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Chronic facial twitches: when tracers reveal their status

A 62-year-old woman was admitted to the emergency room after having been found somnolent and confused on her sofa. After about 90 min, she was again alert and oriented. Besides a bilateral tongue bite, examination revealed subtle semi-rhythmic jerks (about 4–6 Hz) involving her left cheek and tongue, and a rapidly improving left sensory hemineglect with mild facio-brachial hemiparesis. Her abnormal movements had become chronic and fluctuating since their acute onset 2 years earlier. The patient had been unsuccessfully investigated with an EEG and a brain MRI 6 months earlier, following two episodes of loss of consciousness, all preceded by particularly violent cheek jerks, and followed by a left transient hemiparesis. An EEG after 12 h showed a mild, irregular low-voltage right temporal slowing during drowsiness, and muscle artifacts from continuous rhythmic left facial movements. One day after admission, during an episode of increased twitching, an F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET) was performed; this disclosed a well circumscribed hypermetabolic region (Fig. 1). A repeated MRI showed several bilateral old lacunar infarcts, without changes in diffusion-weighted imaging sequences. An extensive work-up including search for infectious, autoimmune and metabolic disorders yielded normal results. Facial movements did neither respond to lorazepam (1 mg tid) nor to clobazam (5 mg tid) and slightly decreased in intensity but were still present after introduction of valproic acid (500 mg bid), which was chosen because of the possibility of a rapid titration. At 3 months follow-up, the patient did not experience any additional episode of loss of consciousness.