Pontine Hemorrhage Mimicking Bell's Palsy: Isolated Facial Nerve Palsy-A Case Report

Bell's palsy, the most common cause of idiopathic peripheral facial palsy, is typically attributed to viral reactivation; however, rare cases due to cerebrovascular disease must always be considered in the differential diagnosis. We report the case of a 75-year-old man with poorly controlled hypertension, diabetes mellitus, and a history of smoking who presented with progressive left-sided facial paralysis over four days. Initially suspected to have Bell's palsy due to the lower motor neuron pattern and gradual onset, further neuroimaging revealed a different etiology. T2^∗-weighted MRI showed a low-signal area in the left pons, and a noncontrast CT confirmed a small hemorrhage. This atypical presentation, characterized by a gradual onset and absence of additional neurological symptoms, was attributed to focal compression of the facial nerve by the hematoma. The patient was treated conservatively with hemostatic agents, bed rest, and rehabilitation, leading to symptomatic improvement. His symptoms began to improve by the fourth day of hospitalization, and follow-up imaging showed no hematoma expansion, with signs of absorption by Day 7. He was discharged after 15 days. This case highlights the diagnostic challenge in distinguishing Bell's palsy from facial peripheral paralysis secondary to brainstem cerebrovascular events, particularly in patients with vascular risk factors. It underscores the importance of a "selective imaging strategy," emphasizing that neuroimaging should be strongly considered in atypical or progressive cases, even when classic signs of a stroke are absent.