This 54-year-old man presenting with a painful ophthalmoplegia (JW Neurology Apr 2012) had a magnetic resonance imaging (MRI) scan with gadolinium and cavernous sinus views (see Figure 1), which showed an enhancing lesion favoring a diagnosis of Tolosa Hunt syndrome. Treatment with prednisone was initiated at 60 mg daily. The headache improved substantially within 48 hours, and extraocular motility and ptosis improved moderately by 1 week. Steroids were continued for 6 weeks; the dosage was tapered every …