Journal of Neurology, Neurosuirgery, and Psychiatry 1984;47: 84-86 Short report Isolated facial palsy: a new lacunar syndrome CHENYA HUANG, GERALD BROE From the Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong and Department of Neurology, Lidcombe Hospital, Lidcombe, Australia SUMMARY Three cases of sudden isolated upper motor neuron facial palsy and two with associated pseudobulbar palsy have been seen. All were without significant limb weakness. Computed tomography demonstrated small deep infarcts in the internal capsular/corona radiata regions. Pure upper motor neuron facial palsy may be another lacunar syndrome, due to a lesion in the internal capsule or corona radiata. On examination blood pressure was 130/90 mm Hg. He Most facial palsies are lower motor neuron lesions. a left upper motor neuron facial paresis, complete had Occasionally however, an isolated facial palsy is seen and aphagia. Jaw jerk was not increased. Tone, which appears to be upper motor neuron in nature. anarthria and sensation were normal; however coordination power, Prior to the availability of CT scan, the site of such the patient veered slightly to the left on walking. CSF lesion was unknown. Some have been ascribed to examination showed 1 mononuclear cell/mm' with normal peripheral facial nerve lesions. ' Puvenendren, Wong biochemistry and serology. EMG of facial muscles showed and Ransome described in 1979 five patients with no abnormality. CT scan showed small low density lesions sudden onset of dysarthria, dysphagia and upper bilaterally in the region of corona radiata adjacent to the motor neuron facial palsy.' EEG and isotope scans basal ganglia (fig 1). Haematology and biochemistry were normal. Two months later a severe residual dysarthria were normal in all their cases. They postulated that remained. There was almost full recovery on review after the lesion may have been in the corticobulbar tracts two years. facial of cases five in the brainstem. We have seen palsy, showing capsular/corona radiata lesions on the Case 2 CT scans. This 61-year-old Laotian male patient developed sudden right-sided throbbing headache which was not severe and Case histories lasted about 24 hours. This was associated with left-side facial weakness but no other neurological symptoms. There Case I was a 10 year history of controlled hypertension and he Four weeks prior to admission to hospital this 49-year-old smoked 20 cigarettes a day. On examination he showed a Egyptian male patient noted the sudden onset of difficulty in speaking associated with weakness of the right side of the face. A diagnosis of Bell's palsy was made by his doctor and he was treated with prednisone. Gradual and almost complete recovery of speech and facial weakness occurred over the following weeks. Two days prior to admission to hospital in August 1979, he noted the sudden onset of weakness of the left side of the face associated with complete inability to speak or swallow. There was no associated disorder of language or understanding and no ataxia nor disturbance of limb function. There was no previous history of hypertension, diabetes or vascular disease. The patient smoked 50 cigarettes a day. Address for reprint requests: Dr CY Huang. Department of Medicine. University of Hong Kong. Queen Mary Hospital. Hong Kong. Received 22 July 1983. Accepted 6 August 1983. mild left facial weakness of upper motor neurone type with no other neurological deficit. CT scan showed a small deep infarct in the region of the right corona radiata (fig 2). Other investigations including nuclear scan and EMG were normal. His facial palsy resolved over a few days. Case 3 This 55-year-old Chinese female patient suddenly developed a dysarthria, dysphagia, incontinence of urine and unsteady gait. Previous health had been unremarkable. On admission blood pressure was 140/90 mm Hg with a right upper motor neuron facial palsy, dysarthria. dysphagia, poor tongue movement, normal gag reflex, bilateral brisk tendor reflexes and extensor plantar response. Tone, power, coordination and sensations were however normal. Routine investigations were normal. She rapidly improved within the next two days. CT scan showed bilateral small infarction in the corona radiata anteriorly (fig 3). 84 ss Isolated facial palsy: a new lacunar syndrome Fig 1 CTscan shows small low density lesions bilaterally in the region of corona radiata adjacent to the basal ganglia. Fig 3 CTscan shows bilateral small infarction in the corona radiata anteriorly. Case 4 This 80-year-old Caucasian lady presented with sudden dysarthria on waking in the morning. There was no history Fig 4 CTscan shows a small lacunar infarct in the left coronata radiata region. Fig2 CTscan showsasmalldeepinfarctintheregionof the right corona radiata. of hypertension, ischaemia, heart disease, diabetes, or cerebrovascular disease. On admission, the patient was normotensive, in sinus rhythm. On neurological examination, she had marked dysarthria, a mild right upper motor neuron facial palsy, and weakness in protrusion of the tongue to the right. There was no limb weakness, reflex abnormality or other abnormalities. Investigation showed haemoglobin 15-1 gm/100 ml, ESR 32 mm/h, random glucose 8-4 mmol/l, ECG showed a left anterior hemiblock, CT scan showed a small lacunar infarct in the left coronata Huang, Broe 86 Discussion Fig5 CTscan shows a small infarct in the posterior limb of the right internal capsule. radiata region (fig 4). She rapidly lost her facial palsy and dysarthria. Case S A 63-year-old male Chinese was admitted because of dysarthria. At the onset of symptoms he noted some transient left hand paraesthesiae and weakness. Nine months ago he had an episode of quadriparesis which recovered after 2-3 hours, for which he did not seek medical advice. Six months ago hypertension had been diagnosed but he did not continue treatment. He smoked 20 cigarettes a day for 30 years. On admission he was found to have blood pressure of 190/100 mm Hg, there was a mild dysarthria with a mild left facial palsy. No other neurological abnormality was noted. CT scan revealed a small infarct in the posterior limb of the right internal capsule (fig 5). The facial palsy resolved quickly. Nine months later however, he developed sudden expressive dysphasia with right hemiparesis. Since Fisher first called attention to the lacunar syndromes in the sixties with a series of papers, many lacunar syndromes have been established: pure motor hemiparesis, pure sensory stroke, dysarthriaclumsy hand syndrome, homolateral ataxia and crural paresis, hemichorea-hemiballismus.' Our five cases were characterised by the presence of facial palsy alone or associated with dysarthria, dysphagia and reflex changes suggesting more diffuse corticospinal pathway involvement. However, there was no actual limb weakness. The CT scan were similar in showing small deep infarcts in the corona radiata regions in four and internal capsule in one. All the patients made a good recovery (table). Our five cases and the five others previously reported by Puvenendren, Wong and Ransome (table) draw attention to a syndrome of sudden onset facio-bulbar weakness which may be confused with Bell's Palsy because of relative sparing of the limbs and good outcome. It appears that such lesions when bilateral may cause both facial palsy and selective pseudobulbar palsy with sparing of limbs. The corona radiata may be the preferential site of lesions in such cases, since the corticospinal projections are more separate and not as tightly packed together as in the internal capsule. Four of the patients were hypertensive, one diabetic and one of Puvenendren's cases had a previous stroke and four of our patients were smokers. It is likely, as in the case of lacunar syndromes, that the actual cause of the arterial lesion varies. References May M, Hardin WB. Facial palsy: interpretation of neurologic findings. Laryngoscope 1978;88:1352-62. ' Puvenendren K. Wong PK, Ransome GA. Syndrome of Dejerine's Fourth Reich. Acta Neurologica Scand 1978;58:345-53. -'MohrJP. Lacunas. Stroke 1982;13:3-11. Table 1 Clinical features of isolated UMN facial palsy syndrome Presentation Risk factor Sex/Age Puvenedren et al Case 1 2 3 4 5 Present Series 1 2 3 4 5 F!41 F/60 M/57 F/62 M/63 M/49 M/61 F/56 F/8() M/63 hvpertension diabetes hypertension previous R hemiplegia smoker smoker hypertension smoker smoker hypertension DYsarthria DYsphagia + + + + + + + + + + + + - - + + + + - Facial palsy left left right bilateral left bilatcral right right right left Others - vecrs to left bilateral extensor plantar transient LUL weakness