Differential Diagnosis for 59-year-old with Left Side Facial Droop and Neck Pain
Single Most Likely Diagnosis
- Stroke (specifically, a lacunar stroke or a small vessel disease): The patient's symptoms of left-sided facial droop and the NIH stroke scale score of 4 suggest a possible stroke. Although the head and neck CT is negative, small vessel diseases or lacunar strokes might not always be visible on initial CT scans, especially if they are small.
Other Likely Diagnoses
- Bell's Palsy: This condition causes sudden weakness in facial muscles, which could explain the left-sided facial droop. However, the presence of neck pain and the NIH stroke scale score might lean more towards a stroke or another neurological condition.
- Cervical Radiculopathy or Disc Herniation: Neck pain and radiating symptoms could be due to a cervical spine issue. However, the facial droop is less commonly associated with these conditions unless there's significant compression or inflammation affecting the facial nerve indirectly.
- Temporal Arteritis or Giant Cell Arteritis: Although less common, this condition can cause facial pain, jaw claudication, and visual disturbances, but it typically affects older adults and is associated with elevated inflammatory markers, which are not mentioned here.
Do Not Miss Diagnoses
- Dissection of the Carotid or Vertebral Artery: This is a critical diagnosis to consider due to its potential for severe consequences, including stroke. The presence of neck pain and facial droop could be indicative of a dissection, especially if there was recent trauma or certain underlying conditions.
- Lymphoma or Other Malignancies: Although rare, malignancies can cause facial weakness and neck pain due to compression or infiltration of nerves. A thorough investigation, including imaging and possibly a biopsy, might be necessary if other diagnoses are ruled out.
- Infectious Causes (e.g., Lyme Disease, Syphilis): Certain infections can cause neurological symptoms, including facial weakness. These would be less common but important to consider, especially with appropriate exposure history.
Rare Diagnoses
- Melkersson-Rosenthal Syndrome: A rare neurological disorder characterized by recurrent, often unilateral, facial paralysis or weakness, along with swelling of the face and lips (usually the upper lip) and the development of folds and furrows in the tongue (fissured tongue).
- Tolosa-Hunt Syndrome: A rare disorder characterized by severe and unilateral headaches with extraocular palsies, but it could potentially cause facial weakness if the facial nerve is involved.
- Sarcoidosis: This condition can cause neurological symptoms, including facial weakness, due to granulomatous infiltration of nerves. It would be considered rare in this context without other systemic symptoms or findings suggestive of sarcoidosis.