Physiotherapy Approach to an Internal Capsule Infarct With Upper Motor Neuron Facial Nerve Palsy: A Case Report

Abstract

The internal capsule (IC) is a vital brain structure housing descending and ascending fiber tracts, with traditional assumptions about the corticobulbar and corticospinal tracts descending through the genu and anterior third of the posterior limb of internal capsule (PLIC), respectively. However, observations of IC infarctions reveal that symptoms often deviate from the expected fiber pattern, prompting a deeper exploration of these complexities. The posterior limb of the IC receives its blood supply from the lenticulostriate branches of the middle cerebral artery and the anterior choroidal artery (AChA). AChA infarctions present a diverse array of symptoms beyond the classic triad, reflecting the intricate vascular supply and lesion patterns within this region. We present a case of a 74-year-old male farmer with right-hand dominance, who experienced a fall resulting in head and right lower limb injuries. Subsequently, he developed weakness in his left upper and lower limbs, facial deviation, slurred speech, and swelling in the right lower limb. Following these symptoms, his family promptly brought him to the hospital on November 30, 2023. Extensive investigations, including magnetic resonance imaging (MRI), revealed a hyper-acute infarct in the posterior limb of the left IC. The patient was admitted to the intensive care unit (ICU) for three days and later shifted to the neurology ward where medical management was commenced, including physiotherapy protocol that was started on December 2, 2023. Physiotherapy interventions were designed to address the patient's weakness, altered sensation, and diminished reflexes. Therapeutic goals focused on preventing complications, improving posture, enhancing range of motion (ROM), and mitigating breathing difficulties and mobility issues. The physiotherapy aimed to enhance the patient's overall physical and mental well-being, emphasizing independence and improved quality of life. Regular assessments and adjustments to the therapeutic interventions were made based on the patient's progress. This case underscores the importance of tailored physiotherapy interventions in addressing the diverse manifestations of IC infarctions, contributing to a comprehensive understanding of rehabilitation strategies in neurologically compromised individuals.

Keywords: anterior choroidal artery; facial palsy; internal capsule; physiotherapy; post-stroke; posterior limb; rehabilitation; rood’s approach; slurred speech; stroke.

Figure 1. MRI findings of hyper-acute infarct in the posterior limb of the left internal capsule (red arrows)

Figure 2. Patient performing (A) facial exercises with mirror feedback and neuromuscular retraining, and (B) constraint-induced movement therapy

(A) Mirror feedback is used for muscular retraining of the face; (B) Constraint-induced movement therapy is given to the unaffected extremity and training to the affected