A 74-year-old man with metastatic pancreatic cancer and a recent deep vein thrombosis (for which he was taking enoxaparin sodium) was brought to our emergency department by his wife. Approximately 2 hours previously, the patient experienced the sudden onset of bilateral facial paralysis and an inability to speak. His examination results were significant for volitional paralysis of his bilateral upper and lower face, including the orbicularis oculi, orbicularis oris, and masseter muscles, anarthria, absence of gag reflex, inability to swallow on command, and inability to protrude his tongue. He did, however, blink in response to threat, smile when his wife came to the bedside, and swallow and yawn spontaneously. The patient presented within the accepted time window for thrombolytic therapy but was not considered to be a candidate owing to his enoxaparin use. Computed tomographic angiography of the head and neck revealed no evidence of arterial occlusions. Magnetic resonance imaging of the brain was performed shortly after admission and confirmed the clinical suspicion of bilateral anterior opercular infarcts (Figure 1 and Figure 2). We presume that the cause of his infarcts was embolic—possibly related to marantic endocarditis given his known condition—but this was not able to be confirmed as he and his family elected for hospice care and declined further stroke evaluation.
Bursaw A, Duginski T. Anterior Opercular Syndrome Caused by Acute, Simultaneous, Isolated Bilateral Infarcts. Arch Neurol. 2011;68(2):254–255. doi:10.1001/archneurol.2010.369
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