oral bleeding already present on admission and history taking were initially difficult.In the cerebral computer tomography with angiography and perfusion imaging, we saw a distal M2 segment occlusion of the right middle cerebral artery with a hypoperfusion in CBV and CBF imaging with preserved mismatch and only incipient demarcation of the central area.Due to the perfusion mismatch and the pronounced clinical symptoms, we initiated an intravenous thrombolysis with 81 mg of rtPA.Treatment was delayed (door-to-needle time 103 min) due to simultaneous emergency imaging of a polytrauma patient and the need for otorhinolaryngological evaluation of the oral bleeding.No significant intraoral, nasal or pharyngeal bleeding source could be objectified and the by that time regredient bleeding was considered minor, most likely caused by mucosal injury due to accidental biting during the acute jaw spasm.A luxation of the temporomandibular joint was excluded in the computer tomography.Due to the distal localization of the thrombus in a non-dominant M2 branch, interventional reperfusion was not performed.Initially, trismus was considered possibly ictal or stress-related and treatment with lorazepam and ketamine was attempted without effect.Regarding the hyperacute treatment setting, unfortunately EEG was not performed to not further delay the imaging or reperfusion treatment in the presence of disabling symptoms.During the following 72 h, the trismus resolved spontaneously.Subsequent neurological examination revealed severe dysarthria, bilateral facial weakness, buccofacial apraxia and pronounced dysphagia.The facial paresis could be overcome when the patient laughed, revealing the cardinal symptom of Foix-Chavany-Marie syndrome (FCMS, see Video 1).MRI workup in the following days confirmed an acute infarction of the right operculum, gyrus praecentralis and insula of the right hemisphere and older infarctions in the territory of the left medial cerebral artery including the left frontal opercular region (see Fig. 1).
Ranke et al. (Thu,) studied this question.