Pontine Hemorrhage Presenting as an Isolated Facial Nerve Palsy

Sherman, Scott C.; Thompson, Trevonne T.

doi:10.1016/j.annemergmed.2004.12.008

Cited by 10 publications

(5 citation statements)

References 8 publications

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“…Cases of strokes mimicking Bell’s palsy have been reported in the literature. 24,25 Infarcts of the dorsal pons may cause ischemia to the motor component of the facial nerve resulting in isolated ipsilateral palsy including the forehead. Additionally, a radiologic analysis of stroke syndromes further challenges the dogma that dual facial innervation leads to sparing of the upper face with upper motor neuron lesions.…”

Section: Discussionmentioning

confidence: 99%

Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Fahimi¹,

Navi²,

Kamel³

2014

Annals of Emergency Medicine

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Study Objective We evaluate the incidence of potentially incorrect emergency department (ED) diagnoses of Bell’s palsy and identify factors associated with identification of a serious alternative diagnosis on follow-up. Methods We performed a retrospective cohort study from California’s Office of Statewide Health Planning and Development (OSHPD) for 2005–2011. Subjects were adult patients discharged from the ED with a diagnosis of Bell’s palsy. Information related to demographics, imaging use, and comorbidities were collected. Our outcome was one of the following diagnoses made within 90 days of the index ED visit: stroke, intracranial hemorrhage, subarachnoid hemorrhage, brain tumor, central nervous system infection, Guillain-Barre syndrome (GBS), Lyme disease, otitis media/mastoiditis, or herpes zoster. We report hazard ratios (HR) and 95% confidence intervals (CI) for factors associated with misdiagnosis. Results A total of 43,979 patients were discharged with a diagnosis of Bell’s palsy. Median age was 45. On 90-day follow-up 356 patients (0.8%) received an outcome diagnosis, and 39.9% were made within 7 days. Factors associated with the outcome included increasing age (HR 1.11, 95% CI 1.01–1.21, every 10 years), black race (HR 1.68, 95% CI 1.13–2.48), diabetes (HR 1.46, 95% CI 1.10–1.95), computed tomography or magnetic resonance imaging use (HR 1.43, 95% CI 1.10–1.85). Private insurance was negatively associated with an alternative diagnosis (HR 0.65, 95% CI 0.46–0.93). Stroke, herpes zoster, GBS, and otitis media accounted for 85.4% of all alternative diagnoses. Conclusion Emergency providers have a very low rate of misdiagnosing Bell’s palsy. The association between imaging use and misdiagnosis is likely confounded by patient acuity. Increasing age and diabetes are modest risk factors for misdiagnosis.

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Section: Discussionmentioning

confidence: 99%

Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Fahimi¹,

Navi²,

Kamel³

2014

Annals of Emergency Medicine

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“…Imaging is commonly warranted in idiopathic facial paralysis if there is slow progression beyond 3 weeks, or if there is no improvement at 3 months. Pontine lacunar infarct may present as isolated facial nerve palsy mimicking Bell's palsy and is traditionally considered rare . It is possible that some central facial palsy patients are incorrectly diagnosed as peripheral facial palsy in clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Increased stroke risk in Bell's palsy patients without steroid treatment

Lee

Chien

et al. 2012

Euro J of Neurology

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“…Therefore, in addition to stroke, our differential diagnosis for the patient's facial paralysis upon admission included Bell's palsy, seizure with Todd's paralysis, and complex migraine. Rare pontine strokes that affect the ipsilateral facial nerve nucleus or facial nerve tract before it exits the pons have been shown to represent a central lesion that presents identically to a peripheral lesion [11][12][13]. These insults occur acutely, whereas the onset of Bell's palsy typically progresses over multiple hours to days and would not be accompanied by nausea, vomiting, dizziness and diplopia [1].…”

Section: Discussionmentioning

confidence: 99%

Pontine Infarct Camouflaged as Bell’s Palsy

Phipps

Joea²,

Strube³

et al. 2019

J Neurol Res

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Facial palsy is a neurological disorder triggered by dysfunction of the seventh cranial nerve, categorized as either central, between the cerebral cortex and brainstem nuclei, or peripheral, between the brainstem nuclei and peripheral organs. Central lesions cause impairment of the contralateral lower facial musculature with associated sparing of the forehead and ocular muscles. Conversely, peripheral lesions produce ipsilateral whole-sided facial hemiplegia including both forehead and ocular muscles. Facial palsy is diagnosed clinically, while imaging studies and additional subsidiary testing (e.g. electromyography, nerve conduction studies), serologies, and rarely biopsy can assist in confirming or refuting the working diagnosis. The differential diagnosis comprises Bell's palsy (idiopathic), HIV infection, Ramsey Hunt syndrome, Lyme, sarcoidosis, amyloidosis, acoustic neuroma, parotid gland tumor, temporal bone biopsy, otitis media, Guillain-Barre syndrome, and brainstem infarct. Facial palsy is branded as Bell's palsy if one of the aforementioned etiologies is not identified as the root cause. Herein, we report the case of a 58-year-old male, who presented with left facial weakness involving both the upper and lower face, posterior circulation symptoms in the setting of hypertensive emergency. Initial magnetic resonance imaging (MRI) was unrevealing for any acute process, however given lack of improvement repeat imaging was ordered. The patient was ultimately confirmed to have an acute versus subacute pontine infarct where the seventh and eighth cranial nerve exits at the cerebellopontine angle. Ancillary laboratory studies were non-contributory. Subsequently, the patient's symptoms continued to improve, blood pressure control was achieved, and was consequently discharged on goal-directed medical therapy.

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Pontine Hemorrhage Presenting as an Isolated Facial Nerve Palsy

Cited by 10 publications

References 8 publications

Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Potential Misdiagnoses of Bell's Palsy in the Emergency Department

Increased stroke risk in Bell's palsy patients without steroid treatment

Pontine Infarct Camouflaged as Bell’s Palsy

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