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Brainstem infarction presenting with trigeminal neuralgia and Bell's palsy

  • Terunori Sano
    Correspondence
    Corresponding Author: Terunori Sano, MD, PhD, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan
    Affiliations
    Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry

    Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry
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  • Masayuki Ohira
    Affiliations
    Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry

    Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry
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  • Masashi Mizutani
    Affiliations
    Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry

    Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry
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  • Kazuhiko Segawa
    Affiliations
    Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry
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  • Masaki Takao
    Affiliations
    Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry

    Department of Laboratory Medicine, National Center Hospital, National Center of Neurology and Psychiatry
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Open AccessPublished:September 22, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.08.036
      To the editor:
      An 84-year-old man came to our hospital with a 3-day history of vertigo, nausea, and vomiting. His comorbidities included type 2 diabetes mellitus, dyslipidemia, and hypertension, with a history of multiple cerebral infarctions. He was taking aspirin, rosuvastatin calcium, nifedipine, and saxagliptin hydrochloride. Neurological examination showed left limb ataxia, dysarthria, and horizontal gaze-evoked nystagmus; neither muscle weakness nor impairment of extraocular movement were evident. Brain magnetic resonance imaging (MRI) showed an acute infarct (10 mm × 10 mm) in the left middle cerebellar peduncle. Oral administration of clopidogrel sulfate (50 mg daily) was introduced as antiplatelet therapy. On day 7 after admission, the patient developed paroxysmal, intense, and stabbing pain towards the frontal part of the head and the periorbital regions of the left side. The pain lasted for 1 to 2 min, recurred every few days, and resolved spontaneously or only with acetaminophen. On day 9, the patient developed complete left-sided facial paralysis. Subsequent brain MRI revealed an expansion of the initial infarct to the pons (Figure A and B). Intravenous argatroban hydrate (220 mg) was administered over 7 days. One month following admission, another brain MRI showed no enlargement of the infarct area. The pain on the left side had diminished, and the left facial paralysis improved to an isolated mild narrowing of the left ocular fissure. The patient was transferred to another hospital for rehabilitation of the residual symptoms.
      Figure 1
      Figure 1Axial diffusion-weighted brain magnetic resonance imaging (MRI) shows a high-intensity signal indicating acute infarct lesions in the root entry zone of the left trigeminal nerve (A, square frame) and in the left lateral pons (B, square frame), along with lesions in the left middle cerebellar peduncle (A and B, arrow). Trigeminal nerve (A, arrowhead). Facial nerve (B, arrowhead).
      Peripheral-type facial palsy (Bell's palsy) may occur as a symptom of pontine stroke,
      • Min YG
      • Jung KH.
      Patterns of pontine strokes mimicking Bell's palsy.
      and trigeminal neuralgia is reported to be induced by infarction of the trigeminal nerve root entry zone in the pons.
      • Shanker RM
      • Kim M
      • Verducci C
      • et al.
      Surgical management of trigeminal neuralgia induced by brainstem infarct: A systematic review of the literature.
      This patient presented with complete peripheral facial palsy and trigeminal neuralgia owing to pontine infarction that extended from a middle cerebellar peduncle infarction. In this case, the regions of the pyramidal tract and cranial nerve nuclei controlling the extraocular movements were spared, while symptoms appeared as part of anterior inferior cerebellar artery syndrome. The patient's symptoms likely emerged from the involvement of the peripheral nerves alone, such as the trigeminal and facial cranial nerves, and these symptoms developed sequentially. In conclusion, brainstem infarction should always be clinically suspected in the context of peripheral facial palsy and trigeminal neuralgia.

      Funding

      an Intramural Research Grant [3-8] from the Neurological and Psychiatric Disorders of NCNP (MT)

      Authorship

      All authors participated in the care of this patient and had a role in writing this manuscript.
      Requests for reprints should be addressed to Terunori Sano, MD, PhD, Department of Laboratory Medicine, National Center Hospiral, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, JapanE-mail address: [email protected]

      Conflict of Interest

      None.

      References

        • Min YG
        • Jung KH.
        Patterns of pontine strokes mimicking Bell's palsy.
        BMC Neurol. 2019; 19: 208
        • Shanker RM
        • Kim M
        • Verducci C
        • et al.
        Surgical management of trigeminal neuralgia induced by brainstem infarct: A systematic review of the literature.
        World Neurosurg. 2021; 151: 209-217