Facial Weakness Research Articles

Facial nerve electrical motor evoked potential in cerebellopontine angle tumors for its anatomical and functional preservation.

Among the technical measures to preserve facial nerve (FN) function, intraoperative neuromonitoring has become mandatory and is constantly being scrutinized. Hence, to determine the efficacy of FN motor evoked potentials (FNMEPs) in predicting long-term motor FN function following cerebellopontine angle (CPA) tumor surgery, an analysis of cases was done. In 37 patients who underwent CPA surgery, FNMEPs through corkscrew electrodes positioned at C5-C6 and C6-C5 (C is the central line of the brain as per 10-20 EEG electrode placement) were used to deliver short train stimuli and recorded from the orbicularis oculi, oris, and mentalis muscles. In 58 patients, triggered electromyography (EMG) was able to identify the FN during resection of tumor, but 8 out of these (4.64%) patients developed new facial weakness, whereas 3 out of 38 (1.11%) patients who had intact FN function MEP (decrement of FN target muscles - CMAPs amplitude peak to peak >50-60%), developed new facial weakness (House and Brackmann grade II to III). The FNMEP has significant superiority over triggered EMG when tumor is giant and envelops the FN.

Efficacy and safety of stereoelectroencephalography (SEEG)-guided radiofrequency thermocoagulation (RF-TC) in the treatment of paediatric drug-resistant epilepsy: A retrospective analysis.

This investigation evaluates the effectiveness and safety of stereoelectroencephalography (SEEG)-guided radiofrequency thermocoagulation (RF-TC) as a treatment modality for drug-resistant epilepsy. A retrospective review of clinical data from 40 paediatric patients with drug-resistant epilepsy, who underwent SEEG-guided RF-TC at our Epilepsy Center between 2020 and 2022, was conducted. This review included the patients' medical history, imaging and electroencephalography results, surgical procedures, and follow-up outcomes. The duration of SEEG monitoring, accompanied by concurrent electrical stimulation tests, varied from 3 days to 4 weeks. Following RF-TC surgery, 4 patients demonstrated temporary neurological impairments, including central facial and tongue weakness, reduced limb strength, and challenges in fine motor hand movements. All these symptoms were related to lesions in the central region, but showed improvement within 2 weeks to 3 months post-surgery. There were no reported instances of status epilepticus, intracranial haemorrhage, or infections. During a follow-up period of 6 months to 2.5 years, seizure control was achieved in 25 patients (62.5%) at 6 months post-surgery, and a > 50% decrease in seizure frequency was observed in 10 patients. In 5 patients where seizure control was not achieved, the management of epilepsy seemed to be independent of factors such as age at surgery, duration of preoperative disease, seizure type, or negative MRI findings ( p > 0.05). Patients with controlled epilepsy exhibited cognitive improvement, with some demonstrating no EEG abnormalities upon follow-up and a decrease in antiepileptic medication. SEEG-guided RF-TC appears to be a potentially effective and safe therapeutic approach for paediatric patients with drug-resistant epilepsy.

Onabotulinum toxin a treatment for posttraumatic trigeminal neuropathic pain: case series and literature review

This case series aimed to assess the treatment outcomes of onabotulinum toxin A (BTX-A) in patients with refractory posttraumatic trigeminal neuropathic pain (PTNP) and to conduct a narrative review of the evidence for BTX-A in PTNP. Thirteen patients were treated with BTX-A infiltrations. Patient demographic and pain characteristics, BTX-A administration, and treatment outcomes were retrospectively analyzed. Papers retrieved after a literature search of articles on PTNP treatment using BTX-A were reviewed. Six patients reported an improvement in pain 3 months after the initial BTX-A injection, with 4 patients reporting a 50% reduction. Two patients achieved an 80% reduction in pain score over 3 years of BTX-A therapy. Three patients reported temporary ipsilateral facial muscle weakness. The literature review revealed five case reports on the use of BTX-A in PTNP patients that reported similar effectiveness to the present cohort study. BTX-A may be a potential treatment modality for refractory PTNP, thus reducing the need for polypharmacy. Multiple intraoral BTX-A injections administered over the painful sites are well tolerated, safe and easily practiced. High-quality studies are required to evaluate the long-term therapeutic efficacy and side effects of BTX-A therapy.

Facial Onset Sensory and Motor Neuronopathy with Neurotrophic Keratitis: A Case Report

Facial-onset sensory and motor neuronopathy (FOSMN) is a rare, progressive neurodegenerative disorder characterized by sensory loss and motor deficits, primarily affecting the face and upper extremities. The condition begins with sensory impairments in the trigeminal nerve distribution, extending to involve the scalp, neck, upper limbs, and trunk. Symptoms include facial weakness, bulbar disturbances (dysphonia, dysarthria, dysphagia, and sialorrhea), and lower motor neuron signs (weakness, atrophy, fasciculation, and cramps) in the limbs. A hallmark of FOSMN is the diminished or absent corneal reflex, indicating trigeminal nerve involvement and leading to potential complications like neurotrophic keratitis (NK), which can cause corneal ulceration and blindness. The etiology of FOSMN remains uncertain, with theories proposing autoimmune or neurodegenerative origins. Diagnosis is challenging due to the overlap with other ocular surface disorders, necessitating careful examination and differential diagnosis. Management focuses on symptomatic relief, including eye protection to prevent corneal complications. Awareness and early detection of ocular symptoms in FOSMN are crucial for preventing severe outcomes like NK and blindness.

Effect of Conventional Physiotherapeutic Techniques on Post-Operative Facial Palsy: A Case Study

This case study highlights the benefits of combining multiple conventional physiotherapeutic methods for post-operative facial palsy with an evidence-based treatment plan using the International Classification of Functioning Disability and Health ICF. A middle-aged female reported with a primary complaint of facial weakness experienced post the surgical removal of parotid gland due to pleomorphic adenomatous growth. Treatment was offered at the out-patient physiotherapy department and each session lasted for 45 minutes with exercises like proprioceptive training facial neuromuscular rehabilitation mime therapy and sensory re-education incorporated as a part of the patients dose-based physical treatment. With outcome measurements Sunnybrook Facial Grading System indicating improvement by 27 points and Facial Disability Index showing improvement by 41 points and a noticeably higher level of confidence the patient demonstrated a considerable reduction in discomfort and improvement of mobility prior to discharge. The case study focuses on how an evidence-based plan of conventional treatment strategies ensures better prognosis for a patient with post-operative facial palsy.

Solitary Sclerosis Presenting as Progressive Brainstem Symptoms

A woman in her 30s, presented with left facial weakness, left eyelid droop, left gaze diplopia as well as right facial and upper limb numbness; which progressively worsened over 1 month. She also developed dizziness, dysphonia, dysphagia, and an imbalanced gait. On exam, she had hoarseness, dysarthria, anisocoria; left pupil miosis, left eyelid ptosis, left gaze diplopia, left lower face weakness, deviation of the palate and uvula towards the left side, right eye nystagmus, right sided facial numbness, right upper limb numbness, right dysmetria, brisk reflexes all-over and an unsteady gait. The work up was positive for OCBs in the CSF analysis and MRI brain revealed a single progressive left medulla oblongata and left cerebellar peduncle hyperintensity lesion.

The characteristics of Polish patients with salivary gland tumors: a ten-year single-center experience

ObjectivesThe study aims to provide insights into the characteristics of Polish patients with different salivary gland pathologies.Materials and methodsThis is a retrospective study conducted at a single center, including patients who underwent surgery for salivary gland pathologies between 2012 and 2022.ResultsThis study included 239 patients who underwent surgery for salivary gland tumors or inflammatory diseases. Malignant tumors were diagnosed in 9.8% of participants, while 64% had benign tumors and 21% suffered from inflammation. The occurrence of complications after surgery was relatively low, with 9.9% of participants experiencing slight facial weakness or mild dysfunction, and 3% experiencing complete paralysis of the facial nerves. Significant differences were observed between patients with cancers and those with benign tumors and inflammation in terms of age. Cancers were more common in females (67% vs. 33%) and predominantly localized in the parotid glands (95%).ConclusionBenign tumors, such as Warthin's tumors and polymorphous adenoma, were predominantly found in the parotid glands of patients aged 39–72 years. On the other hand, inflammatory diseases were primarily localized within the submandibular glands of males aged 40–68 years. Additionally, the presence of a malignant tumor was associated with longer hospitalization periods related to surgery and a higher risk of severe complications.Clinical relevanceThis study on Polish patients with salivary gland tumors provides valuable clinical insights that can aid in diagnosis, treatment planning, patient counseling, and further research in the field of oncology. It contributes to the overall understanding of salivary gland tumors, potentially benefiting both patients and healthcare providers.

Stroke Riskometer App as an educational campaign in outpatient clinics and its association with knowledge of stroke Warning Signs

BACKGROUND: Stroke is highly prevalent worldwide; however, the associated symptoms and risk factors are commonly unknown among the general population. No study has been carried out in the Mexican population about the risk of stroke and knowledge of warning signs. AIM: Describe the knowledge of early signs of stroke and their association with the risk of cerebral infarction at 5 and 10 years using the American Stroke Association validated application "Stroke Riskometer." METHODS: Observational, descriptive, cross-sectional study including adult outpatients from the Neurology department at "Dr. José Eleuterio González" University Hospital. Anthropometric measurements and vital signs were taken, and the "Stroke Riskometer" was used to calculate the stroke risk at 5 and 10 years. Early signs of stroke were assessed, with emphasis on the acronym "CAMALEON", a mnemonic that includes the three main early signs of Stroke in Spanish. Descriptive statistics were performed. For inferential statistics, Chi-Square test for categorical variables, Mann-Whitney U and Kruskal-Wallis for numerical variables, Spearman correlation for numerical and ordinal variables were conducted, considering significance at p<0.05, using SPSSv25 for statistical analysis. RESULTS: Total of 200 individuals were included; 142 (71%) were women; with an average age of 54.72 (±14.63) years. The most prevalent stroke risk factors were sedentary lifestyle (54%), high blood pressure (41%), and diabetes mellitus (32%). 72.5% were unaware of any early signs of stroke, 10.5% knew 1 sign, 6% knew 2 signs, and 11% knew 3 signs. "Facial Weakness" was the most recognized sign (19.5%), followed by "Arm Weakness" (16%) and "Speech Disturbance" (15.5%). A weak correlation was found between knowledge of early signs and 5 or 10-year risk (r=0.14, p=0.048; r=0.138, p=0.051, respectively). There is a significant difference between knowledge of early signs and educational level (p=0.004), with higher knowledge in higher education. A difference was observed between male and female genders and 5 and 10-year risk (Median 5.3 vs 3.6, p=0.007 and Median 11 vs 5.4, p=<0.001, respectively). Additionally, a significant difference was found between current occupation and 5 and 10-year stroke risk (p=<0.001). Post-hoc analysis and percentage risk analysis found significant differences between students and other occupations. There is an increase in stroke risk as an individual's life decade advances. CONCLUSION: Awareness of stroke warning signs is low, remaining an unfinished goal despite educational campaigns in Mexico. A national, massive, and ongoing campaign for the population is necessary.

Management of Ardita through Nasya with special reference to Bell's Palsy : A Single Case Study

In modern era, prevalence of neurological disorders are rising due to fast-paced and stressful lifestyle. Ayurveda categorizes neurological disorder as Vata Vyadhi. Of the 80 Nanatmaj Vatavyadhi, Ardita is the one. Ardita is the disease characterized by Mukhardha Vakrata & results in Facial asymmetry & dysfunction. Ardita can be correlated to Bell's Palsy. Bell's Palsy is a neurological condition that involves the 7th cranial nerve & results in facial drooping and weakness. As per Acharya Charaka, Nasya is the specific treatment for Ardita. Nasya is one of the Panchakarma procedure in which the drug (medicated oil / ghee / decoction / powder, etc.) is administered through Nasa, essentially to eliminate the vitiated Dosha present in Shira. The present case deals with the 50 years old man diagnosed with Ardita and treated with Ayurvedic Shaman Aushadh along with Nasya. Patient got complete relief in all symptoms with appreciable changes. Criteria of assessment was based on House-Brackmann facial paralysis scale. To explore and elaborate the role of Nasya in Ardita with special reference to Bell's Palsy, various Samhitas along with contemporary books, research articles available on Nasya and Ardita are studied. Panchakarma procedure like Nasya proves to be the promising Ayurvedic management in Ardita.

Tuberculosis manifesting as bilateral acute parotid swelling with unilateral lower motor neuron facial palsy: an unusual presentation

A 41-year-old female presented to the otorhinolaryngology department with a history of painful swelling over the bilateral parotid region, low-grade fever for the past one month and progressively worsening left-side facial weakness for the last 15 days. She had received multiple courses of antibiotics elsewhere, which did not result in any improvement except pain. She had no past history of any comorbidities or any previous history of tuberculosis. Examination revealed that she had a non-tender, circumscribed, solitary, 3×3 cm size, firm swelling over the bilateral parotid region. Clinical signs of grade V facial nerve palsy (House and Brackmann classification) were noted. There was a severe grade left lower motor neuron facial nerve palsy (left side) seen. There was no cervical lymphadenopathy. The rest of the head and neck examination was unremarkable. Fine needle aspiration cytology (FNAC) from the most prominent part of the swelling was suggestive of granulomatous inflammation. The patient was initially treated with intravenous antibiotics, supportive care and started on antitubercular drugs (once the diagnosis was established) under the National Tuberculosis Eradication Program (NTEP) to which she responded well and after three months of therapy, her swelling and facial weakness improved significantly. In addition to reporting a completely rare kind of presentation, this paper reviews relevant literature and stresses the need for a high degree of suspicion for tuberculous parotitis in a patient with bilateral parotid swelling. The use of fine needle aspiration is important so that this curable condition can be diagnosed early and medically treated. In this way, surgical intervention can be avoided and further complications can be prevented.

Severe axonal motor neuropathy after heat stroke

A 22-year-old healthy man experienced heat stroke while hiking and collapsed, resulting in multiorgan failure, cerebral edema, and prolonged intensive care unit stay. He developed flaccid tetraplegia, facial weakness, and dysphagia, and was diagnosed with severe axonal sensorimotor polyneuropathy. Rehabilitation improved dysphagia, but he remained dependent on daily activities and required assistance for transfers. The prognosis of critical illness polyneuropathy is typically good in young, healthy individuals. Peripheral neuropathy is a rare complication of heat stroke due to hyperthermia-induced neuronal injury. As global temperatures continue to rise, it is essential to recognize the potential impact of climate change on the incidence of heat stroke and to implement public health interventions to mitigate its effects.

Centronuclear myopathy with a novel variant (p.Asp646Tyr) in the DNM2 gene exhibits mild clinical manifestations: A case report

Centronuclear myopathy (CNM) is one of the congenital myopathies characterized by centrally located nuclei in the muscle fibers. Currently, more than 30 pathogenic variants in the dynamin 2 (DNM2) genes have been identified. Here, we describe a 63-year-old female who presented with slowly progressive limb weakness with no facial weakness or ophthalmoplegia. Electromyographical myotonia without clinical myotonia was noted. In the DNM2 gene, whole-genome sequencing revealed the heterozygous variant c.1936G>T (p.Asp646Tyr), which was not reported previously. Muscle pathology identified many fibers with centrally located nuclei, with the predominance of type 1 fibers. Thus, the patient was finally diagnosed with DNM2-associated CNM with a novel pathogenic variant and with unusually mild phenotype.

Myotonic Dystrophy Type 1: A Comprehensive Literary Review

Myotonic Dystrophy Type 1 (DM1) is a degenerative neuromuscular disease that costs 448 million dollars in the US annually to combat. Caused by the abnormal expansion of the CTG sequence located along the Dystrophia Myotonica Protein Kinase (DMPK) gene of chromosome 19, DM1 results in several different observable effects that include, but are not limited to cataracts, facial weakness, hypersomnia, cardiomyopathy, and arrhythmias. Symptoms are attributed to the rapid degeneration of muscles that leads to weakened control over the heart, lungs, gastrointestinal systems, and face. Treatments for DM1 are limited to minimizing morbidity such as through assistive mobility devices. In pursuit of a cure, pre-clinical models have provided a foundation for deeper investigations into the pathogenesis of DM1. Ongoing studies utilize molecular genetics and pharmacology to target the underlying molecular mechanisms, fortunately, many of these studies have shown potential in pre-clinical trials. Antisense therapy targets expanded trinucleotide regions and has demonstrated recovery of cardiac muscle in mice. CRISPR/SpCas9, when injected, has shown beneficial effects in several DM1 animal models. Furthermore, given the pre-clinical success of the novel pharmacologic agent AOC 1001, clinical trials have been initiated and are ongoing. Unfortunately, due to the nuances and difficulties in treating DM1, there is currently no Food and Drug Administration-approved disease-modifying therapies, and as such DM1 represents a growing public health concern.

Potential reasons for failure and recurrence in microvascular decompression for hemifacial spasm.

To examine the factors contributing to persistent and recurrent hemifacial spasms (HFS) following a microvascular decompression (MVD) procedure and to suggest technical improvements to prevent such failures. A retrospective review was conducted on fifty-two cases of repeat surgery. The extent of the previous craniotomy and the location of neurovascular compression (NVC) were investigated. The operative findings were categorized into two groups: "Missing Compression" and "Teflon Contact". The analysis included long-term outcomes and operative complications after repeat MVD procedures. Missing compression was identified in 29 patients (56%), while Teflon contact was observed in 23 patients (44%). Patients with missing compression were more likely to experience improper craniotomy (66%) compared to those with Teflon contact (48%). Medially located NVC was a frequent finding in both groups, mainly due to compression by the anterior inferior cerebellar artery. In the missing compression group, during the repeat MVD, Teflon sling retraction was utilized in 79% of cases, while in the Teflon contact group, the most common procedure involved removing the Teflon in contact (65%). After the repeat MVD procedure, immediate spasm relief was achieved in 42 patients (81%), with six (12%) experiencing delayed relief. After a median follow-up of 54 months, 96% of patients were free from spasms. Delayed facial palsy, facial weakness, and hearing impairment were more frequently observed in the Teflon contact group. A proper craniotomy that provides adequate exposure around the REZ is crucial to prevent missing the culprit vessel during the initial MVD procedure. Teflon contact on the REZ should be avoided, as it poses a potential risk of procedure failure and recurrence.

Fat Embolism Syndrome from Bone Marrow Necrosis Following Peg-Filgrastim in a Patient with Primary Mediastinal B-Cell Lymphoma

Background: The mechanism of atraumatic fat embolization syndrome (FES) is poorly understood. However, mechanical and biochemical processes are the two plausible theories that exist. FES from bone marrow necrosis caused by hemoglobinopathies, use of chemotherapy in hematopoietic malignancies and from use of G-CSF has been reported. In our case, a young male patient with primary mediastinal large B-cell lymphoma presented with microhemorrhages and punctiform ischemic brain lesions after receiving chemoimmunotherapy and pegylated G-CSF. Case: A 29-year-old male recently diagnosed with primary mediastinal large B-cell lymphoma presented to our ED with severe bone pain after receiving his first cycle etoposide, prednisone, vincristine sulfate, cyclophosphamide, doxorubicin, and rituximab (DA R-EPOCH) with peg-filgrastim support. He was discharged with pain control and subsequently received his second cycle of DA-R-EPOCH (20% increase in etoposide, doxorubicin, and cyclophosphamide) with a retrial of peg-filgrastim. His WBC count rose to a peak of 41,100K/UL on the seventh day of his second cycle. Ten days after receipt of his 2 nd peg-filgrastim, he presented to the ED with complaints of generalized weakness, decreased oral intake and mild imbalance with his gait. His blood pressure was 103/71 mmHg, heart rate was 138 beats per minute, respiratory rate was 22 breaths per minute and oxygen saturation was 91% on room air; and he required 2 liters of supplemental oxygen. Laboratory studies showed Hb of 8.1 gm/dL, PLT of 47,000k/UL and WBC of 10,100k/UL. The WBC differential was consistent with myeloid predominance with a left shift and some enucleated RBC consistent with use of peg- filgrastim. LDH was 2874 U/L, albumin was 3.8 g/L, PTT 23.1 seconds, PT 13.8 seconds, INR 1.2. A CT with angiography of the chest showed no pulmonary embolism but an anterior mediastinal soft tissue mass, which decreased in size compared to his prior image, with erosive changes of sternum. Mediastinal and axillary lymphadenopathy also overall decreased in size. Due to developing confusion and mild left-sided facial weakness, MRI with and without intravenous contrast of the brain demonstrated numerous petechial microhemorrhages throughout the brain parenchyma in the supratentorial compartment and posterior cranial fossa with involvement of superficial and deep parenchymal regions. Many were seen clustered in the internal/external watershed regions. Transthoracic echocardiogram with bubble study demonstrated a patent foramen ovale (PFO). Prophylactic low molecular weight heparin was started and he was discharged after improvement of symptoms. He proceeded to complete 4 more cycles of standard dose R-EPOCH with prophylactic levofloxacin instead of peg-GCSF. His neurologic symptoms resolved and did not recur. Conclusion: This case highlights a rare but severe complication of BMN causing fat embolization syndrome in a patient receiving G-CSF following R-EPOCH for high PMBCL with sternal bone involvement. We hypothesize that the rapid proliferation of myeloid cell lines induced by G-CSF led to vascular occlusion and relative hypoxemia. Furthermore, the prolonged incorporation of corticosteroids is known to cause adipose tissue disruption. His underlying disease involved invasion into his sternum which further would support the theory of bone marrow necrosis being able to dislodge into the vasculature. This case is important to alert physicians to be cognizant of this severe complication and to provide some evidence for continuing curative intent treatment with the omission of G-CSF support.

Combination of Manual Acupuncture, Penetrating Needling, and Electroacupuncture to Treat Bell's Palsy.

Bell's palsy is an acute idiopathic paralysis of lower motor neurons on only 1 side of the face without any identifiable etiology. The condition affects a patient's physical, social, and psychologic health. It is important for the patient to recover quickly and minimize the risk of long-term sequelae. Therefore, researchers recommend a combination of several therapeutic modalities to shorten the disease's course and improve curative effects. A 34-year-old woman had with right facial weakness. She was diagnosed with House-Brackmann grade III Bell's palsy and received medical therapy. She was also given manual acupuncture at GB-20, BL-2, ST-36, LI-4, TE-5 bilateral, and GV-20. Penetrating needling was given at GB-14 toward Ex-HN-3, ST-7 toward SI-18, SI-18 toward LI-20, ST-6 toward ST-4, and ST-5 toward ST-4 on the affected area, with a 30-minute needle retention. Electroacupuncture (EA) was delivered at ST-7-SI-18, ST-6-ST-5, GB-14-Ex-HN-5, and ST-4-CV-24, with a dense-disperse wave, at a frequency of 10/50 Hz for 20 minutes. She had treatment sessions twice per week, for a total of12 sessions. From her 7th to 12th visit, this patient had reached House-Brackmann grade I. No adverse effects occurred. In this patient, a combination of acupuncture penetrating needling technique and EA played a role to shorten her recovery time and minimize the risk of sequelae of Bell's palsy. The treatment combination used in this case report can be considered in other clinical cases.

An Uncommon Diagnosis of Necrotizing Mastoiditis Presenting as Bell's Palsy: A Case Report.

The benign nature of Bell's palsy has led to a lack of a standardized work-up, and dangerous underlying mimics are at risk of being missed. An 84-year-old female with a history of vertigo presented to the emergency department with a left-sided facial droop consistent with Bell's palsy. After further work-up, the patient was diagnosed with bilateral necrotizing mastoiditis. Unilateral facial weakness involving the forehead and palpebral fissures is often diagnosed as idiopathic Bell's palsy. Various pathologies can present with unilateral facial weakness, and the differential needs to remain broad.

Abstract 18126: A Rare Case of a Left Ventricular Papillary Fibroelastoma With an Initial Presentation of Unilateral Vision Loss

A 59-year-old female with hypertension presented with acute onset of decreased vision in the right eye. She reported waking up 3 days prior to admission with sudden onset of shadow in the right eye appearing like a falling curtain which eventually progressed to total visual loss. She also complained of headaches and palpitations. The patient denied pain, nausea, vomiting, photophobia, changes in speech, aphasia, facial weakness, arm or leg weakness or numbness. She states that this is her first experience of vision loss. At the time of admission, she was hypertensive to 170/100s and started on amlodipine 5mg and losartan 25mg. Neurology and ophthalmology were consulted for concerns of stroke and new vision loss. She was started on heparin drip, aspirin 81mg, atorvastatin 80mg, and methylprednisolone 1g. Ocular examination revealed right brachial retinal artery occlusion. MRI brain showed chronic microvascular changes, but no acute intracranial hemorrhage or infarction. CT angiogram of the neck showed mild soft plaque in right carotid bifurcation. Transthoracic echocardiogram revealed a 1.6cm x 1.6cm left ventricular mobile mass which appeared to be attached to the posteromedial papillary muscle and left ventricle ejection fraction of 60%. The patient underwent open heart surgery for removal of the mass. The mass was confirmed to be a papillary fibroelastoma attached to the left ventricular trabeculum. The mitral valve and subvalvular apparatus were not involved. New onset of stroke or acute vision loss is generally a result of thromboembolism. Most times it can be caused by a clot formed in a patient with atrial fibrillation. In other cases, it can be due to a ruptured cholesterol plaque. However, primary cardiac tumors are rare, especially ones on the papillary muscle. We presented a rare case of papillary fibroelastoma that possibly embolized causing acute unilateral vison loss. This case reinforces the importance of cardiac imaging in new stroke or acute vision loss.

Abstract 102: Pseudo‐Internuclear Ophthalmoplegia in a Patient with an Acute Globus Pallidus Infarct: A Case Report

Introduction Internuclear ophthalmoplegia (INO) is an ocular movement disorder typically due to a lesion in the medial longitudinal fasciculus (MLF). Rarely, similar ocular movement abnormalities can be observed in the absence of an MLF lesion. This case report aims to highlight a potential association between acute globus pallidus (GP) infarct and an ocular movement abnormality resembling INO. Methods N/A Results Case Presentation: A 72‐year‐old male with a medical history significant for chronic myeloid leukemia, prostate cancer, type 2 diabetes mellitus, hypertension, prior stroke, and heart failure presented with dizziness. Examination revealed right INO, skew deviation with right hypertropia, left lower extremity weakness, left upper extremity dysmetria, right facial weakness (prior deficit), and ataxic gait. MRI of brain confirmed an acute lacunar infarct in the right globus pallidus with no apparent brainstem or cerebellar lesion. The patient was started on dual antiplatelet therapy and discharged with home rehabilitation services to improve his balance. Discussion: The patient presented with pseudo‐INO in the setting of an acute globus pallidus infarct. This case introduces the idea that ocular motor abnormalities resembling INO could occur due to a GP lesion, which was not previously reported. The basal ganglia control saccadic eye movements by means of their connection to the superior colliculus (SC). GP was shown to have a role in this connection which may provide a plausible explanation for this observation. Another possible explanation can be based on the concept of diaschisis, where a lesion in a specific area of the brain (GP in this case) can lead to deficits or impairments in various functions associated with that region (the SC and its pathway for controlling saccadic eye movement). Conclusion This case emphasizes that slow adducting saccades and associated nystagmus is not always INO.

Abstract 212: Percutaneous Carotid access in Mechanical Thrombectomy ‐ a safe alternative to transfemoral approach

Introduction Emergent percutaneous carotid artery MER approach for acute ischemic large vessel strokes are rare given the risk of complications and seldom reported. Methods 75‐year‐old left‐handed functional male (mRs:0) with past medical history of HTN, HLD presented to ED after being found on the floor by his family with slurred speech, new onset right sided weakness, with a last known well of 17 hours. NIHSS on arrival was 14 for expressive aphasia, right visual field defect, right facial weakness, significant dysarthria, right hemiparesis, and sensory defect. CT Head demonstrated left MCA territory early ischemic changes. CTA head/neck demonstrated left M1 occlusion with large penumbra. Perfusion data demonstrated no area of core infarct with area of ischemic penumbra in the left MCA territory involving the left frontal, temporal and parietal lobes measuring 161 ml. ASPECT score 5‐6. The patient was deemed a candidate for mechanical endovascular thrombectomy (MER). The procedure was initiated via ultrasound‐guided right common femoral access. After multiple attempts using a wide range of techniques and wire/catheter combinations in order to establish left intracranial access and given extreme angulation/tortuosity/elongation in the proximal left common carotid artery, it was decided to proceed with the catheter position in the left common carotid or the left internal carotid artery that would allow for subsequent catheterization of the intracranial circulation for MER. Results Near complete revascularization with minimal distal thrombus material beyond endovascular reach corresponding to a TICI 2C degree of revascularization was achieved. Closure of the femoral puncture site was performed using an Angio seal femoral closure device. Surgical closure of the puncture site was performed by vascular surgery. The patient was eventually discharged to short term acute rehabilitation and continues to follow up outpatient with the Stroke clinic. Conclusion Older patients with ischemic stroke commonly have tortuous vessels or peripheral vascular disease. As a result, they may greatly benefit from emergent direct carotid access, as the trans‐femoral approach often poses challenges in accessing the thrombus. For patients with complex and unfavorable vascular anatomy for mechanical endo‐vascularization, direct percutaneous carotid puncture can be advantageous, effectively reducing the aforementioned difficulties. When opting for such an approach it is vital to factor in the aortic arch appearance and its branches.