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Título

Peripheral facial palsy as a false localizing sign of intracranial hypertension: a case report

RESUMO

Case presentation: A 30-year-old female patient presented with acute, pulsatile, progressive, continuous left occipitofrontal headache, nausea and vomiting. One week later, she started feeling a heavy sensation on right hemiface and low vision in the right eye, and after 1 week in the left eye. She denied diplopia She used combined contraceptives daily. On physical examination, she had low visual acuity of 20/80 in the right eye and 20/60 in the left eye; funduscopy showed papilledema; she also had right peripheral facial palsy with lagophthalmos and Bell's sign. CT angiography showed filling failure in the left transverse sinus and in the transition between the sigmoid sinus and the jugular bulb, without signs of venous infarction. Cerebrospinal fluid showed an opening pressure of 50cmH₂O and a closing pressure of 25cmH₂O, with no changes in the CSF laboratory analysis. The diagnosis of intracranial hypertension (HI) secondary to cerebral venous thrombosis (CVT) was defined and full anticoagulation and acetazolamide were initiated. Thus, an etiological investigation of peripheral facial paralysis was carried out; however, CT of the sinuses and temporal bones, as well as the MRI of the inner ear, were normal, concluding as a probable cause of a false localizing signal of HI and CVT. Discussion: The pathogenesis of false intracranial localization signals usually occurs in the context of IH with herniation syndromes, with VI nerve palsy being more common in 14% of idiopathic intracranial hypertension (IIH) cases. The finding of VII nerve palsy is uncommon in HI, in a case series of 140 patients with IIH, only 2 cases had VII nerve palsy with a peripheral pattern. As a possible pathophysiology, there may be compression or stretching of the facial nerve in its intratemporal segment close to the facial canal, in addition to reduced drainage of the extensive venous plexus that accompanies the nerve in the facial canal. Final comments: Although rare, the finding of peripheral facial paralysis may have intracranial hypertension as one of the possible etiologies.