A case of CVA in the RVH
ER…
Chenjie Xia (PGY-3)
AHD Interactive Case
Wednesday, Feb. 23rd, 2011
On call at the RVH…
• RVH ER page at 9:30PM
• Code purple, please see stroke patient for
admission…
Patient Background
• ID: 74M, right handed
• RFC: stroke
• Social history: Chinese origin, retired real
estate agent, lives with wife
Patient Background
• PMHx:
– HCC with cirrhosis
• Dx since 2006, s/p radiofrequency ablation, RTX
• Episodic encephalopathy
• Esophageal varices
– Diabetes
– HTN
– Left putamen lacunar infarct
• Right sided parkinsonian Sx, now resolved
• ASA discontinued due to bleed from esophageal varices
– Gout
– Right parotid tumour (biopsy 2008  pleomorphic
adenoma)
Patient Background
• Meds
– Allopurinol, MVI, Ca/Vit D, Mg, Remeron,
HCTZ, Nadol, lactulose, Flagyl, lantus
– Recently added: Celebrex, Dilaudid, Lyrica
• All:
– NKDA
• Habits
– Non-smoker, non-drinker
History
• Woke up this AM and notes new right
facial weakness, i.e. right mouth droop
What more do you want to
know on history?
More history
• Isolated right facial droop, i.e. no arm or
leg weakness, no sensory change, no
speech difficulties
• Feels lips “thickened” and right eyelid
“stuck to eyeball”
• Right ear deaf for many years, no change
• No change in taste noted
• No vertigo, no n/v
More history
• Right sided headache x few months
• Increased pain in right parotid tumour x
Nov. 2010.
• Consulted multiple MDs (GP, ENT,
neurologist)
• Ultrasound shows stable right parotid
mass?
• Suboptimal pain control despite Celebrex,
Dilaudid and Lyrica
What is your differential at this
point?
Differential Diagnosis
• Idiopathic facial nerve palsy (Bell’s palsy)
• Facial nerve palsy from other causes (e.g.
infectious, autoimmune, granulomatous,
neoplastic, etc)
• Stroke
– Right brainstem (pons)
– Left hemisphere
On exam
• Looks well, non toxic, head drooped
(because “the light is bothering my right
eye”)
• BP 155/70, HR 62 (reg), RR 20, 100%
(RA), 36.1oC
• No carotid bruit, normal S1, S2
What more do you want to
know on exam?
Be specific…
More exam findings
• No aphasia
• Large, palpable, firm, tender right parotid
mass
• Pupils 21mm (bilat), VFs normal, EOMs
(saccadic SP, otherwise normal)
• Normal sensation (LT/PP)
• Right facial droop (frontalis, orbicularis
oculi, and orbicularis oris involved)
How do you differentiate between
UMN and LMN facial palsy?
Can you name the main motor
branches of the facial nerve?
Muscles innervated by the Facial
Nerve
•
•
•
•
•
•
The: Temporal branch
Zebra: Zygomatic branch
Bit: Buccal branch
My: Mandibular branch
Carrot: Cervical branch
(Stapedius and post. auricular branches)
More Exam Findings
• Taste: decreased on right hemi-tongue
• Hearing: No lateralization on Weber,
decreased air conduction on Rinne on the
right
• Palate, SCM, trap, tongue mvts normal
• Rest of exam (tone, strength, reflexes,
sensation, coordination, gait)
unremarkable
What is your top differential
diagnosis at this point?
Differential Diagnosis
• Idiopathic facial nerve palsy (Bell’s palsy)
• Facial nerve palsy from other causes (e.g.
infectious, autoimmune, granulomatous,
neoplastic, etc)
• Stroke
– Right brainstem (pons)
– Left hemisphere
Differential Diagnosis
• Idiopathic facial nerve palsy (Bell’s palsy)
• Facial nerve palsy from other causes (e.g.
infectious, autoimmune, granulomatous,
neoplastic, etc)
• Stroke
– Right brainstem (pons)
– Left hemisphere
Findings
CT head: old left putamen lacune, nil acute
Question
• Does the decreased taste favor Bell’s
palsy or facial nerve injury secondary to
parotid lesion?
Facial nerve enters parotid gland after it exits the stylomastoid
foramen; fibers carrying taste and subserving lacrimation
should NOT be affected.
However, in malignant lesion, extension of lesion may very well
invade nearby nerve branches
Question
• Can you name the 4 functional categories
of the facial nerve and briefly describe
what they do?
Answer
• 1) Branchial motor
– Muscles of facial expression
– Stapedius muscle
• 2) Parasympathetic
– Lacrimal glands
– All salivary glands (e.g. submaxillary, submandibular) except
parotid
• 3) Visceral sensory (special)
– Taste from anterior 2/3 of tongue
• 4) General somatic sensory
– Sensation from small region near external auditory meatus
Question
• With the help of the diagram, can you
point out the nerves and ganglia involved
in each of the functional categories?
Branchial motor
• Facial nucleus
• Facial nerve exits at CPA
• Traverses internal
auditory meatus
• Turns at genu
• Exits at stylomastoid
foramen
• Passes through parotid
gland
• Divides into branchial
motor branches
Branchial motor
• Facial nucleus
• Facial nerve exits at CPA
• Traverses internal
auditory meatus
• Turns at genu
• Exits at stylomastoid
foramen
• Passes through parotid
gland
• Divides into branchial
motor branches
Parasympathetic (1)
• Superior salivatory
nucleus
• GT petrosal nerve
leaves genu
• Reach the
sphenopalatine
ganglion
• post-ganglionic fibers
 lacrimal glands
Parasympathetic (1)
• Superior salivatory
nucleus
• GT petrosal nerve
leaves genu
• Reach the
sphenopalatine
ganglion
• post-ganglionic fibers
 lacrimal glands
Parasympathetic (2)
• Superior salivatory
nucleus
• Chorda tympani branches
off before the
stylomastoid foramen
• Goes through
petrotympanic fissure
• Joins lingual nerve
• Submandibular ganglion
• postganglionic fibers 
submandibular and
sublingual glands
Parasympathetic (2)
• Superior salivatory
nucleus
• Chorda tympani branches
off before the
stylomastoid foramen
• Goes through
petrotympanic fissure
• Joins lingual nerve
• Submandibular ganglion
• postganglionic fibers 
submandibular and
sublingual glands
Visceral sensory (Special)
• Sensory fibers carrying taste
from anterior 2/3 of tongue
• Cell bodies in geniculate
ganglion
• Synapse onto secondary
neurons in the rostral nucleus
solitarius
• Travel via CTT  VPM
nucleus of thalamus 
cortical taste area (inferior
margin of postcentral gyrus,
extends into parietal
operculum and insula)
Visceral sensory (Special)
• Sensory fibers carrying taste
from anterior 2/3 of tongue
• Cell bodies in geniculate
ganglion
• Synapse onto secondary
neurons in the rostral nucleus
solitarius
• Travel via CTT  VPM
nucleus of thalamus 
cortical taste area (inferior
margin of postcentral gyrus,
extends into parietal
operculum and insula)
General Somatic Sensory
• Region near external
auditory meatus
• Synpase in spinal
trigeminal nucleus
General Somatic Sensory
• Region near external
auditory meatus
• Synpase in spinal
trigeminal nucleus
F/U Imaging
• CT neck (compared to Nov 2010)
– Significant increase in mass size compared to
Nov.
– Peripheral enhancement, central area of
necrosis
– Extension into deep lobe
– Possibility of malignant transformation