Facial palsy: stroke mimic or stroke chameleon?

초록

Background & Significance: Stroke should be differentiated with many stroke mimic such as peripheral nerve lesion, metabolic condition, seizure, psychiatric illness, etc. On the other hand, stroke sometimes present with unusual clinical profile (stroke chameleon) and often confused with other disease, such as hand or foot drop, Bell’s palsy, and so on. We experienced an unusual case of peripheral type facial palsy, and report with descriptions and suggestions. Case: 76-year-old female patient visited our emergency room with the chief complaint of facial asymmetry, which developed rather suddenly a few hours ago. She said she could not move her left side mouth so had difficulty in chewing and also speaking. She had a history of ischemic stroke 3 years ago, which was bilateral scattered infarction presented with dysarthria. Hypertension was her only cardiovascular risk factor, and work up to find stroke cause including MR angiography, echocardiography, Holter monitor, transcranial and carotid sonography revealed no particular finding tother than mild atherosclerosis in both proximal internal carotid arteries. She had been taking antiplatelet, statin, and antihypertensive since then with regular follow up. On neurologic exam, facial weakness around left mouth was noticed. She could not firmly close her left eye. Her forehead expression was also asymmetric. Other cranial nerve exam was normal. Sensory motor, reflex, and cerebellar function was symmetric. Because her facial palsy was typical peripheral type, ER physician called ENT department and short-term steroid and acyclovir were prescribed under the impression of Bell’s palsy. However, because she had history of stroke, and also complained of dysarthria though not severe, we recommended brain MR evaluation, and DWI revealed linear high signal intensity lesion in right motor cortex along the facial homunculus. Work up to find embolic source was repeated with negative result. To completely rule out the possibility o