Authors: Wiame Bougrine , Brahim El Mahjoub , Hajar Ouazzani Chahdi , Ismail Chaouche , Amal Akammar , Nizar El Bouardi , Meriem Haloua , Badreddine Alami , Mly Youssef Alaoui Lamrani , Mustapha Maaroufi , Meryem Boubbou

Abstract

Background: Cavernous sinus syndrome (CSS) is a rare but potentially life-threatening condition caused by a heterogeneous group of neoplastic, vascular, and inflammatory lesions. Its diagnosis represents a significant clinical challenge owing to overlapping presentations and the complex anatomy of the cavernous sinus region. Early and accurate imaging is essential to guide timely management and prevent serious complications including vision loss and stroke.

Aims and Objectives: To describe the etiologic distribution and imaging features of CSS in a North African tertiary care cohort, and to evaluate the contribution of multimodal imaging in establishing the underlying diagnosis.

Settings: Radiology Department, University Hospital Hassan II, Fez, Morocco (January 2021–December 2024).

Methods: Retrospective observational study of 26 consecutive patients evaluated between 2021 and 2024 at University Hospital Hassan II of Fez, Morocco. Morocco. All patients underwent contrast-enhanced CT, and 13 (50%) received 1.5 T MRI with T1-, T2-, FLAIR-, diffusion-weighted, and post-gadolinium sequences; MR angiography and venography were performed when vascular lesions were suspected. Diagnoses were confirmed by histopathology, angiography, hormonal assay, microbiological workup, or clinical and therapeutic response as appropriate.

Results: The mean age was 49 ± 18 years (14 men, 12 women). Neoplastic etiologies predominated (n = 16, 62%): meningiomas, pituitary adenomas, lymphomas, cavernous hemangioma, chordoma, chondrosarcoma, and nasopharyngeal carcinoma. Vascular causes accounted for 31% (cavernous sinus thrombosis, carotid-cavernous fistulas, aneurysms). Inflammatory etiologies represented 8% (Tolosa-Hunt syndrome and orbital pseudotumor). CT provided a working diagnosis in all cases; MRI offered superior soft-tissue characterization and vascular delineation where available.

Conclusion: Multimodal imaging, particularly contrast-enhanced MRI supplemented by CT and vascular sequences, enables reliable differentiation between neoplastic, vascular, and inflammatory causes of CSS, facilitating prompt diagnosis and targeted management in settings with variable access to advanced imaging.

Keywords: Cavernous sinus syndrome, painful ophthalmoplegia, multimodal imaging, cavernous sinus thrombosis, Tolosa–Hunt Syndrome, carotid-cavernous fistula.