Bi-opercular Syndrome: A Case Report and Minireview

Abstract

A 40-year-old right handed healthy man had sudden onset of loss of speech and inability to swallow. He did not have any prior history of similar complaints or seizures. There was no history of headache, fever, vomiting or visual symptoms. He was neither a diabetic nor a hypertensive. He was a chronic smoker and alcoholic. On examination, his pulse was 72 per minute, regular and all peripheral pulses were well felt and BP was 130/80 mm Hg. Neurologically, he was conscious and responding to commands, but, he could not vocalize and he could not protrude his tongue or swallow on comm and [Table/ Fig-1]. However, opening of mouth was noted during yawning and laughing [Table/ Fig-2]. He had bilateral central facial paresis with preserved involuntary facial movements. Jaw jerk, palatal and pharyngeal reflexes were normal. Pronator drift of left upper limb and bilateral brisk deep tendon reflexes with bilateral extensor plantars were noted. Fundi and other examinations were normal. Cardiovascular, respiratory and per-abdomen examinations revealed no abnormality. CT head revealed bilateral perisylvian infarcts . MRI brain and angiography could not be done due to financial constraints. Complete hemogram, renal function tests, serum electrolytes and serum transaminases were normal. ECG and echocardiogram including transesophageal echo were normal. Bilateral carotid and vertebral doppler did not reveal any obstruction or stenosis. Transcranial doppler was normal. Stroke in young workup including serum homocysteine level, collagen vascular profile, APLA antibodies and thrombophilia workup were normal. Serum VDRL and HIV I and II were negative. Fasting lipid profile revealed total cholesterol of 296 mg/dl and LDL cholesterol of 138 mg/dl. He was put on Ryle's tube for feeding. He was started on antiplatelets and statins. A psychiatrist consultation was sought for advice regarding de-addiction. Speech and swallowing assessment was done by the therapist. He has shown no improvement in speech and swallowing at discharge and over 4 weeks follow up. He has been advised regular follow ups. DisCussionThe patient presented here had classical features of bilateral opercular syndrome characterised by cortical pseudo-bulbar paralysis (faciolabio-pharyngo-glosso-masticatory paralysis). A salient aspect of this syndrome is voluntary -automatic dissociation, so that the patient cannot voluntarily smile or cry, not even swallow food but has preserved automatic or emotional movements of those muscles (corneal reflex, threaten reflex, laughing, crying, yawning) [1-6]. Internal medicine SectionOpercular syndrome is a well known but neglected entity and is quite common, but it is difficult for non-neurologists to diagnose this entity because of lack of awareness. Inability to speak and swallow with dissociation of automatic voluntary movements in the affected muscles are the essential features of this syndrome. The aetiology in most of the reported cases is vascular (thrombosis or embolism) involving branches of middle cerebral artery supplying...