A Silent Stroke in Disguise: Isolated Facial Numbness Preceding the Discovery of Multifocal Infarcts and Competing Etiologies

TL;DR

A man with facial numbness was found to have multiple brain infarcts and a possible brain parasite, highlighting the importance of focusing on treatable stroke causes.

Contribution

This case emphasizes the importance of prioritizing modifiable stroke risk factors over incidental findings in stroke diagnosis.

Findings

Isolated facial numbness can precede multifocal brain infarcts.

Incidental brain lesions may not be the primary cause of symptoms.

Aggressive management of vascular risk factors is crucial in stroke prevention.

Abstract

Effective secondary prevention depends on determining the exact cause of an ischemic stroke, but unusual presentations, such as localized facial numbness, might make the diagnosis difficult to make and confound the etiological research. We describe the case of a 47-year-old man who had a 12-day history of isolated perioral and tongue numbness and several untreated vascular risk factors. A neurological examination showed sensory deficiencies in the right hemi-tongue and the right V2 and V3 distributions of the trigeminal nerve. While magnetic resonance angiography (MRA) detected focal stenoses (>50%) in the left internal carotid artery, brain magnetic resonance imaging (MRI) showed acute multifocal infarcts in the right pons, right cerebral peduncle, left thalamus, and left occipitotemporal area. Transthoracic echocardiography was normal, but in the right occipital lobe, an incidental ring-enhancing lesion with a central "dot sign" was found, strongly suggesting neurocysticercosis (NCC). Because of his uncontrolled diabetes and the lesion's passive look, therapy for the incidental NCC was postponed while management focused on aggressively controlling his vascular risk factors and preventing additional strokes with antiplatelets and a statin. This case highlights the need for a hierarchical approach where management is guided by the most likely and modifiable thromboembolic sources rather than by asymptomatic incidental findings that could serve as "red herrings" and worsen underlying comorbidities.

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