What is the best course of action for a patient with intermittent numbness, facial numbness, and throat pressure, and no history of seizures?

Management of Intermittent Numbness, Facial Numbness, and Throat Pressure in a Patient with No History of Seizures

For a patient presenting with intermittent numbness, facial numbness, and throat pressure without a history of seizures, neuroimaging with MRI of the brain without contrast is strongly recommended as the first diagnostic step.

Differential Diagnosis

The constellation of symptoms suggests several possible etiologies:

1. Transient Ischemic Attack (TIA)/Stroke

   • Focal neurological symptoms like numbness, especially involving the face, may indicate cerebrovascular pathology
   • The absence of seizure history makes this more likely than epilepsy

2. Cavernous Malformation

   • Can present with focal neurological deficits without hemorrhage 1
   • May cause transient symptoms without evidence of bleeding

3. Multiple Sclerosis

   • Can present with sensory symptoms including facial numbness 2
   • Often presents with transient neurological symptoms

4. Compression Neuropathy

   • Vascular compression (e.g., aneurysm) can cause facial numbness
   • Throat pressure sensation may indicate involvement of lower cranial nerves

Diagnostic Approach

Step 1: Neuroimaging

• MRI brain without contrast is the preferred initial imaging study
  • Superior to CT for detecting posterior circulation infarcts, demyelinating lesions, and subtle structural abnormalities 1
  • Diagnostic yield is approximately 4% in isolated dizziness but higher with focal neurological symptoms 1

Step 2: Additional Testing Based on MRI Results

• If MRI shows vascular abnormalities: Consider MRA/CTA of head and neck
• If MRI shows demyelinating lesions: Consider lumbar puncture for CSF analysis
• If MRI is normal but symptoms persist: Consider EEG to rule out atypical seizure presentation

Clinical Reasoning

1. Why MRI over CT?

   • MRI has greater sensitivity for intracranial pathology 3
   • CT should only be performed first if intracranial bleeding is suspected due to recent trauma, coagulopathy, or severe headache 3

2. Why neuroimaging before EEG?

   • The presentation of focal neurological symptoms without a history of seizures makes a structural lesion more likely than epilepsy
   • According to guidelines, focal neurological findings warrant neuroimaging 1

3. Why not start antiepileptic drugs?

   • No history of seizures makes epilepsy less likely
   • Treatment with antiepileptic drugs after a first seizure (which hasn't occurred in this case) does not prevent epilepsy long-term 3

Important Considerations

• Syncope vs. Seizure: The symptoms described (numbness, facial numbness, throat pressure) do not match typical seizure semiology and are more consistent with TIA or other structural pathology 1

• Red Flags: Persistent symptoms, progression of symptoms, or development of additional neurological deficits should prompt urgent evaluation

• Follow-up: Even with a normal initial MRI, if symptoms persist or recur, consider:

  1. Repeat imaging in 3-6 months
  2. Extended vascular imaging
  3. Referral to neurology for specialized evaluation

Pitfalls to Avoid

1. Misdiagnosing as anxiety: Intermittent neurological symptoms are often misattributed to anxiety or stress, delaying proper diagnosis

2. Overlooking posterior circulation events: Symptoms like dizziness and sensory changes can represent posterior circulation TIAs, which may be missed on CT

3. Premature diagnosis of seizures: Without typical seizure semiology or EEG findings, avoid labeling as seizures, which can have significant implications for driving privileges and employment 4

4. Delaying imaging: When focal neurological symptoms are present, prompt neuroimaging is indicated rather than watchful waiting 1