Foville syndrome is a midbrain syndrome that manifests as gaze paralysis, fascial paralysis, and bilateral hemiplegia. It is usually caused by circulatory disorders or tumors in the cerebral area of the bridge foot. Treatment of paralysis symptoms depends on the primary cause.
What is Foville syndrome?
The brainstem (truncus cerebri or encephali) lies below the diencephalon, excluding the cerebellum. In addition to the midbrain (mesencephalon), the brainstem area encompasses the bridge (pons) and medulla oblongata (medulla oblongata). Like all other brain areas, the midbrain can be affected by damage. Such damage is accompanied by localization-dependent functional impairments, which are included in the group of midbrain syndromes. Foville syndrome is also a midbrain syndrome. It was first described in 1859 by the French neurologist and psychiatrist Achille-Louis-François Foville, who gave the syndrome its name. The name Foville palsy, Foville bridge syndrome, or caudal syndrome of the bridge hood is also considered common in the medical literature. Clinically, associated damage to the bridge foot is characteristically manifested by a symptom triad of gaze paresis, crossed hemiparesis, and facial nerve paresis.
Causes
Foville syndrome is a midbrain syndrome. Accordingly, damage to the midbrain underlies the symptomatic complex. Midbrain lesions in the bridge foot region, in particular, are associated with Foville syndrome. The cause of damage can be of different nature. Besides tumors, circulatory disturbances are considered the most important causes. At the base of the bridge are two longitudinal bulges through which the pyramidal tract runs. In the middle groove sulcus basilaris runs a tributary for the oxygen and blood supply of the brain: the arteria basilaris. If circulatory disturbances are associated with Foville syndrome, they are usually circulatory disturbances in the basilar artery or its flow areas. In principle, other causes of Foville syndrome are also conceivable. Bacterial or autoimmunologic inflammation, for example, are among them.
Symptoms, complaints, and signs
Like all syndromes, Foville syndrome corresponds to a characteristic complex of individual symptoms from a clinical point of view. The clinical criteria of the syndrome include, in terms of leading symptoms, paralysis symptoms such as ipsilateral peripheral fascial palsy, ipsilateral abducens palsy, and contralateral hemiparesis with hemianesthesia. Fascioplegia is manifested by a loss of function of the mimic muscles. This facial paralysis occurs on the same side as the causative brain lesion. Due to abducens palsy, the eye muscle Musculus rectus lateralis, which turns the eyeballs outward, is paralyzed on the same side. Hemiparesis is defined by the medical profession as hemiparesis. Unlike abducens palsy and fascial palsy, hemiparesis in Foville syndrome occurs on the opposite side of the brain damage and is related to an impairment of the pyramidal tracts that run close to the bridge foot. Usually, hemiparesis is a spastic hemiparesis that pathologically increases the tone of the affected side.
Diagnosis
The neurologist makes the initial tentative diagnosis of Foville syndrome on the basis of clinical features. Relevant to the diagnosis in this context is the characteristic triad of paralysis consisting of contralateral hemiparesis as well as ipsilateral gaze paresis and fascial paresis. To confirm the diagnosis, the neurologist orders imaging of the brain. In the slice images, any damage in the area of the bridge foot can be identified. After the diagnosis is confirmed, a fine diagnosis takes place. Tumoral lesions, for example, show a relatively typical image on MRI. Fine diagnosis may also require a cerebrospinal fluid analysis. For this purpose, cerebrospinal fluid is taken from the external cerebrospinal fluid space and analyzed in the laboratory for its composition. The composition of the cerebrospinal fluid changes in a relatively characteristic manner during pathological processes in the brain area. For example, tumor markers as well as inflammatory markers can be identified in the CSF analysis. For patients with Foville syndrome, the prognosis depends on the primary cause.
Complications
Foville syndrome causes a number of complications as it progresses. Typical symptoms include paralysis such as hemiparesis and fascial paralysis. The latter leads to a rapid loss of function of the affected muscles and, as a consequence, sometimes to severe movement disorders. If spastic hemiparesis occurs as a result of the stroke, which is usually the cause, the limbs can only be moved to a limited extent or not at all. As a result of the facial paralysis, there may be a decrease in vision and a number of other complaints. Depending on the cause of Foville syndrome, severe brain damage can occur as the disease progresses. These can manifest as behavioral abnormalities and physical dysfunction, among other symptoms. Long-term therapy for the syndrome also carries risks. For example, the prescribed immunosuppressants and antibiotics can lead to severe side effects. If radiation therapy is required, there is often further physical and mental deterioration, manifested for example by weight loss, fatigue and hair loss. Affected individuals usually suffer severe health impairments throughout life after Foville syndrome, which can only be slowly reduced by physiotherapy and speech therapy.
When should you see a doctor?
A visit to the doctor is necessary as soon as irregularities occur during the exercise of habitual body movements. Paralysis or skin numbness is considered unusual and should be evaluated by a physician. If numbness, severe sensitivity to temperature effects or sensory disturbances occur, a physician should be consulted. If the impairments increase in scope and intensity, a visit to the doctor is necessary as soon as possible. There is a risk of serious illnesses that must be prevented. If the limbs can no longer be moved in the natural way or if the body becomes crooked and it is difficult to compensate for this with the patient’s own resources, a medical examination is necessary. If there are noticeable changes in facial features or an inability to display the usual facial expressions, there is cause for concern. If the eyelids can no longer be moved in the natural way or if there are impairments in the facial muscles, a doctor should be consulted. If the affected person notices disturbances in his motor function, feels unwell or suffers from a reduced level of performance, a medical check-up should be initiated. Dysfunctions or failure symptoms of various systems must be examined and treated. Problems with vision or changes in vision should always be presented to a physician. A physician should be consulted if unusual headaches, a diffuse feeling of illness, or general weakness occur.
Treatment and therapy
For patients with Foville syndrome, therapy depends on the cause. In general, causative therapeutic approaches are preferable to symptomatic treatment options. Whereas symptomatic approaches merely alleviate individual symptoms, causal approaches address the primary cause of the overall complex. Thus, actual healing from symptoms can only be achieved through causal treatment approaches. Symptomatic approaches are unsuitable for healing. If tumors are identified as the primary cause of the failure symptoms, excision is available as a causative treatment approach. The tumors are removed over as large an area as possible in an invasive operation. However, consideration must be given to the sensitive nerve tissue structures of the brain in order not to cause permanent damage. If the tumor can only be operated on at high risk, a drug-based approach to damage limitation is an option. Basically, the treatment decision in this case depends mainly on the degree of malignancy. If instead of a tumor, circulatory disturbances are responsible for Foville syndrome, these disturbances are usually related to a primary cardiovascular disease. Risk factors for cardiovascular disease should be reduced. Smoking should be stopped, for example. Excess weight should be reduced and the diet can be changed if necessary. Long-term treatment in this case is usually conservative medication. In the case of causative inflammation, the first step is to heal the acute inflammation.Depending on the type of inflammation, cortisone or antibiotic treatments may be considered. To regain full range of motion, physiotherapy measures can help in all cases of Foville syndrome.
Outlook and prognosis
Depending on how quickly the causative condition is treated, the outcome of Foville syndrome can vary greatly. With early treatment, any secondary musculoskeletal damage can often be avoided. In any case, however, the patient must undergo physiotherapy, since Foville syndrome is always associated with certain paralysis symptoms. In addition, brain damage can occur in the course of the disease, which represents a considerable burden for the affected person. Physical dysfunction as well as behavioral problems are also conceivable and usually cause further complications that worsen the prognosis. In spite of all measures, the patients usually suffer permanently from physical and mental impairments. Measures such as speech therapy, physiotherapy and drug treatment can only slowly alleviate the symptoms. In addition, due to the limited physical condition resulting from the movement disorders, there is an increased risk of another stroke or the development of further tumors. If Foville syndrome is not treated, it can be fatal. Then paralysis, hemiparesis, visual disturbances and many other complaints develop, which considerably reduce the quality of life and also lower the life expectancy. An untreated tumor eventually forms metastases and thus leads to the death of the patient. An untreated stroke can lead directly to death.
Prevention
Circulatory conditions in the form of Foville syndrome can be prevented in moderation via the general preventive measures in the context of cardiovascular disease. Few preventive measures are available for causative inflammation and tumors in the brain.
Follow-up
Despite a variety of aftercare measures, affected individuals usually remain permanently physically and mentally impaired. Therapies such as speech therapy, physical therapy, and drug treatment contribute only to gradual, slow relief of symptoms. However, potential musculoskeletal impairments can often be avoided if Foville syndrome is treated early. However, physiotherapeutic treatment is generally indicated in all cases, since paralysis symptoms always occur as a result of Foville syndrome. Likewise, continued medical treatment remains essential. However, affected persons and their relatives can also actively participate themselves. A healthy lifestyle, such as abstaining from alcohol and tobacco, changing the diet and reducing excess weight, as well as physiotherapy and rehabilitation sports, generally have a positive effect on the course of the disease. Frequently occurring infections are concomitant diseases of Foville syndrome. Here, too, patients and their relatives can play an active role in prevention. Particularly in the home environment, attention should be paid to hygiene, such as frequent hand washing by all persons and the daily changing of patients’ underwear and bed linen. In order to cope with their daily lives, patients of all ages need a great deal of support. Here it is very beneficial if family and friends can stand by. A positive and supportive social environment almost always promotes the healing process and can help to alleviate psychological upsets and depression. It is also often useful for sufferers, relatives and friends to seek support in a self-help group.
What you can do yourself
Foville syndrome usually cannot be cured by self-help measures. In any case, medical examination and treatment are necessary to make everyday life easier for the affected person. However, a healthy lifestyle and the avoidance of excess weight can have a positive effect on the course of the disease. Since the affected persons often also depend on physiotherapy measures, the respective exercises can also be performed by the patient at home. Due to the Foville syndrome, inflammations or infections often occur. For this reason, patients must also pay attention to excellent hygiene in order to prevent complications if necessary. In most cases, the patient’s daily life is made much easier by the assistance of other people.The help of friends and family in particular has a very positive effect on everyday life and can prevent or alleviate possible psychological upsets or depression. In the case of children, a loving approach is necessary, as they can suffer particularly severely from the paralysis. Furthermore, discussions with a psychologist or with a therapist can also be helpful.
