Logan Steele
Strokes are a time-critical illness and must be differentiated from Bell's Palsy to avoid treatment delays. A stroke occurs when the blood supply to the brain is cut off, causing brain cells to become damaged or die due to oxygen deprivation. This can lead to facial palsy, where messages are not transferred properly to the facial nerve, resulting in loss of movement, expression, and function on one side of the face. However, strokes typically spare the forehead muscles, with patients retaining the ability to wrinkle their foreheads and move their eyes, while the lower face is affected. This is because the forehead receives innervation from both hemispheres of the brain, while the lower face only receives innervation from the contralateral hemisphere. This knowledge is crucial for distinguishing strokes from Bell's Palsy, which affects the entire face, causing flattening of the forehead and difficulty raising eyebrows.
| Characteristics | Values |
|---|---|
| Facial weakness | Caused by strokes in many different locations in the brain and brainstem |
| Strokes involving the brain | Cause central facial weakness involving the mouth and sparing the eye and forehead |
| Strokes involving the brainstem | Can involve the eye and forehead |
| Central lesions | Result in forehead sparing |
| Peripheral lesions | Result in no forehead sparing |
| Peripheral nerve effect | Characteristic of Bell's Palsy |
| Central process | Characteristic of ischemic stroke |
| Age | Patients over 60 are most at risk for acute ischemic strokes |
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What You'll Learn
Central vs peripheral lesions
The facial nerves emerge from the middle of the brainstem and carry motor fibres to the muscles of facial expression. These fibres can be split into additional fibres that supply muscles in the upper face, including those controlling eye closure and forehead movement, and fibres that supply muscles in the lower face, such as the mouth.
When a stroke impacts one hemisphere of the brain, it causes facial weakness on the opposite side of the face. This usually presents as having difficulty smiling and the nasolabial fold may appear flattened. Strokes involving the brain typically cause central facial weakness that involves the mouth and spares the eye and forehead.
Central lesions result in forehead sparing, as the facial nerve is innervated by ipsilateral and contralateral fibres from the motor cortex. Patients with forehead sparing need a head CT to rule out a central cause such as a stroke or mass. Peripheral lesions, on the other hand, are below the nucleus, and all the fibres innervating the facial nerve are affected, resulting in no forehead sparing. In a peripheral lesion, the patient will be unable to wrinkle their forehead on one side or have fewer wrinkles on that side. Asymmetry in forehead wrinkles is a sign of peripheral facial nerve palsy.
While not definitive, a patient's age can indicate whether they are at higher risk for Bell's Palsy or stroke. Bell's Palsy patients are typically in their 30s to 50s, whereas patients over 60 are most at risk for acute ischemic strokes.
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Bell's Palsy vs stroke
Bell's Palsy and stroke are two conditions that can cause similar problems, such as single-sided facial paralysis or weakness. However, it is crucial to distinguish between the two as their treatments differ significantly. This differentiation can be challenging, but a quick assessment can help identify the condition and ensure the patient receives the appropriate care.
Bell's Palsy patients typically experience a reactivation of the herpes simplex virus-1, leading to lesions that affect the facial nerves originating from the brain stem. The condition usually affects individuals in their 30s to 50s, causing acute facial weakness, watering from the eye on the affected side, changes in taste, sound sensitivity, and ringing in the ears. The paralysis can make it difficult to smile, raise eyebrows, wrinkle the forehead, or close the eye tightly. A patient with Bell's Palsy will have normal strength and sensation, with no weakness in the arms or legs, and no difficulty moving their tongue or eyes. Treatment for Bell's Palsy includes a course of steroids and, in some cases, antiviral therapy.
On the other hand, a stroke is caused by an occlusion of an artery supplying the brain. It is a time-critical illness that requires quick treatment to prevent issues like disability or death. Strokes can occur in the brain or brainstem, resulting in different symptoms. Strokes involving the brain typically cause central facial weakness, affecting the mouth while sparing the eye and forehead. In contrast, strokes in the brainstem can lead to weakness in the mouth, eye, and forehead, mimicking a peripheral lesion. However, there will be other focal neurological deficits in the case of a brainstem stroke. Symptoms of a stroke may include trouble finding words, eyes gazing in one direction, trouble walking, vision changes, numbness on one side of the body or face, and weakness in the arms and legs on one side.
To differentiate between Bell's Palsy and a stroke, a physician may perform a neurologic exam and order additional tests, such as an MRI or CT scan, blood tests, and electromyography for testing facial nerves. A quick assessment involves asking the patient to wrinkle their forehead, as forehead sparing is indicative of a central lesion, which is more likely to be caused by a stroke.
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The impact of misdiagnosis
Bell's palsy, or idiopathic facial paralysis, is the most common cause of unilateral facial paralysis, resulting in the acute onset of paralysis on one side of the face. It is typically characterized by flattening of the forehead and the inability to raise eyebrows or smile on the affected side. On the other hand, a stroke can cause facial palsy when brain damage occurs, interrupting the transmission of messages to the facial nerve. This usually results in paralysis of the lower half of the face, while the forehead may still have movement due to receiving innervation from the unaffected hemisphere.
Misdiagnosing Bell's palsy as a stroke can lead to unnecessary interventions and delays in appropriate treatment. Acute stroke is a time-critical illness, and distinguishing it from Bell's palsy is crucial to ensure prompt and effective care. A misdiagnosis can result in patients undergoing unnecessary neuroimaging, such as computed tomography (CT) scans and magnetic resonance imaging (MRI), which can increase healthcare costs and expose patients to additional radiation.
Additionally, misdiagnosis can lead to the administration of incorrect medications. Bell's palsy is typically treated with corticosteroids and, in some cases, antivirals and eye lubricants to prevent corneal abrasions. On the other hand, stroke treatment focuses on addressing the underlying cause, such as restoring blood flow to the brain and providing supportive care to minimize brain damage. Misdiagnosis can delay the administration of clot-busting drugs or other interventions necessary to treat a stroke effectively.
Furthermore, misdiagnosis can have emotional and functional implications for patients. Bell's palsy can be emotionally challenging, and early diagnosis and treatment are crucial for improving recovery rates. A misdiagnosis may delay the initiation of corticosteroid therapy, potentially leading to permanent aesthetic, functional, and emotional deficits. Additionally, patients with Bell's palsy may be inappropriately referred to stroke prevention clinics or neurology specialists, causing unnecessary anxiety and impacting their overall well-being.
In summary, the impact of misdiagnosis in cases of stroke and Bell's palsy can lead to unnecessary interventions, delays in appropriate treatment, increased healthcare costs, exposure to additional medical procedures, incorrect medication administration, and potential emotional and functional consequences for patients. Therefore, it is essential to accurately differentiate between these two conditions to ensure optimal patient care and outcomes.
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Facial weakness
Bell's Palsy patients are typically in their 30s to 50s, while patients over 60 are most at risk for acute ischemic strokes. Bell's Palsy causes sudden and usually temporary one-sided facial weakness. It is responsible for 70% of cases of facial paralysis and typically improves over several weeks. Some of the symptoms of Bell's Palsy include:
- Watering from the eye on the affected side of the face
- Changes in the ability to taste
- Sound sensitivity
- Ringing ears
On the other hand, a stroke can cause facial drooping and muscle weakness that affects the eyes, cheeks, lips, and mouth on one or both sides of the face. Typically, a stroke affects the lower part of one side of the face and not the forehead. However, if the stroke occurs in the brainstem, it may affect the forehead as well. Other symptoms specific to a stroke include:
- Trouble finding words
- Eyes gazing in one direction
- Trouble walking
- Vision changes
- Numbness on one side of the body or face
- Weakness in the arms and legs on one side
To differentiate between Bell's Palsy and a stroke, a physician may order an MRI or a CT scan, blood tests, and additional testing. Treatment for Bell's Palsy may include antiviral and steroid medications, while treatment for a stroke will vary depending on the situation.
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Treatment and recovery
If a stroke is suspected, imaging and urgent intervention with a neurologist are necessary. A head CT scan may be required to rule out central causes, such as a stroke or mass, especially if there is potential forehead sparing, as this can be indicative of a central lesion.
Treatment for stroke may include medications such as valacyclovir and prednisone, as well as eye care, such as patching the eye and using lubricating eye drops to prevent exposure keratitis.
The prognosis for stroke patients depends on the severity of the facial nerve dysfunction. Most patients will see improvement within weeks, and many will experience a full recovery within 3-4 months. However, it is important to note that acute stroke is a time-critical illness, and immediate medical attention is required to prevent permanent damage.
In addition to medical treatment, patients may benefit from speech therapy and physical therapy to help with any speech disturbances and muscle weaknesses that may occur after a stroke.
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Frequently asked questions
If you're experiencing a sudden drop in your facial expression, seek urgent medical attention immediately. A skilled provider will be able to differentiate between a stroke and Bell's palsy. If there is a concern for stroke, imaging and urgent intervention with a neurologist should be done promptly.
Bell's palsy is a peripheral nerve effect, whereas a stroke is a central process. The eyes and forehead receive innervation from both hemispheres, while the lower face only receives innervation from the contralateral hemisphere. Therefore, a stroke will cause central facial weakness that involves the mouth and spares the eye and forehead.
Bell's palsy is the most common cause of unilateral facial paralysis. Symptoms include the acute onset of unilateral upper and lower facial paralysis, flattening of the forehead and an inability to raise eyebrows on the affected side. On smiling, the face lateralizes to the opposite (normal) side.
