Facial nerve palsy is shared in ENT, ophthalmology, and neurological emergencies. The facial nerve is one of the essential cranial nerves which highly considerable for both communication and emotion. So, functional impairment facial nerve can cause a remarkable reduction in quality of life. Either paralysis or paresis of the facial nerve can occur. If there is a total loss of facial nerve it will be named facial nerve paralysis but if there is a partial loss of nerve function paresis it will be named incomplete recovery. Infection (viral infection, Lyme disease, otitis media), trauma (penetrating temporal bone fracture, basilar skull fracture, and birth related-trauma), neoplastic (facial nerve neuroma, meningioma, schwannoma, and parotid gland tumor), iatrogenic (brain, middle ear, mastoid, parotid or facial surgery), neurological (myasthenia gravis, multiple sclerosis, brain stem infarct), metabolic (diabetes mellitus and hypertension), congenital (Moebius syndrome and Goldenhar syndrome), and idiopathic (Bell’s palsy) are implicated causes [1]. Monoplegia is the paralysis of a single limb, usually an arm. Weakness, spasticity, numbness, and pain in the affected limb are commonly associated symptoms. Monoplegia is a paralytic type of hemiplegia. Monoplegia may be a precursor for hemiplegia, paraplegia, and quadriplegia. [2]. Stroke, direct physical trauma to the affected limb, central nervous mass lesion (such as tumor, hematoma, and abscess), complicated migraine, epilepsy, head or spinal trauma, brachial plexus paralysis, neuropathy, plexopathy, traumatic peroneal neuropathy, vaccine-induced paralytic poliomyelitis, hemiparetic seizures, monomeric spinal muscular atrophy, hereditary neuropathy with liability to pressure palsy, hereditary brachial neuritis, and cerebral palsy are implicated causes. It is a physical diagnosis. Needle Electromyography is mostly used to study all limbs [3]. However, magnetic resonance imaging (MRI) is the choice modality for the diagnosis of all forms of hemiplegia [4]. Currently, there is no cure for all types of paralysis. Rehabilitation is the recommended therapy [5]. The vertebral arteries are major arteries of the neck. Typically, the vertebral arteries originate from the subclavian arteries. Each vessel courses superiorly along each side of the neck, merging within the skull to form the single, midline basilar artery. As the supplying component of the vertebrobasilar vascular system, the vertebral arteries supply blood to the upper spinal cord, brainstem, cerebellum, and posterior part of the brain. Inside the skull, the two vertebral arteries join to form the basilar artery at the base of the pons. The basilar artery is the main blood supply to the brainstem and connects to the Circle of Willis to potentially supply the rest of the brain if there is a compromise to one of the carotids. At each cervical level, the vertebral artery sends branches to the surrounding musculature via the anterior spinal arteries. The vertebral arteries supply blood to the upper spinal cord, brainstem, cerebellum, and posterior part of brain. The basilar artery is the main blood supply to the brainstem and connects to the Circle of Willis to potentially supply the rest of the brain if there is compromise to one of the carotids [6]. The left and right common carotid arteries are arteries that supply the head and neck with oxygenated blood; they divide in the neck to form the external and internal carotid arteries. At approximately the level of the fourth cervical vertebra, the common carotid artery splits ("bifurcates" in literature) into an internal carotid artery (ICA) and an external carotid artery (ECA). While both branches travel upward, the internal carotid takes a deeper (more internal) path, eventually traveling up into the skull to supply the brain. The external carotid artery travels more closely to the surface and sends off numerous branches that supply the neck and face [7,8]. The internal carotid artery is a terminal branch of the common carotid artery, larger than the other terminal branch (the external carotid artery. It is an important cause of cerebrovascular disease. The internal carotid artery is a major branch of the common carotid artery, supplying several parts of the head with blood, the most important one being the brain. Along its course, the internal carotid artery gives rise to many branches, ultimately dividing into its two terminal ones called the anterior and middle cerebral arteries [9,10].

In this manuscript, I report a case of a middle-aged female patient who presented with left arm monoplegia and left facial palsy. It showed a dramatic relief of monoplegia and facial palsy accidentally after applying the sphygmomanometer pressure.

A 40-year-old married housewife Egyptian female patient presented to the physician outpatient clinic (POC) with left arm monoplegia, left facial palsy, ipsilateral tongue deviation, and difficult speech for about 48 hours. Local myalgia was an associated symptom. The patient gave a recent history of psycho-familial stress. Informed consent was taken. The patient denied similar conditions, head trauma, medications, abuse substances, and medical diseases. Upon general physical examination; generally, the patient was sad, and calm, with a regular pulse rate VR of 76, blood pressure (BP) of 110/70 mmHg, respiratory rate of 16 bpm, a temperature of 36.5 °C, and pulse oximeter of oxygen (O₂) saturation of 98%. He seemed average in weight and length. No more relevant clinical data were noted during the clinical examination. The patient was refused to be referred to the hospital. Serial images of the patient during blood pressure measurement were taken (Figures 1A-1E). The initial complete blood count (CBC); Hb was 10.4 g/dl, RBCs; 4.3*103/mm3, WBCs; 9. *103/mm3 (Neutrophils; 56%, Lymphocytes: 40%, Monocytes; 2%, Eosinophils; 2% and Basophils 0%), and Platelets; 154*103/mm3. RBS was; 95 mg/dl. SGPT was (27U/L) and SGOT was (29U/L). Serum albumen was (3.1g/dl). Serum creatinine was (1.0mg/dl) and blood urea was (250 mg/dl). Plasma sodium was (137.6mmol/L). Serum potassium was (3.54mmol/L). Ionized calcium was (1.20 mmol/L) and total calcium was (9.8mg/dl). The troponin test was negative. Non-contrast axial multi-slice brain CT was done 3 days of the patient presentation showed no detected abnormalities (Figure 2). Left facial palsy and monoplegia with an innovative retrograde flushing Yasser's phenomenon post-Yasser's pressure maneuver was the most probable diagnosis. After dramatic improvement of both left facial palsy and monoplegia, the patient was advised to follow up with a neurologist.

Figure 1: Serial images for the patient: A. The first image after the pressure test with normalization of left monoplegia showing inability to wrinkle the left eyebrow (light blue arrow), drooping of the eyelid (orange arrow), normal left eye conjugate movements (white arrows), equal mouth corners (rose arrows). B. The second image during the pressure test with still normalization of left monoplegia showing the ability to wrinkle the left eyebrow (lime arrow), normalization of above drooping of the eyelid (orange arrow), unequal upper lip (grey and yellow arrows), unequal mouth corners (light turquoise arrow). C. The third image after the release pressure test shows still normalization of left monoplegia with inability to wrinkle the left eyebrow (light blue arrow), drooping of the eyelid (orange arrow), normal right upper eye conjugate movements (white arrows), equal mouth corners (rose arrows). ). D. The fourth image during the pressure test shows still normalization of left monoplegia, ability to wrinkle the left eyebrow (lime arrow), normalization of above drooping of the eyelid (orange arrow), equal upper lip (green arrows), equal mouth corners (light turquoise arrow).  E. The fifth image during pressure test showing still normalization of left monoplegia and eye movements left eye conjugate movements (white arrows).

Figure 2: Non-contrast axial multi-slice brain CT was done after 3 days of the patient presentation and showed no detected abnormalities.

Overview

A middle-aged married Housewife Egyptian female patient was presented to the physician outpatient clinic (POC) with clinic with left arm monoplegia, left facial palsy, tongue deviation, and difficulty speech. 

The primary objective for my case study was the presence of a middle-aged married Housewife Egyptian female patient with left arm monoplegia and ipsilateral facial palsy in the POC.

The secondary objective for my case study was the question; how did you manage the case?

• There was a history of acute left arm weakness with spasticity and loss of movement. This indicates the presence of left-arm monoplegia.
• There are inability to wrinkle the left eyebrow, drooping of the eyelid, and unequal mouth corners. This is strengthens the presence of left facial paralysis.
• There is a dramatic reliving of both monoplegia and facial palsy that was accidentally noted after applying measurement of the blood pressure using a sphygmomanometer.
• Monoplegia was initially recovered. Facial palsy is also relived in later stages on measurement the blood pressure using sphygmomanometer.

The Yasser's Pressure Maneuver and Retrograde Yasser's Flushing Phenomenon Description

Definitions: "Yasser's pressure maneuver" is a newly described maneuver causing transient arterial compressive effect with a sphygmomanometer. It is used to relieve both monoplegia and facial palsy. It has some similarities to "Yasser’s sphygmomanometer procedure" [11]. "Retrograde Yasser's flushing phenomenon" is also a newly described phenomenon causing retrograde arterial organ hyperemia due to transient compressive effect and is used to relieve facial palsy. It is a reversal reflective phenomenon. 

Preparation:

• Take a rapid history from patients, relatives, friends, or neighbors. Drug history, acute emotional stress, abuse of substances, psychiatric diseases, swallowing foreign bodies, organic diseases such as IHD, HTN, and DM, etc. History of poisons is mandatory.
• Do a quick and complete physical examination. Vital signs, measuring O2 saturation using pulse oximetry, and random blood sugar are essential before the maneuver.
• Do not allow any visitors and place the patient in a quiet observation area.

Indications:

•  
• Facial palsy.

Principal and Interpretations

• For "Yasser's pressure maneuver": It is an unknown mechanism (Figure 3). But in a similarity to "Yasser’s sphygmomanometer procedure" [11]. The pressure of the sphygmomanometer cuff on inflation may produce an obstructive power at the distal to the compressive site and another transmission power at the proximal to the compressive site. Distal power may be due to compression of local blood arteries resulting in decreasing blood flow to the paralyzed limb inducing some increasing pain over the present pain stimulating the local nerves to produce trial to the movement of this limb. Local hypocalcemia for the paralyzed limb due to this local obstruction may also be a suggestive theory for this pain. On contradictory, the proximal power to the compressive site may be due to transient increasing the diameter of the proximal local blood arteries to the compressive cuff while increasing the blood flow to the proximal area in the paralyzed limb also may be stimulant for the local nerves to produce trial to the movement of this limb. The author thinks that it is different than "Yasser’s sphygmomanometer procedure" that in the distal power will be relevant to monoplegia (yellow arrow) and the proximal power will be for facial palsy (red arrow) [11] (Figure 3).
• For "Retrograde Yasser's flushing phenomenon": "Retrograde Yasser's flushing phenomenon" is also a newly described secondary phenomenon causing retrograde arterial organ hyperemia due to transient compressive effect and used to relieve facial palsy. It is a reversal reflective phenomenon. Based on the arterial supply, there are two possibilities for understanding this phenomenon for the recurrent case study. The first weak but direct and minor possibility is the sphygmomanometer compression of the left brachial artery and sequentially retrograde effects on the axillary artery, then the left subclavian artery, then, the vertebral artery (It supplies 20% of blood to the brain) ended as posterior cerebral artery. The first strong but indirect and major possibility is the sphygmomanometer compression of the left brachial artery and sequentially retrograde effects on the left common carotid artery, then the left internal carotid artery (It supplies 80% of blood to the brain) ended as anterior and middle cerebral arteries [6-10].

Target: The aim of this maneuver is the full regaining of the movements in the paralyzed extremity and recovery of facial palsy. 

The Maneuver and Response:

• Measure the blood pressure using a stethoscope and sphygmomanometer as a standard measurement. Again wrap the cuff of the sphygmomanometer around the ipsilateral paralyzed extremity, just above the brachial area as in the current study.
• The brachial artery is the target artery in the upper limb.
• Inflate the cuff with air using a manometer monitoring of sphygmomanometer with no need to use a stethoscope.
• The guide is just the patient sense with pain or pressure sense with no need for mercurial level.
• Ask the patient to move his paralyzed extremity.
• Then the air is slowly let out of the cuff.
• The trial number or times frequency was a single (Figure 3).
• As soon as the patient moves the paralyzed limb, stop the maneuver.
• Try the maneuver again for on the side for the facial palsy.
• Do the same above steps.
• Examine the facial, mouth deviation, eyelid, and eyebrow movements
• The trial number or times frequency may be more than one trial.
• As soon as the recovery of the facial palsy, stop the maneuver.

Advantages

• The maneuver is easy, available, quick, non-costive, and extremely safe.
• The early recognition and treatment of monoplegia with regaining of limb movements, and recovery of facial palsy can result in reduced later complications, hospital costs, family efforts, and physician anxiety.
• Dramatic relief effects.
• No need to perform an expensive workup routinely.

Disadvantages:

There were no reported complications.

Contraindication: The author thinks that the patients on b-blockers, peripheral arterial disease, and shock will not be appropriate for this maneuver.

Post-Procedure Measures:

• When the patient becomes more responsive, re-examine him, obtain a more complete history, and offer him follow-up care.
• Do not ignore or release the patient who has not fully recovered. If the patient does not show the above recovery, urgent neuro-psychiatrist consultation will be recommended.

Figure 3: Showing the author caricaturing a graphical presentation of Yasser's pressure maneuver with retrograde Yasser's flushing phenomenon in left facial palsy with monopelgia.

Differential Diagnosis:

• Yasser’s sphygmomanometer procedure is the common entity for the differential diagnosis for the current case study. But there are several differences between the above descriptions.
• I can’t compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison.

Limitations of the Study:

Needle Electromyography and brain magnetic resonance imaging were the main study limitations.

• "Yasser's pressure maneuver" is a newly described maneuver causing transient arterial compressive effects with a sphygmomanometer. It is used to relieve both monoplegia and facial palsy. The maneuver is easy, available, quick, and costless has dramatic relief effects, and is extremely safe.
• "Retrograde Yasser's flushing phenomenon" is also a newly described secondary phenomenon causing retrograde arterial organ hyperemia due to transient compressive effect. It is used to relieve facial palsy. It is a reversal reflective phenomenon.
• Yasser’s sphygmomanometer procedure for psychogenic hemiplegia is indirectly implicated in interpretation.
• Future wide-research studies for "Yasser's pressure maneuver" for sensitivity and specificity will be recommended.

Conflicts of Interest

There are no conflicts of interest.

Acknowledgment

I want to thank my wife for saving time and improving the conditions for supporting me.

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