visual symptoms. Inflammation may extend to affect other nerves such as the facial nerve (CN VII). 1 Here we describe a 35-year old male patient who presented to the hospital with headache and right eye pain. A magnetic resonance imaging (MRI) scan showed thickening in the cavernous sinus region. He was diagnosed as a case of Tolosa-Hunt syndrome after exclusion of all other potential diagnosis. This case report follows the CARE checklist. 8 Case presentation A 35-year-old Egyptian male patient, with no past medical history presented to the emergency department (ED) of Hamad hospital complaining of a four-day history of progressively increasing headaches associated with right eye pain and double vision. According to the patient, the headache mainly affected the right and frontal sides of the head and was associated with nausea and three episodes of non-bloody vomiting. He denied any recent history of head trauma, loss of consciousness, fever, neck stiffness, or photophobia. In the ED, his vital signs were within normal limits. Physical examination revealed impaired abduction of the right eye with horizontal nystagmus on lateral gaze consistent with right abducens nerve palsy. Careful examination of both upper and lower extremities was unremarkable. No motor or sensory deficits were noted. Kernig’s and Brudzinski’s signs were negative. Examination of other systems was unremarkable. The patient’s lab results, including a complete blood count and comprehensive metabolic panel, were within normal ranges. A computed tomography (CT) scan result showed subtle asymmetric thickening of the right cavernous sinus. However, given the strong clinical suspicion of Tolosa-Hunt syndrome, the radiologist recommended doing magnetic resonance imaging (MRI) scan of the head and orbital region. Following discussion with neurology team, the patient received painkillers and was admitted to the medical floor for further management. The neurology team recommended cerebrospinal fluid analysis (CSF), autoimmune, and vasculitis workups to narrow down the differential diagnoses. Results of the MRI revealed an intensely enhanced soft tissue thickening in the right cavernous sinus region, slightly extending to the right orbital apex, which caused enlargement of the cavernous sinus and appeared isointense to the adjacent muscles on T1 and T2 ( Figure 2 ). Figure 1. Computed Tomography (CT) scan showing subtle asymmetrical thickening of the cavernous sinus. Figure 2. Magnetic resonance imaging (MRI) showing enhancing soft tissue thickening in the right cavernous sinus region (red arrow). Magnetic resonance imaging (MRI) showing enhancing soft tissue thickening in the right cavernous sinus region (red arrow). (A): Axial view. (B) Coronal view. CSF analysis through Lumbar puncture (LP) was done and the opening pressure was 17, and while waiting for the results, the patient was started on oral prednisolone 60 mg for three days and then tapered off. The results of the CSF analysis showed no abnormalities which ruled out the possibility of TB and meningitis, and the results of the autoimmune and vasculitis workup also came back negative which ruled out the possibility of sarcoidosis. A diagnosis of Tolosa-Hunt Syndrome was made, and the patient was discharged on oral prednisolone at 60 mg with a follow-up visit to a neurology clinic after 6 weeks. Two weeks later, the patient presented to the ED again with a headache and right eye pain after his symptoms had initially improved. He was treated symptomatically as a known case of Tolosa-hunt syndrome and discharged on the same day. Discussion Tolosa-Hunt syndrome stands as an uncommon entity of painful ophthalmoplegia, originating from non-specific inflammation within the cavernous sinus. The National Organization for Rare Disorders (NORD) states that the disease typically emerges around the median age of 41 years, affecting both sexes. 3 Our patient, however, was a 35-year-old male, which is relatively young in contrast to the average age of onset. The specific etiology of the disease is not fully understood. 2 A non-specific granulomatous inflammation of the cavernous sinus with varying extension into the superior orbital fissure and orbital apex, along with infiltration of lymphocytes and plasma cells, is the primary characteristic of the disease. When patients present with symptoms of ophthalmoplegia and headache, it is necessary to rule out other malignant and autoimmune conditions, even though it is typically thought of as a benign condition. Understanding the differential diagnosis is more crucial to exclude other causes than it is to confirm the condition, 4 as a requirement for the diagnostic criteria as per The International Classification of Headache Disorders (ICHD). Tolosa Hunt’s Diagnostic criteria as per ICHD’s latest edition in 2018 5 includes the following: “ A. Unilateral orbital or periorbital headache fulfilling criterion C B. Both of the following: 1. Granulomatous inflammation of the cavernous sinus, superior orbital fissure or orbit, demonstrated by MRI or biopsy 2. Paresis of one or more of the ipsilateral cranial nerves III, IV and/or VI C. Evidence of causation demonstrated by both of the following: 1. Headache is ipsilateral to the granulomatous inflammation 2. Headache has preceded paresis of the nerves III, IV and/or VI by 2 weeks, or developed with it D. Not better accounted for by another ICHD-3 diagnosis ” Generally, MRI is a cornerstone in diagnosing pathologies of the cavernous sinus. In the case of Tolosa Hunt syndrome, the classical appearance is enhancing soft-tissue thickening of the cavernous sinus and superior orbital fissure that appears isointense to gray matter on T1-weighted images and iso- to hypointense on T2-weighted images. 6 Our patient presented with a headache and right eye pain, and the physical examination showed a sixth (IV) cranial nerve palsy (Abducens nerve palsy). The results of the CT scan showed subtle asymmetric thickening of the right cavernous sinus. However, the radiology team recommended an MRI scan, as the clinical history and examination were highly suggestive of Tolosa-Hunt syndrome. The MRI results showed intensely enhanced soft tissue thickening in the right cavernous sinus region, slightly extending to the right orbital apex, which caused enlargement of the cavernous sinus and appears isointense to the adjacent muscles on T1 and T2. In addition, the results of the autoimmune, vasculitis, and CSF workups were all negative. Since the disorder is inflammatory, high-dose glucocorticoids are the main course of therapy. 1 A progressive oral taper over a period of weeks is advised after an initial high-dose steroid therapy. Neuropathies may take months to resolve, requiring a longer steroid regimen. Neurological impairments may occasionally last a lifetime. Persistent MRI abnormalities should not affect the recommended length of therapy unless they show no regression because radiological improvement also takes time to resolve. Overall, 50% of individuals have a recurrence of the illness. 7 After admission, our patient started prednisolone treatment with an initial dose of 60 mg for three days, followed by a tapering dose. He was discharged with a follow-up with a neurology clinic after 6 weeks. Two weeks later, he presented again to the ED with a headache and right eye pain, although his symptoms had initially improved with treatment. He was treated symptomatically and discharged on the same day. Conclusions Tolosa-Hunt syndrome is a very rare neuroinflammatory condition that presents as painful ophthalmoplegia. Thickening of the cavernous sinus on MRI images with a background history of ophthalmoplegia and headache is highly suggestive of Tolosa-Hunt syndrome. However, as the disease is a diagnosis of exclusion, it’s very crucial for clinicians to exclude other possible pathologies of painful ophthalmoplegia before establishing the diagnosis of Tolosa-Hunt syndrome. Consent Written informed consent for publication of their clinical details and clinical images was obtained from the patient. Data availability Underlying data All data underlying the results are available as part of the article and no additional source data are required. Reporting guidelines Zenodo: CARE checklist for “Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia”. https://doi.org/10.5281/zenodo.8360931 . 8 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments Open Access funding provided by Qatar National Library. References 1. Amrutkar C, Burton EV: Tolosa-Hunt Syndrome. [Updated 2023 Aug 8]. StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 Jan. Reference Source 2. Paovic J, Paovic P, Bojkovic I, et al. : Tolosa-Hunt syndrome—diagnostic problem of painful ophthalmoplegia. Vojnosanit. Pregl. 2012; 69 : 627–630. PubMed Abstract | Publisher Full Text 3. Tolosa hunt syndrome - symptoms, causes, treatment: Nord.2023 [cited 2023 Jul 10]. Reference Source 4. Singh MK, Marshall B, Hawley J: Painful ophthalmoplegia: A case of tolosa–hunt syndrome. Mil. Med. 2014; 179 (11): e1409–e1410. Publisher Full Text 5. Headache classification committee of the International Headache Society (IHS) the International Classification of Headache Disorders, 3rd Edition. Cephalalgia. 2018; 38 (1): 1–211. PubMed Abstract | Publisher Full Text 6. Mahalingam HV, Mani SE, Patel B, et al. : Imaging spectrum of cavernous sinus lesions with histopathologic correlation. RadioGraphics. 2019; 39 (3): 795–819. PubMed Abstract | Publisher Full Text 7. Siddhanta KC, Shreeyanta KC, Kunwar P, et al. : Tolosa-Hunt Syndrome: A case report. J. Nepal Med. Assoc. 2021; 59 (238): 604–607. PubMed Abstract | Publisher Full Text | Free Full Text 8. Abdelrahman A: Case report: Tolosa Hunt Syndrome: A rare cause of painful ophthalmoplegia. [Dataset]. Zenodo. 2023. Publisher Full Text Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 14 Dec 2023 ADD YOUR COMMENT Comment Author details Author details 1 Medical Education Department, Hamad Medical Corporation, Doha, Doha, Qatar 2 Medicine Department, University of Khartoum, Khartoum, Khartoum, Sudan Amro Abdelrahman Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Moayad Elgassim Roles: Writing – Original Draft Preparation Asmaa Abdalkarim Roles: Writing – Original Draft Preparation Anas Mohamed Babiker Roles: Conceptualization, Writing – Original Draft Preparation Muhnad Abdeen Roles: Writing – Original Draft Preparation Shahd M. Abass Roles: Writing – Original Draft Preparation Isra Babiker Roles: Writing – Original Draft Preparation Gufran Algaly Roles: Writing – Original Draft Preparation Khalid Y. Fadul Roles: Supervision, Writing – Review & Editing Sara M.I. Ahmed Roles: Writing – Review & Editing Fajr Jamal A. Bagi Roles: Writing – Original Draft Preparation Muhammad Abugabala Roles: Writing – Original Draft Preparation Amin Saied Roles: Supervision, Validation, Writing – Review & Editing Mohamed Elgassim Roles: Conceptualization, Supervision Competing interests No competing interests were disclosed. Grant information Open Access funding provided by the Qatar National Library. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 20 Aug 2024, 12:1594 https://doi.org/10.12688/f1000research.142749.2 version 1 Published: 14 Dec 2023, 12:1594 https://doi.org/10.12688/f1000research.142749.1 Copyright © 2024 Abdelrahman A et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Abdelrahman A, Elgassim M, Abdalkarim A et al. Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.12688/f1000research.142749.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 20 Aug 2024 Revised Views 0 Cite How to cite this report: Jha S. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315511 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315511 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Oct 2024 Shreyashi Jha , Institute of Neurosciences, Kolkata, West Bengal, India Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.170126.r315511 I have significant reservations with the diagnosis and management of this purportedly report case of Tolosa Hunt Syndrome. Abstract Background: only word "neuropathy" misleading, specify cranial neuropathy It would be advisable to avoid labeling the cavernous sinus thickening ... Continue reading READ ALL I have significant reservations with the diagnosis and management of this purportedly report case of Tolosa Hunt Syndrome. Abstract Background: only word "neuropathy" misleading, specify cranial neuropathy It would be advisable to avoid labeling the cavernous sinus thickening as Tolosa-Hunt Syndrome without a contrast study to support the diagnosis. The authors report as "intensely enhancing", but no images have been provided of T1 contrast. The images provided of T1 are of poor quality. CSF Opening pressure is 17 ..units?? what was CSF cytology protein glucose? Detailed autoimmune and vasculitis markers have to be provided, which markers were done Why steroids were not repeated when the patient relapsed when the diagnosis was supposedly Tolosa Hunt Syndrome? Furthermore, THS can be diagnosed only after reasonable exclusion of alternative causes, which has not been done in this study. References 1. Jha S, Tiwari M, Agarwal N, Datta A, et al.: Pituitary Hyperplasia in Tolosa Hunt Syndrome: Demystifying the Great Mimic. Ann Indian Acad Neurol . 2023; 26 (4): 608-610 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Movement Disorders Neuroinfections Neuroimmunology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Jha S. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315511 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315511 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Khaladkar SM. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315510 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315510 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 18 Sep 2024 Sanjay Mhalasakant Khaladkar , Dr. D. Y. Patil Medical College, Pune, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.170126.r315510 Additions are done at appropriate places. Contrast-enhanced MRI ... Continue reading READ ALL Additions are done at appropriate places. Contrast-enhanced MRI and CT images are to be added at appropriate places. Competing Interests: No competing interests were disclosed. Reviewer Expertise: RADIOLOGY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Khaladkar SM. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315510 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315510 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 14 Dec 2023 Views 0 Cite How to cite this report: Khaladkar SM. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r290337 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v1#referee-response-290337 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Jun 2024 Sanjay Mhalasakant Khaladkar , Dr. D. Y. Patil Medical College, Pune, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.156331.r290337 -Kindly provide results of tests done to rule out other causes of cavernous sinus involvement(Elaborate results of lab. investigations in short and how these helped in ruling out differential diagnosis) -images of contrast MRI, CT plain and ... Continue reading READ ALL -Kindly provide results of tests done to rule out other causes of cavernous sinus involvement(Elaborate results of lab. investigations in short and how these helped in ruling out differential diagnosis) -images of contrast MRI, CT plain and contrast in region of interest. -Mention names after whom the entity is labelled. -Painful ophthalmoplegia- definition, causes. -Clinico-anatomical correlation -Role of thin T2 (early diagnosis),CT(rule out erosion, hyperostosis) -Any role of dynamic MRI?(early diagnosis) -Role of angiography/ MRangiography . -Similarity and how to differentiate from IgG4 related ophthalmic disease Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Kapila AT, Ray S, Lal V: Tolosa-Hunt Syndrome and IgG4 Diseases in Neuro-Ophthalmology. Ann Indian Acad Neurol . 2022; 25 (Suppl 2): S83-S90 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: RADIOLOGY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Khaladkar SM. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r290337 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v1#referee-response-290337 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 20 Aug 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 20 Aug 2024 Author Response We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - ... Continue reading We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - Differential diagnosis in (case presentation) - CT image We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - Differential diagnosis in (case presentation) - CT image Competing Interests: No conflict of interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 20 Aug 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 20 Aug 2024 Author Response We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - ... Continue reading We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - Differential diagnosis in (case presentation) - CT image We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - Differential diagnosis in (case presentation) - CT image Competing Interests: No conflict of interests Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Jha S. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r247747 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v1#referee-response-247747 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 Feb 2024 Shreyashi Jha , Institute of Neurosciences, Kolkata, West Bengal, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.156331.r247747 The authors have described a case of painful right lateral rectus palsy secondary to possible Tolosa Hunt Syndrome. However, I have some concerns: 1. Did patient have any past significant medical history? 2. Since the patient showed right ... Continue reading READ ALL The authors have described a case of painful right lateral rectus palsy secondary to possible Tolosa Hunt Syndrome. However, I have some concerns: 1. Did patient have any past significant medical history? 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? 4. Kindly include T1 contrast images for better clarity 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. 6. What do the authors mean by CSF analysis negative? 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Movement Disorders Neuroinfections Neuroimmunology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Jha S. Reviewer Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r247747 ) The direct URL for this report is: https://f1000research.com/articles/12-1594/v1#referee-response-247747 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 31 May 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 31 May 2024 Author Response 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF ... Continue reading 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF opening wasn't done (this point will be added to the next version as a limitation) however, Fundoscopic examination was normal . 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? comperensive metabolic panel includes both renal function test and liver function test 4. Kindly include T1 contrast images for better clarity I will try 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. imaging was not done on recurrence of symptoms (will be mention in case presentation) 6. What do the authors mean by CSF analysis negative? CSF showed no abnormalities (will be rephrased) 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? CT chest and abdomen wasn't done 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF opening wasn't done (this point will be added to the next version as a limitation) however, Fundoscopic examination was normal . 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? comperensive metabolic panel includes both renal function test and liver function test 4. Kindly include T1 contrast images for better clarity I will try 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. imaging was not done on recurrence of symptoms (will be mention in case presentation) 6. What do the authors mean by CSF analysis negative? CSF showed no abnormalities (will be rephrased) 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? CT chest and abdomen wasn't done Competing Interests: no conflict of interest Close Report a concern Author Response 20 Aug 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 20 Aug 2024 Author Response Opening pressure was 17. (Added to the new version) Competing Interests: no conflict of interests Opening pressure was 17. (Added to the new version) Opening pressure was 17. (Added to the new version) Competing Interests: no conflict of interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 31 May 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 31 May 2024 Author Response 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF ... Continue reading 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF opening wasn't done (this point will be added to the next version as a limitation) however, Fundoscopic examination was normal . 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? comperensive metabolic panel includes both renal function test and liver function test 4. Kindly include T1 contrast images for better clarity I will try 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. imaging was not done on recurrence of symptoms (will be mention in case presentation) 6. What do the authors mean by CSF analysis negative? CSF showed no abnormalities (will be rephrased) 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? CT chest and abdomen wasn't done 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF opening wasn't done (this point will be added to the next version as a limitation) however, Fundoscopic examination was normal . 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? comperensive metabolic panel includes both renal function test and liver function test 4. Kindly include T1 contrast images for better clarity I will try 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. imaging was not done on recurrence of symptoms (will be mention in case presentation) 6. What do the authors mean by CSF analysis negative? CSF showed no abnormalities (will be rephrased) 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? CT chest and abdomen wasn't done Competing Interests: no conflict of interest Close Report a concern Author Response 20 Aug 2024 Amro Abdelrahman , Medical Education Department, Hamad Medical Corporation, Doha, Qatar 20 Aug 2024 Author Response Opening pressure was 17. (Added to the new version) Competing Interests: no conflict of interests Opening pressure was 17. (Added to the new version) Opening pressure was 17. (Added to the new version) Competing Interests: no conflict of interests Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 14 Dec 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 20 Aug 24 read read Version 1 14 Dec 23 read read Shreyashi Jha , Institute of Neurosciences, Kolkata, India Sanjay Mhalasakant Khaladkar , Dr. D. Y. Patil Medical College, Pune, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Jha S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Oct 2024 | for Version 2 Shreyashi Jha , Institute of Neurosciences, Kolkata, West Bengal, India 0 Views copyright © 2024 Jha S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have significant reservations with the diagnosis and management of this purportedly report case of Tolosa Hunt Syndrome. Abstract Background: only word "neuropathy" misleading, specify cranial neuropathy It would be advisable to avoid labeling the cavernous sinus thickening as Tolosa-Hunt Syndrome without a contrast study to support the diagnosis. The authors report as "intensely enhancing", but no images have been provided of T1 contrast. The images provided of T1 are of poor quality. CSF Opening pressure is 17 ..units?? what was CSF cytology protein glucose? Detailed autoimmune and vasculitis markers have to be provided, which markers were done Why steroids were not repeated when the patient relapsed when the diagnosis was supposedly Tolosa Hunt Syndrome? Furthermore, THS can be diagnosed only after reasonable exclusion of alternative causes, which has not been done in this study. References 1. Jha S, Tiwari M, Agarwal N, Datta A, et al.: Pituitary Hyperplasia in Tolosa Hunt Syndrome: Demystifying the Great Mimic. Ann Indian Acad Neurol . 2023; 26 (4): 608-610 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Movement Disorders Neuroinfections Neuroimmunology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Jha S. Peer Review Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315511) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315511 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Khaladkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 18 Sep 2024 | for Version 2 Sanjay Mhalasakant Khaladkar , Dr. D. Y. Patil Medical College, Pune, India 0 Views copyright © 2024 Khaladkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Additions are done at appropriate places. Contrast-enhanced MRI and CT images are to be added at appropriate places. Competing Interests No competing interests were disclosed. Reviewer Expertise RADIOLOGY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Khaladkar SM. Peer Review Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.170126.r315510) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1594/v2#referee-response-315510 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Khaladkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Jun 2024 | for Version 1 Sanjay Mhalasakant Khaladkar , Dr. D. Y. Patil Medical College, Pune, India 0 Views copyright © 2024 Khaladkar S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions -Kindly provide results of tests done to rule out other causes of cavernous sinus involvement(Elaborate results of lab. investigations in short and how these helped in ruling out differential diagnosis) -images of contrast MRI, CT plain and contrast in region of interest. -Mention names after whom the entity is labelled. -Painful ophthalmoplegia- definition, causes. -Clinico-anatomical correlation -Role of thin T2 (early diagnosis),CT(rule out erosion, hyperostosis) -Any role of dynamic MRI?(early diagnosis) -Role of angiography/ MRangiography . -Similarity and how to differentiate from IgG4 related ophthalmic disease Is the background of the case’s history and progression described in sufficient detail? Yes Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? Yes Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? Yes Is the case presented with sufficient detail to be useful for other practitioners? Yes References 1. Kapila AT, Ray S, Lal V: Tolosa-Hunt Syndrome and IgG4 Diseases in Neuro-Ophthalmology. Ann Indian Acad Neurol . 2022; 25 (Suppl 2): S83-S90 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise RADIOLOGY I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 20 Aug 2024 Amro Abdelrahman, Medical Education Department, Hamad Medical Corporation, Doha, Qatar We did not address all points because our goal is a focused-case study of tolosa hunt disease. However new points were added: - Other neurons that could be affected - Differential diagnosis in (case presentation) - CT image View more View less Competing Interests No conflict of interests reply Respond Report a concern Khaladkar SM. Peer Review Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r290337) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1594/v1#referee-response-290337 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Jha S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Feb 2024 | for Version 1 Shreyashi Jha , Institute of Neurosciences, Kolkata, West Bengal, India 0 Views copyright © 2024 Jha S. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (2) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have described a case of painful right lateral rectus palsy secondary to possible Tolosa Hunt Syndrome. However, I have some concerns: 1. Did patient have any past significant medical history? 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? 4. Kindly include T1 contrast images for better clarity 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. 6. What do the authors mean by CSF analysis negative? 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? Is the background of the case’s history and progression described in sufficient detail? Partly Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes? No Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment? No Is the case presented with sufficient detail to be useful for other practitioners? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Movement Disorders Neuroinfections Neuroimmunology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (2) Author Response 31 May 2024 Amro Abdelrahman, Medical Education Department, Hamad Medical Corporation, Doha, Qatar 1. Did patient have any past significant medical history? No 2. Since the patient showed right abducens nerve palsy was raised ICT ruled out? What did the fundi show? CSF opening wasn't done (this point will be added to the next version as a limitation) however, Fundoscopic examination was normal . 3. What do the authors mean by "comprehensive metabolic panel" and kindly enlist the "autoimmune and vasculitic workup" done? What was the CSF opening pressure? comperensive metabolic panel includes both renal function test and liver function test 4. Kindly include T1 contrast images for better clarity I will try 5. What were the MRI findings of the patient when he had a recurrence of symptoms? Imaging should have been ideally repeated. imaging was not done on recurrence of symptoms (will be mention in case presentation) 6. What do the authors mean by CSF analysis negative? CSF showed no abnormalities (will be rephrased) 7. Was a CT chest and abdomen done? Were other neoplastic infectious and granulomatous causes including sarcoidosis excluded? CT chest and abdomen wasn't done View more View less Competing Interests no conflict of interest reply Respond Report a concern Author Response 20 Aug 2024 Amro Abdelrahman, Medical Education Department, Hamad Medical Corporation, Doha, Qatar Opening pressure was 17. (Added to the new version) View more View less Competing Interests no conflict of interests reply Respond Report a concern Jha S. Peer Review Report For: Case Report: Tolosa-Hunt syndrome, a neuroinflammatory origin of painful ophthalmoplegia [version 2; peer review: 1 approved with reservations, 1 not approved] . F1000Research 2024, 12 :1594 ( https://doi.org/10.5256/f1000research.156331.r247747) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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