Clinical Reasoning: A 16-year-old girl with fixed unilateral grimace

Waugh, Jeff L.; Prabhu, Sanjay P.; Bourgeois, Blaise; Kothare, Sanjeev V.

doi:10.1212/wnl.0b013e31822e55f9

Cited by 3 publications

(3 citation statements)

References 8 publications

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“…Though HFS is a well-recognized disorder among movement disorder specialists, similar conditions can at times imitate its appearance such as partial motor seizures. It's better for nonspecialists to prompt diagnose instead of under or misdiagnose the symptoms as focal cortical seizures involving the facial muscles for example [13]. It is important to distinguish the two entities especially in emergency department and intensive care unit, as seizures are common to handle with and misdiagnosis or inappropriate diagnostic or therapeutic measures may be taken inadvertently [14][15].…”

Section: Discussionmentioning

confidence: 99%

Symptom of Hemifacial Spasm Is Not Affected By State of Consciousness: A Case Report

Feng

Song

et al. 2021

Preprint

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Background: Hemifacial spasm is characterised by twitching of the muscles innervated by facial nerve. It is believed to result from hyperexcitability of the facial nerve nucleus or ephaptic transmission within the proximal facial nerve segment of the facial nerve nucleus. Often we observe spasm in an awakening situation. Actually contractions persist during sleep. To our knowledge, there were no reports on how it manifests under disturbance of consciousness. Herein we report a case whose symptoms sustained under coma status.Case presentation: A 74-year-old female suffered from right side primary hemifacial spasm for 20 years and used to accept botulinum toxin injection in our clinic. Unfortunately she was carried to emergency department in our hospital after traumatic right pneumothorax by accident. During emergency rescue cardiac arrest and apnea happened. She was then hospitalized in emergency intensive care unit for further therapy. During hospitalization, she was under coma status. Vital signs were stable and symptoms of hemifacial spasm sustained. A multidisciplinary consultation was request to identify whether it was focal cortical seizures involving the right side facial muscles. Physical examination revealed brief involuntary clonic or tonic contractions accompanied with the ‘Babinski-2’ sign. Synthesize the relevant data including past history, clinical manifestation and negative head computed tomography scanning, diagnosis was made as hemifacial spasm. Herein symptoms of hemifacial spasm were not life threatening and anti-epileptic drug was not necessary.Conclusions: It’s better for nonspecialists to prompt diagnose instead of under or misdiagnose the symptoms as seizures as inappropriate diagnostic or therapeutic measures may be taken inadvertently.

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Section: Discussionmentioning

confidence: 99%

Symptom of Hemifacial Spasm Is Not Affected By State of Consciousness: A Case Report

Feng

Song

et al. 2021

Preprint

View full text Add to dashboard Cite

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“…Although HFS is recognized as a disorder by movement disorder specialists, similar disorders can sometimes mimic its appearance, such as partial motor seizures. For the layperson, it is crucial to seek a multidisciplinary consultation to differentiate the diagnosis of focal cortical epilepsy involving the face and to obtain a correct diagnosis [ 13 ]. It is important to distinguish between the two conditions, particularly in the emergency department and intensive care unit, as seizures are common and may be inadvertently misdiagnosed or inappropriately diagnosed or treated [ 14 , 15 ].…”

Section: Discussionmentioning

confidence: 99%

Hemifacial spasm is not affected by state of consciousness: a case report

Feng

Song

et al. 2021

Eur J Med Res

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Background Hemifacial spasm (HFS) is a movement disorder caused by mechanical compression of the facial nerve after it has left the brainstem and is characterized by brief or sustained twitching of the muscles innervated by that nerve. Often we observe spasm in an awakening situation. Actually contractions persist during sleep. To our knowledge, there were no reports on how HFS manifests under disturbance of consciousness. Here, we report a case of primary HFS in which the patient's symptoms persisted in a coma. Case presentation A 74-year-old female with right-sided primary HFS for 20 years and had received botulinum toxin injections in our hospital. Unfortunately she was carried to emergency department after traumatic right pneumothorax by accident. During the emergency treatment, she lost consciousness due to simultaneous cardiac arrest and respiratory arrest. She was then admitted to the emergency intensive care unit for further treatment. During her hospitalization, she was in a coma with stable vital signs and persisting symptoms of HFS. Thus, a multidisciplinary consultation was requested to identify whether it was focal cortical seizures involving the right-side facial muscles. Physical examination revealed brief involuntary clonic or tonic contractions accompanied with the ‘Babinski-2 sign’. A combination of relevant data, including her past history, clinical presentation and a negative computed tomography scan of the head, led to a diagnosis of right-sided HFS. As the symptoms of HFS are not life-threatening, the use of anticonvulsants is unnecessary. Conclusions For the layperson, it is crucial to seek a multidisciplinary consultation to obtain a correct diagnosis.

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“…For example, a clinical event that has no electrographic correlate on a high-quality EEG is likely non-epileptic. The probability of a small or deep epileptic focus whose dipole is insufficient to be detected by surface EEG 22 is nonzero, but is not typically sufficient to necessitate performing more invasive testing, such as PET (positron emission tomography), SPECT (single-photon emission computerized tomography), or intracranial EEG electrodes. We wished to determine if neurologists had differing thresholds of completion for common organic and functional disorders.…”

Section: Diagnostic Thresholds In Organic Vs Functional Disordersmentioning

confidence: 99%

When neurologists diagnose functional neurological disorder, why don’t they code for it?

et al. 2021

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Background Clinicians who recognize functional neurological disorders (FND) may not share that diagnosis with patients. Poor communication delays treatment and contributes to substantial disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an insight into clinicians’ face-to-face communication. Therefore, quantifying the phenomenon of noncoding, and identifying beliefs and practice habits that reduce coding, may suggest routes to improve medical communication in FND. Methods We reviewed all pediatric neurology consultations in our hospital from 2017 to 2020, selecting those in which neurologists explicitly stated an FND-related diagnosis (N = 57). We identified the neurological symptoms and ICD-10 codes assigned for each consultation. In parallel, we reviewed all encounters that utilized FND-related codes to determine whether insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related coding through a nationwide survey of pediatric neurologists (N = 460). Results After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure when substantiated by electroencephalography; in practice, they coded for 36.7% of such consultations. For other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less often. The strongest predictor of noncoding was the outdated belief that FND is a diagnosis of exclusion. Coding for FND never resulted in insurance nonpayment. Conclusion Noncoding for FND is common. Most factors that amplify noncoding also hinder face-to-face communication. Research based on ICD-10 coding (eg, prevalence and cost) may underestimate the impact of FND by >fourfold.

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Clinical Reasoning: A 16-year-old girl with fixed unilateral grimace

Cited by 3 publications

References 8 publications

Symptom of Hemifacial Spasm Is Not Affected By State of Consciousness: A Case Report

Symptom of Hemifacial Spasm Is Not Affected By State of Consciousness: A Case Report

Hemifacial spasm is not affected by state of consciousness: a case report

When neurologists diagnose functional neurological disorder, why don’t they code for it?

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