Stroke or Bell's Palsy? Facial Droop, Slurred Speech and Atrial Fibrillation

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 75-year-old Caucasian male was admitted to the hospital because his daughter noticed that he woke up with a left facial droop and slurred speech.

She called 911 because she suspected a stroke. On arrival in the emergency room (ER), the patient's electrocardiogram (ECG) showed a new onset atrial fibrillation (Afib) with a rate of 75 beats per minute (bpm).

Past medical history (PMH)

End-stage renal disease on hemodialysis (ESRD on HD), hypertension (HTN), diabetes type 2 (DM2), severe aortic stenosis (AS), 0.6 cm2, deemed inoperable due to ESRD.

CT of the head showed an occipital stroke of unknown age (it was new since the previous CT scan done 4 years ago), atrophy and ventriculomegaly.

Is it a stroke?

The physical examination was remarkable for left facial drooping and slurred speech (dysarthria).

What is the most likely diagnosis?

Stroke?
TIA?
Bell's palsy?

Diagnosis

The patient was unable to wrinkle his forehead which was indicative of lower motor neuron (LMN) palsy of cranial nerve (CN) 7 (Bell's palsy).

Remember:

U MN damage
U pper face is OK (the patient is able to wrinkle his forehead)

LMN damage = patient is unable to wrinkle his forehead (our patient)

The examination of CN 7 palsy can be remembered by the mnemonic COWS:

C lose your eyes
O pen (the examining physician tries to open the patient's eyes)
W rinkle your forehead
S mile

Don't ask "show me your teeth" because a common reply is "I don't have any teeth!".


Image source: Yale University.

The rest of the examination was unremarkable apart from a high pitched 4/6 ejection systolic murmur (ESM) in the aortic area radiating to the carotids (murmur of the previously known 0.6 cm2 AS).

What is another additional important point on the physical examination of an ESRD patient?

Where is the HD access? What is the status of the access? In this patient the access was a left upper extremity (LUE) AV fistula with a good thrill and pulse. A thrill is the sensation that is felt over the anastomosis, typically described like a buzzing or vibration under the skin.

What treatment would you recommend?

The patient was started on enoxaparin (Lovenox) 1 mg/kg SQ BID for anticoagulation for atrial fibrillation with a plan to start warfarin (Coumadin) the next day.

Acyclovir and prednisone were started for his Bell's palsy. No evidence of herpetic skin or ear canal lesions was found.

What about the dose of the medications? He is a hemodialysis patient.

Excellent point. You cannot just start enoxaparin (Lovenox) and acyclovir. You have to adjust the doses in a HD patient.

The enoxaparin (Lovenox) dose was reduced by 50% and it was given once a day (QD) (1 mg/kg SQ daily).

Acyclovir was given BID instead of 5 times per day (q 4 hr).

What happened?

The patient had a persistent bleeding from the arteriovenous fistula (AVF) for HD which resolved only after enoxaparin (Lovenox) was stopped.

He was sent home on aspirin (ASA), acyclovir, prednisone and H2-blocker.

What did we learn from this case?

Not all cases with a facial droop and slurred speech are caused by stroke. Bell's palsy is relatively common. Always check if the medication you are prescribing to your patient has to be adjusted for their creatinine clearance (CrCl).

Related reading

They Called Him "Mac". Emergiblog describes the story of her father's stroke and its aftermath.
Stroke Risk Calculator http://goo.gl/elmc

Published: 09/01/2004
Updated: 03/03/2010

21 comments:

  1. Bell palsy : slurred speech

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    Replies
    1. Not that this matters as your comment is 6 years old but both stroke AND bell's cause slurred speech. What is diffrent is the involvment of the forehead. In a stroke the forehead is spared while in bell's it is affected.

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  2. Finally!!! Thanks for this..now i know how to explain the forhead wrinkling thing..

    Thank u very much!

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  3. yeah i understand now that if the lesion is umn , then the forehead remains alright because both of its sides are supplied by both the side nerves, and the lower part of the face is supplied by only the opposite side nerve, so the forehead wrinkling test is correct.
    can someone suggest some good book for neuroanatomy basics with some clinical orientation

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  4. Blumenfeld's "Neuroanatomy through Clinical Cases" is a good text for studying clinical background. It is a text for medical students, but it is clear enough for anyone interested in Neuro. Good luck!

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  5. We don't all use the same alphabet soup. .I was going to use the case for teaching medical students as it illustrates a confusing point, but unfortunately the case is almost unintelligable because of the abbreviations.

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  6. Anon,

    "This is how the real medicine looks like in patient charts. You have to know that "WNL" means within normal limits, otherwise you may never figure out what the note is about."

    Check out:

    Complete List of Medical Abbreviatons and Acronyms

    http://casesblog.blogspot.com/2006/10/complete-list-of-medical-abbreviatons.html

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  7. According to MKSAP 14 current edition on neurology: No longer use both aspirin and clopidogrel (Plavix) since adding aspirin to plavix increased risk of bleeds 3 fold and offers no benefit compared to plavix alone.

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  8. This is correct.

    According to UpToDate, ASA plus Plavix is no longer recommended for secondary prevention of stroke due to increased risk of bleeding complications.

    Either ASA or Plavix can be used for primary or secondary prevention of stroke in high risk patients.

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  9. A recent study suggests that steriods alone are indicated for most cases of Bell's Palsy and that Acyclovir is not useful (unless truly HSV associated Ramsey-Hunt Syndrome): Prednisolone and valaciclovir in Bell's palsy: a randomised, double-blind, placebo-controlled, multicentre trialLancet Neurol. 2008 Nov;7(11):993-1000. Epub 2008 Oct 10.

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  10. IN FIRST ATTACK OF STROKE U HAVE TO USE ASA ALONE
    IN CASE OF RECURENCE OF STROKE U HAVE TO INCREASE THE DOSE WITH ADDITION OF EITHER CLOPIDOGREL OR DYPERIDAMOLE

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    Replies
    1. THX U MUST REALLY KNOW WHAT UR DOING IF ITS IN ALL CAPS N POOR SPLEELING!!!!!!!!!!!!!!!

      Delete
  11. Hanan,

    ASA plus Plavix is no longer recommended for secondary prevention of stroke due to increased risk of bleeding complications.

    ReplyDelete
  12. after taking the medication, will the patient's face comes back to normal?

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  13. Re: "after taking the medication, will the patient's face comes back to normal?"

    In many cases, yes. It depends on the rate of recovery after Bell's palsy. The medications don't make a major difference as far as I can remember. Please correct me if I'm wrong.

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  14. How about Accupressure/Acupunture for Bells Palsy...has this been tried and what were the results?

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  15. How long does Bell's Palsey usually last, for a male in his mid 50's? Also, the eye on the effected side of the face does not close, which cause dryness. Any suggestions for this, please. Thank You.

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  16. Bell's palsy may take 3-5 months to resolve.

    Source: http://clinicalevidence.bmj.com/ceweb/conditions/nud/1204/1204-get.pdf

    Artificial tears help eye dryness - available without prescription in the U.S.

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  17. I wa sdiagnosed with Bells Palsey in 2007, I had a stroke in 2011. The MRI in 2011 showed what was diagnosed as BP was actually a stroke

    Had I known I had aprevious stroke I would have been much more careful, now my life is in shambles

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    Replies
    1. Question for you> Did you ever have the strength test done at the doctors?

      Just asking....
      My husband was diagnosed with Bell's Palsey. Typical diagnosis....can't wrinkle forehead, left side of face is drooping, etc.... His left arm feels tingley. We went back to the doctors and they did a strength test and said hes fine and sent us home.
      He probably is fine, but wondering if you had any other symptoms and or if your symptoms were exactly as the typical case? Thanks

      Delete
  18. well, this case was a LMN problem, and dysarteria was because of facial muscle who inhibits the normal articulation of tongue,
    because he is at high rise in CHAADSS scoring for stroke (newly diagnosed AFli) he has to come on Anticoagulation, but there is risk of bleeding, i think its wise to set him only on Aspirin (individual decision)
    for Facial palsy, there is no benefit of double therapy with aciclovir and pridnisolon.
    1.prednisolon can alone get good outcome after 3 and 9 months compared with double therapy ( if neuroinfection is excluded) by LP and no history of vesicles in face and ear.

    ReplyDelete