Facial pain as a presenting feature of intracerebral haemorrhage.

A literature review from 1966 using Medline with keywords 'cerebral haemorrhage' and 'facial pain' failed to reveal any cases in which facial pain was the initial feature of intracranial haemorrhage. The following case describes ipsilateral facial pain which is previously undescribed as a presentation of intracranial bleeding. A 53 year old female who was previously well, with no significant history of headache, developed right facial pain from the orbit to the maxilla. Ten to 15 min later she developed nausea and vomiting with unsteadiness and confusion. She had difficulty with left-hand fine finger movements, with normal sensation and reflexes but an extensor plantar response on the left. Facial pain persisted for 3 days. Initial imaging revealed a 4 x 3 cm right temporal lobe haemorrhage with mass effect and oedema extending into the subarachnoid space. Angiogram revealed a right temporal lobe arteriovenous malformation. The basis of the pain remains speculative but includes sensation from the torn vessel wall being referred to the face and subarachnoid blood irritation of the meninges in the middle cranial fossa. Another possibility is irritation of somatosensory cortex II, but why this should result in only ipsilateral pain is unclear. Facial pain should be an alerting symptom to the neurologist when it appears with no apparent cause.