BACKGROUND

A 76-year-old right handed woman awoke with sudden onset of difficulty with swallowing, slurred speech and left-sided facial weakness and numbness. She had multiple vascular risk factors: hypertension, hypercholesterolaemia, impaired glucose tolerance and a 50 pack-year smoking history. Twelve days before presentation she had developed right-sided facial weakness. Ten days before presentation she had sustained a right supraorbital laceration which required suturing after falling on to pavement (figure 1). A CT scan of the head at the time of injury was normal (figure 2). On examination, there was left-sided upper motor neurone facial palsy and right lower motor neurone facial palsy, with dysarthria but no dysphasia, diminished sensation over the left maxillary and mandibular areas, and normal limb examination. Given her constellation of signs, we considered the possibility of brainstem stroke and recent right Bell's palsy.

CT scan of head and CT angiogram showed a large right supraorbital haematoma, but no acute stroke (figure 3 …