IMAGES IN NEUROLOGY Anterior Opercular Syndrome Caused by Acute, Simultaneous, Isolated Bilateral Infarcts A 74- YEAR - OLD MAN with metastatic pancreatic cancer and a recent deep vein thrombosis (for which he was taking enoxaparin sodium) was brought to our emergency department by his wife. Approximately 2 hours previously, the patient experienced the sudden onset of bilateral facial paralysis and an inability to speak. His examination results were significant for volitional paralysis of his bilateral upper and lower face, including the orbicularis oculi, orbicularis oris, and masseter muscles, anarthria, absence of gag reflex, inability to swallow on command, and inability to protrude his tongue. He did, however, blink in response to threat, smile when his wife came to the bedside, and swallow and yawn spontaneously. The patient presented within the accepted time window for thrombolytic therapy but was not considered to be a candidate owing to his enoxaparin use. Computed tomographic angiography of the head and neck revealed no evidence of arterial occlusions. Magnetic resonance imaging of the brain was performed shortly after admission and confirmed the clinical suspicion of bilateral anterior opercular infarcts (Figure 1 and Figure 2). We pre- sume that the cause of his infarcts was embolic—possibly related to marantic endocarditis given his known condition—but this was not able to be confirmed as he and his family elected for hospice care and declined further stroke evaluation. COMMENT Anterior opercular syndrome, or Foix-Chavany-Marie syndrome, was first reported by Magnus1 in 1837 and later described in detail by Foix et al2 in 1926. Unique is its presentation of voluntary-autonomic dissociation3 in which volitional, but not reflexive, movements of the face and throat are affected. Patients cannot speak or show their teeth on command, but they might yell out if frightened or smile when they see a familiar face. Sequential infarcts to the bilateral anterior opercula or subcortical insular regions are the most commonly described cause. Less commonly, infections, developmental anomalies, epilepsy, or neurodegenerative disease involving this region of the brain can cause Foix-Chavany-Marie syndrome. Much less commonly, simultaneous bilateral infarcts, as in our patient, can cause this syndrome. Andrew Bursaw, DO Thomas Duginski, MD (REPRINTED) ARCH NEUROL / VOL 68 (NO. 2), FEB 2011 254 Author Affiliations: Department of Neurology, Wilford Hall Medical Center, US Air Force, Lackland Air Force Base, Texas. Correspondence: Dr Bursaw, Department of Neurology, Wilford Hall Medical Center, US Air Force, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236 (andrew.bursaw.1@us.af .mil). Author Contributions: Study concept and design: Bursaw. Acquisition of data: Bursaw. Analysis and interpretation of data: Duginski. Drafting of the manuscript: Bursaw. Critical revision of the manuscript for important intellectual content: Duginski. Administrative, technical, and material support: Bursaw. Study supervision: Duginski. Financial Disclosure: None reported. REFERENCES 1. Magnus A. Fall von Aufhebung des Willenseinflusses auf einige Hirnnerven. Arch Anat Physiol Wiss Med. 1837:258-266. 2. Foix C, Chavany J-A, Marie J. Diplégie facio-linguomasticatrice d’origine cortico sous-corticale sans paralysie des membres (contribution à l’étude de la localisation des centres de la face du membre supérieur), par MM. Rev Neurol (Paris). 1926; 33:214-219. 3. Weller M. Anterior opercular cortex lesions cause dissociated lower cranial nerve palsies and anarthria but no aphasia: Foix-Chavany-Marie syndrome and “automatic voluntary dissociation” revisited. J Neurol. 1993;240(4):199-208. WWW.ARCHNEUROL.COM ©2011 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a Nanyang Technological University User on 06/04/2015 Figure 1. Axial diffusion-weighted magnetic resonance images showing acute, bilateral anterior opercular infarcts. Figure 2. Axial apparent diffusion coefficient magnetic resonance images of the acute, bilateral anterior opercular infarcts. (REPRINTED) ARCH NEUROL / VOL 68 (NO. 2), FEB 2011 255 WWW.ARCHNEUROL.COM ©2011 American Medical Association. All rights reserved. Downloaded From: http://archneur.jamanetwork.com/ by a Nanyang Technological University User on 06/04/2015