What are the known non-stroke causes of facial droop and gait changes that could appear similar on video?
Executive summary
Facial droop and altered gait captured on video can be caused by many conditions other than cortical stroke; common non‑stroke mimics include peripheral facial nerve palsies (most commonly Bell’s palsy), peripheral nerve injury or trauma, vestibular and cerebellar disorders that produce vertigo and ataxia, tumors or compressive lesions, demyelinating disease such as multiple sclerosis, and rare brainstem lesions that are non‑vascular or inflammatory in origin [1] [2] [3] [4]. Clinicians rely on pattern recognition — forehead movement, associated limb weakness, eye movements, speech and timing — to distinguish these in person, but video alone can be misleading and has known pitfalls [5] [6] [7].
1. Bell’s palsy and other peripheral facial nerve injuries: a frequent, video‑friendly mimic
Bell’s palsy — an idiopathic peripheral seventh‑nerve palsy thought to follow viral inflammation — causes sudden unilateral facial weakness including inability to raise the eyebrow or close the eye, producing a classic droop that can look like stroke on camera; most patients recover over weeks to months and the condition is typically limited to the face without limb weakness [1] [2] [8]. Traumatic injury, surgical injury, or compressive lesions of the facial nerve produce similar asymmetric facial movement on video and are clinically distinguished from central causes by involvement of the forehead musculature and absence of contralateral limb symptoms [2] [9].
2. Brainstem and pontine lesions that masquerade as peripheral palsy
Not all non‑cortical causes are benign: small pontine infarcts or other brainstem lesions can produce an apparent complete hemifacial palsy that mimics Bell’s palsy on video, and may be missed if assessment relies only on facial appearance; case series show that a small but real fraction of presumed Bell’s palsy cases are reclassified as stroke or intracranial hemorrhage on follow‑up (about 0.8% in a large ED surveillance, with pontine strokes comprising an important subset) [10] [7]. Other inflammatory or neoplastic brainstem processes can produce facial and gait findings resembling stroke while being non‑ischemic in origin [7] [4].
3. Vestibular disorders and cerebellar problems: droop plus gait instability via different pathways
Vertigo, nausea, nystagmus and wide‑based ataxic gait may accompany facial numbness or droop in posterior‑fossa disorders such as vestibular neuritis, cerebellar pathology, or lateral medullary (Wallenberg) syndromes; when observed on video, eye movement abnormalities and unsteady gait can look stroke‑like even when originating from peripheral vestibular or cerebellar causes or from non‑ischemic etiologies [3] [4]. Clinicians look for preserved forehead movement and isolated cranial nerve patterns to separate peripheral facial palsy from central lesions, but video may lack the detail needed for these distinctions [3] [5].
4. Tumors, masses and compressive lesions: gradual or fluctuating droop that confuses viewers
Neoplasms affecting the facial nerve, parotid region, skull base, or posterior fossa can produce progressive or fluctuating facial weakness and gait disturbance that may be mistaken for acute stroke when an acute decompensation is filmed; imaging and clinical history are essential because these processes evolve over time and often produce additional symptoms such as hearing loss or cranial neuropathies [2] [11] [3].
5. Demyelinating and inflammatory disorders that mimic stroke clinically and on video
Multiple sclerosis and other inflammatory disorders can present with brainstem or cerebellar syndromes causing facial sensory changes, ataxia or cranial nerve deficits that mimic lateral medullary or pontine strokes; case reports document MS presenting with syndromes indistinguishable from stroke without imaging and laboratory correlation [4]. Because these conditions can affect different neurological systems simultaneously, the combination of facial droop plus gait change is a known presentation outside of vascular infarction [4].
6. Practical takeaways: why video alone can mislead and what features matter
Video evidence can compellingly show facial asymmetry or unsteady gait, but it cannot substitute for bedside testing of limb strength, forehead motion, speech, pupil/eye movement and timing nor for imaging when indicated; triage tools like FAST focus on face, arm and speech because limb involvement and slurred speech more strongly suggest stroke, while isolated facial weakness with forehead involvement points to peripheral palsy [5] [6]. Epidemiologic studies and case reports caution that a small but meaningful number of presumed peripheral palsies are actually central lesions, underscoring the limits of visual diagnosis from footage alone [10] [7].