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Central Facial Palsy

Original Editor - User:Wendy Walker Top Contributors - Wendy Walker, Alexandra Stead and Vidya Acharya

Introduction

Facial palsy (also known as facial paralysis or paresis) is divided into two categories: central (upper motor neuron) and peripheral (lower motor neuron). Peripheral facial palsy (PFP) has its own dedicated Physiopedia page. Please note that this current page is confined to central (upper motor neuron) facial palsy. An important distinction between the two being that CFP is a brain issue, whereas PFP is a nerve problem.

Central facial palsy (CFP) results from lesions in the pons, the motor cortex and the corticobulbar pathway, whereas peripheral facial palsy results from lesions in the facial nerve (cranial nerve VII) itself.[1] The most common cause of CFP is stroke.[2][3]

Post-stroke facial palsy impacts the person's communication, drinking, eating and overall quality of life. Despite its prevalence, standardised management guidelines are lacking, an evidence both for assessment and treatment protocols is very limited.[4]

"Forehead Sparing"

It is commonly stated that CFP results in paralysis or weakness of only the lower portion of the face (often labelled "forehead sparing") due to bilateral cortical connections to the ventral division of the facial nucleus, which supplies the upper branches of the facial nerve.[5][6] However, recent studies have demonstrated that this is not always the case, with one 2025 study reporting upper face weakness in 76% of patients with facial palsy following ischaemic stroke, with the majority showing milder palsy in the upper portions of the face (eyebrow raise and eye closure) than in the lower facial areas of mouth and chin.[7][1] The authors of the study conclude: "Contrary to traditional teaching, upper facial weakness is common in CFP due to acute ischemic stroke. The severity of stroke and the presence of lower facial weakness are key predictors of upper facial involvement. These findings underscore the need for clinicians to reconsider the diagnostic paradigm, recognizing that upper facial weakness can occur in CFP".[1]

Clinically Relevant Anatomy

A drawing of the brain with the fibres of the corticobulbar tract shown.
Image of the corticobulbar tract in the brain.

Fibres of the corticobulbar tract originate in the motor cortex (precentral gyrus and anterior part of the paracentral lobule).[8] [9] It consists of the upper motor neurons for the following cranial nerves:

The corticobulbar tract page gives more detailed anatomy.

Causes of Central Facial Palsy

The causes of CFP can be separated into the following groups:

Vascular

Neoplastic

  • Primary intracranial tumour
  • Brain metastases
  • Meningioma

Inflammatory

Other

Prevalence following Stroke

A large 2024 study examined facial palsy in patients admitted with acute stroke; it found that 43% had facial palsy on admittance, and of that cohort 60% still had facial symptoms 7 days later.[2] Facial palsy was found to be more prevalent and more severe in patients with more severe motor impairments.

Clinical Presentation

Appearance and Range of Movement

Facial asymmetry at rest is often present to some degree, with the affected corner of the mouth sitting lower than the other side, and flattening of the nasolabial fold being common signs.[1]

Range of movement on the affected side is diminished or occasionally absent, resulting in an asymmetrical smile. The lip seal on the affected side typically lacks range of movement and strength.[10]

Functional Effects

Drinking functions is often affected, as a weak lip seal means that the person may dribble fluid out of the affected side of the mouth. Also eating can be difficult due to food falling out of the affected side of the mouth, due to lack of lip seal, and/or food collecting in the cheek.[11]

Speech may be affected, with some difficulty in pronouncing the labial consonants - B, P, M, F, V, W - due to poor lip seal. Frequently in stroke, the tongue is also affected and shows reduced range of movement and control, so in these cases most speech sounds are affected.[12]

Psychological Issues

The face is an important means of non-verbal communication, providing the ability to communicate emotions e.g., a smile to show pleasure, so in all cases of facial palsy, both central and peripheral causes, the lack of range of movement in one side of the face has a severe impact on this. There are studies which demonstrate that facial palsy has a significant psychological impact, although these are primarily on people with peripheral facial palsy.[13] There is small study demonstrating psychological impact of central facial palsy following stroke.[14]

Differential Diagnosis - Central versus Peripheral Facial Palsy

It is important at onset of any facial palsy to establish the cause, as initial management varies depending on whether it is central facial palsy or is peripheral facial palsy, such as Bell's Palsy.

Diagnostic Procedures

At initial onset of the facial palsy, it is essential that a thorough neurological assessment is implemented; this is time-critical, as the causes of central facial palsy are frequently life-threatening, and result in more widespread disability than the facial palsy. In particular, acute stroke - the most common cause of CFP - requires urgent investigation and management as it is one of the leading causes of death and disability world-wide.

Ischaemic and haemorrhagic stroke cannot be reliably differentiated by clinical examination alone, so imaging is essential, with CT, MRI, MRA and carotid duplex scanning frequently being employed.[15]

Outcome Measures

Outcome measures which have been validated on PFP are suitable for evaluating CFP, although they have not been validated in this particular group of patients. There is a growing consensus among physiotherapists and speech and language therapists that the most useful outcome measure is the Sunnybrook Facial Grading System, as it provides a comprehensive evaluation of movement of the face (comparing to the unaffected side) as well as scoring resting symmetry.[7][1] In addition there is one small study, test-retest design, looking at the use of the Facial Grading System with stroke patients in a sub-acute unit; it concludes "The SFGS resulted reliable in its overall score to assess the facial palsy also in patients affected by stroke".[16] Surgeons and Neurologists more often use the House-Brackmann Scale, as this is quick to administer; however, it is a much cruder tool for scoring facial asymmetry so is not as useful to therapists wishing to monitor improvement.

Management/Interventions

Medical and Surgical Management

Ischaemic stroke is caused by thrombotic or embolic occlusion of a cerebral artery; the person may be a candidate for thrombolysis intervention.[17]

If the cause is a haemorrhagic stroke, surgical intervention may be indicated.[18][19]

Physiotherapy

A range of standard physiotherapy techniques can be used:

  • Neuromuscular retraining (NMR); for more information on this concept please see the Neuromuscular Reeducation in Facial Palsy page
  • Teach self-massage to any areas of hypertonicity
  • Taping
  • Facilitation strategies such as tapping, vibration
  • Mirror feedback
  • sEMG guided biofeedback
  • Mime therapy

Evidence for Therapy Interventions

There are very few studies investigating physiotherapy management of CFP, in contrast to PFP where there are many studies.[7][10] In addition, there are no validated, evidence-based guidelines for CFP. Current clinical practice tends to utilise PFP protocols, although it is important to remember that the two conditions have different neurophysiology and also different recovery patterns and sequelae.[11]

Speech and Language Therapy

SLTs occupy a distinctive position within a stroke multidisciplinary team, providing rehabilitation for problems with communication, cognition and swallowing - areas which frequently can be affected alongside Central Facial Palsy.[20]

In addition to direct management of the palsy, SLT intervention encompasses dysarthria and dysphagia rehabilitation, with evidence supporting the use of targeted oral and pharyngeal motor exercises to improve speech intelligibility, swallowing function and sleep-related breathing.[21]

The assessment and treatment of post-stroke facial palsy in many countries including the UK, USA, Canada, Australia and Japan is led predominantly by SLTs and physiotherapists, although standardised guidelines for this specific role are lacking.[11] In most high income countries, both physiotherapists and SLTs will be part of a multidisciplinary stroke team, and joint working practices are often established, with shared goal setting and outcome measures.[20] However, in low and middle income countries there is often a lack of SLT personnel.[20]

Summary

Central facial palsy is characterised by unilateral weakness or paralysis of the facial muscles, contralateral to the lesion, with the most common cause being stroke.[3] The resulting loss of strength and range of movement impacts eating, drinking and speaking functions, as well as causing visible asymmetry of the face at rest. In cases where the facial palsy persists long term, rehabilitation has an important part to play in improving function and appearance. However, there are very few published investigating studies on rehabilitation in CFP specifically, so current clinical practice tends to utilise existing PFP protocols.[11]

Resources

  • Facial Palsy UK has a website giving comprehensive information on facial palsy from all causes, including central causes such as stroke. There is a page specifically describing facial palsy caused by stroke. This page has a video of a neurologist discussing the difference between onset and symptoms of stroke compared to Bell's Palsy.
  • The Brain Charity website has a page devoted to facial palsy.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Wongwandee M, Hongdusit K. Analysis of Upper Facial Weakness in Central Facial Palsy Following Acute Ischemic Stroke. Neurology International. 2025; 17(1):12. https://doi.org/10.3390/neurolint17010012
  2. ↑ 2.0 2.1 2.2 2.3 Lu Z, Eroglu HS, Naess H, et al. Post-stroke facial palsy: Prevalence, recovery patterns within the first 7 days, risk factors, and effect of hyperacute treatments. Clin Rehabil. 2026;40(3):397-408. doi:10.1177/02692155251391672
  3. ↑ 3.0 3.1 Volk GF, Steinerstauch A, Lorenz A, et al. Facial motor and non-motor disabilities in patients with central facial paresis: a prospective cohort study. J Neurol. 2019;266(1):46-56.
  4. ↑ 4.0 4.1 Schimmel M, Ono T, Lam OL, Müller F. Oro-facial impairment in stroke patients. J Oral Rehabil. 2017;44(4):313-326. doi:10.1111/joor.12486
  5. ↑ Yildiz N, Ertekin C, Ozdemirkiran T, et al. (2005). "Corticonuclear innervation to facial muscles in normal controls and in patients with central facial paresis". J. Neurol. 252 (4): 429–35.
  6. ↑ AC Ottaiano, GD Gomez, TAL Freddi. The Facial Nerve: Anatomy and Pathology. Seminars in Ultrasound, CT and MRI, Volume 44, Issue 2, April 2023, pages 71-80
  7. ↑ 7.0 7.1 7.2 Fabricius J, Kothari SF, Kothari M. Assessment and rehabilitation interventions for central facial palsy in patients with acquired brain injury: a systematic review. Brain Inj. 2021;35(5):511-519. doi:10.1080/02699052.2021.1890218
  8. ↑ Leo J. Corticobulbar tract and cranial nerve nuclei. In: Medical neuroanatomy for the boards and the clinic. Cham: Springer; 2023. p.23–30.
  9. ↑ Corticobulbar tract. In: Encyclopedia of the neurological sciences. Cham: Springer; 2026. DOI: 10.1007/978-3-031-76696-1_63
  10. ↑ 10.0 10.1 Vaughan A, Gardner D, Miles A, Copley A, Wenke R, Coulson S. A Systematic Review of Physical Rehabilitation of Facial Palsy. Front Neurol. 2020;11:222. Published 2020 Mar 31. doi:10.3389/fneur.2020.00222
  11. ↑ 11.0 11.1 11.2 11.3 Eroglu HS, Bowen A, Checketts M, Mitchell C. Managing Facial Palsy After Stroke: Results From an Online Survey of Health Professionals. Int J Lang Commun Disord. 2025;60(5):e70127. doi:10.1111/1460-6984.70127
  12. ↑ Miya EK, et al. Dysarthria-facial paresis and rostral pontine ischemic stroke. Case Rep Neurol. 2022;14(1):104–110.
  13. ↑ Shamil E, Noriega M, Moin S, et al. Psychological Aspects of Facial Palsy. Facial Plast Surg. 2024;40(4):433-440. doi:10.1055/s-0044-1782678
  14. ↑ Konecny P, Elfmark M, Urbanek K. Facial paresis after stroke and its impact on patients' facial movement and mental status. J Rehabil Med. 2011;43(1):73-75. doi:10.2340/16501977-0645
  15. ↑ Steiner T, Purrucker JC, Aguiar de Sousa D, et al. European Stroke Organisation (ESO) and European Association of Neurosurgical Societies (EANS) guideline on stroke due to spontaneous intracerebral haemorrhage. Eur Stroke J. 2025;10(4):1007-1086. doi:10.1177/23969873251340815
  16. ↑ Tramontano M, Morone G, LA Greca FM, et al. Sunnybrook Facial Grading System reliability in subacute stroke patients. Eur J Phys Rehabil Med. 2021;57(5):685-690. doi:10.23736/S1973-9087.21.06629-6
  17. ↑ Zhang B, Li S, Meng X, Xiong Y, Jing J, Xie X, et al. 30 years of thrombolysis for ischaemic stroke: expanded agents, widened windows and accelerated delivery. Stroke and Vascular Neurology. 2026;:svn-2025-004987. https://doi.org/10.1136/svn-2025-004987
  18. ↑ Prabhakaran S, Gonzalez NR, Zachrison KS, et al. 2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association. Stroke. Published online January 26, 2026. doi:10.1161/STR.0000000000000513
  19. ↑ Phung JYH, Yogendrakumar V, Dowlatshahi D. Acute Spontaneous Intracerebral Hemorrhage Management Update: Five New Things You Should Know. Ann Indian Acad Neurol. 2025;28(2):155-158. doi:10.4103/aian.aian_174_25
  20. ↑ 20.0 20.1 20.2 Charalambous M, Pierce JE, Pastou G, Kola E, Savitz SI. The Role of Speech and Language Therapists (SLTs) in International Stroke Teams: A Systematic Review. Int J Lang Commun Disord. 2025;60(4):e70062. doi:10.1111/1460-6984.70062
  21. ↑ Marzouqah R, Huynh A, Chen JL, Boulos MI, Yunusova Y. The role of oral and pharyngeal motor exercises in post-stroke recovery: A scoping review. Clin Rehabil. 2023;37(5):620-635. doi:10.1177/02692155221141395
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