Auris Nasus Larynx 48 (2021) 194–200

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Auris Nasus Larynx

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Increased risk of ischemic stroke in patients with Bell’s palsy:

A longitudinal follow-up study using a national sample cohort
Sang-Yeon Lee a, Jae-Sung Lim b, Dong Jun Oh c, Bumjung Park d, Il-Seok Park e,
Hyo Geun Choi d,∗
a Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of
Medicine, Seoul, South Korea
b Department of Neurology, Hallym University College of Medicine, Anyang, South Korea
c Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
d Department of Laboratory Medicine, Hallym University College of Medicine, Anyang, South Korea
e Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University College of Medicine, Dongtan, South Korea

A R T I C L E I N F O A B S T R A C T

Article history: Objective: To investigate the association between Bell’s palsy and stroke according to the
Received 25 May 2020 different types of stroke, using a sample cohort based on the national Korean population.
Accepted 21 July 2020
Available online 3 August 2020 Methods: Individuals aged ≥ 20 years were collected from the Korean National Health Insurance
Service National Sample Cohort between 2002 and 2013. We extracted the data for Bell’s palsy
Keywords: patients (n = 3658) and 1:4 matched controls (n = 14,632) and analyzed the occurrence of
Stroke hemorrhagic or ischemic stroke in both groups. Matching was performed on the basis of age,
Bell’s palsy gender, income, and region of residence. For Bell’s palsy, we included only participants who
Cohort study received the diagnosis (ICD-10 code, G510) 2 or more times via ambulatory visits for the same
episode with steroid treatment. Patient admission histories were used to identify occurrences of
hemorrhagic stroke (I60, I61 and I62) and ischemic stroke (I63). Adjusted hazard ratios were
calculated using stratified Cox proportional hazard models for the Charlson comorbidity index
and 95% confidence intervals (CIs). For the subgroup analyses, we divided the participants by
age, sex, and each time period after the onset of Bell’s palsy (≤1 year, 1 to 2 years, 2 to 3years,
> 3years).
Results: The risk of ischemic stroke was significantly increased in Bell’s palsy patients compared
to that in the controls (adjusted HR = 1.74, 95% CI = 1.38–2.19, P < 0.001). In the subgroup
analyses, a significant association between two clinical disorders was observed in patients aged
≥ 50 years old, regardless of gender. The risk of ischemic stroke was significantly increased,
especially within 2 years after Bell’s palsy. In contrast, the risk of hemorrhagic stroke was not
significantly increased.
Conclusion: There is an association of Bell’s palsy with ischemic stroke but not with hemorrhagic
stroke.
© 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights
reserved.

∗ Correspondence to: Department of Otorhinolaryngology-Head & Neck Surgery, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170beon-gil,

Dongan-gu, Anyang-si, Gyeonggi-do 14068, South Korea.

E-mail address: pupen@naver.com (H.G. Choi).

https://doi.org/10.1016/j.anl.2020.07.020
0385-8146/© 2020 Oto-Rhino-Laryngological Society of Japan Inc. Published by Elsevier B.V. All rights reserved.

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 S.-Y. Lee, J.-S. Lim and D.J. Oh et al. / Auris Nasus Larynx 48 (2021) 194–200
1. Introduction
Bell’s palsy, an acute idiopathic facial neuropathy, is a con-
sequence of inflammation of the facial nerve in the fallopian
canal due to focal ischemia and demyelination [1]. The global
annual incidence of Bell’s palsy has been reported to range
from 13.1 to 53.3 per 100,000 population [2-6]. The annual
incidence of Bell’s palsy in Korea appeared to be 40.3 per
100,000 in a large population-based case-control study [7].
This condition affects patients of all ages, but its incidence
increases gradually with advancing age [2]. The risk factors
of Bell’s palsy, such as hypertension, diabetes mellitus, and
dyslipidemia, have been associated with a systemic inflam-
matory profile [8].
Stroke is a cerebrovascular condition resulting from a lim-
itation of blood flow to the brain due to a blockage or rupture
in the cerebrovascular system. Stroke can cause various neu-
rological dysfunctions and systemic disability [9]. More than
80% of stroke cases are known to be ischemic, the rest be-
ing hemorrhagic [10]. Stroke is responsible for approximately
700,000 deaths annually in the Western world [11]. In a large
population-based case-control study in Korea, the estimated
incidence was reported as 216 per 100,000 person-years [12].
Stroke and Bell’s palsy share common predisposing factors,
including hypertension, diabetes mellitus, and dyslipidemia
[13].
Recently, two population-based case-control studies re-
ported significant associations between Bell’s palsy and stroke
[14,15]. However, to date, the association between Bell’s
palsy and stroke has not been specified by stroke type. Be-
cause the natures of hemorrhagic stroke and ischemic stroke
patients are different, including risk factors and genetic pre-
dispositions [10,16], they should be analyzed separately. Thus,
the aim of this study was to examine the association between
Bell’s palsy and stroke according to the different types of
stroke, using a sample cohort based on the national Korean
population. We extracted data for patients with Bell’s palsy
and a 1:4-matched control group and analyzed the occurrence
of ischemic stroke and hemorrhagic stroke in this cohort.
2. Materials and methods
2.1. Study population and data collection
The ethics committee of Hallym University (2017-I102)
approved the use of these data. Written informed consent
was exempted by the Institutional Review Board. This na-
tional cohort study relied on data from the Korean Health
Insurance Review and Assessment Service-National Sample
Cohort (HIRA-NSC). The detailed description of this data
was described in our previous studies [17-19].
2.2. Participant selection
Among 1,125,691 patients with 114,369,638 medical claim
codes, we included individuals who were diagnosed with
Bell’s palsy (ICD-10: G510). Among them, For Bell’s palsy,
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195
Fig. 1. A schematic illustration of the participant selection process used in
the present study. Out of a total of 1,125,691 participants, 3658 Bell’s palsy
patients were matched with 14,632 control participants based on age, group,
sex, income group, and region of residence.
we included only participants who received the diagnosis
(ICD-10 code, G510) 2 or more times via ambulatory vis-
its for the same episode with steroid treatment. From 2002
through 2013 year, 3996 of Bell’s palsy participants were se-
lected.
Histories of admission for hemorrhagic stroke (I60: sub-
arachnoid hemorrhage, I61: intracerebral hemorrhage, and
I62: other non-traumatic intracranial hemorrhage) and is-
chemic stroke (I63: cerebral infarction) were identified using
ICD-10 codes. We selected participants who were treated for
stroke ≥ 1 time. These methods were used in other studies
that evaluated the incidence of stroke in Korea [12,20].
As previously described before [21,22], Bell’s palsy sub-
jects were matched 1:4 with subjects in the cohort who were
never diagnosed with Bell’s palsy from 2002 to 2013 (the con-
trol group). The control group was selected from the mother
population (n = 1,121,695). Matching was performed based
on age, group, sex, income group, and region of residence.
To prevent selection bias when choosing the matched partic-
ipants, the potential control group subjects were sorted using
a random number order and were then selected from top to
bottom. We set the index date as the date of the diagnosis of
Bell’s palsy. It was assumed that each Bell’s palsy patient and
the matching control participants were receiving any needed
medical treatment during concurrent time periods (based on
the relevant index date). Therefore, the subjects in the con-
trol group who died before the index date were excluded.
In both the Bell’s palsy and control groups, the participants
with a history of hemorrhagic or ischemic stroke prior to the
index date were excluded. In the Bell’s palsy group, 113 par-
ticipants were excluded. The Bell’s palsy patients for whom
we could not identify enough matching participants were ex-
cluded (n = 2). We also excluded the individuals under 20
years of age (n = 223). Finally, 1:4 matching resulted in the
inclusion of 3658 Bell’s palsy patients and 14,632 control
participants (Fig. 1).
196 S.-Y. Lee, J.-S. Lim and D.J. Oh et al. / Auris Nasus Larynx 48 (2021) 194–200

2.3. Variables Table 1. General characteristics of participants.

Characteristics Total participants

The following age groups were defined using 5-year in-
Bell’s palsy (n, %) Control (n, %) P-value
tervals: 20–24, 25–29, 30–34…, and 85+ years. A total of
14 age groups were designated. The income groups were ini- Age (years old) 1.000
tially divided into 41 classes (one health aid class, 20 self- 20–24 129 (3.5) 516 (3.5)
25–29 218 (6.0) 872 (6.0)
employment health insurance classes, and 20 employment 30–34 258 (7.1) 1032 (7.1)
health insurance classes). These groups were re-categorized 35–39 311 (8.5) 1244 (8.5)
into 11 classes (class 1 [lowest income]-class 11 [highest in- 40–44 309 (8.4) 1236 (8.4)
come]. Region of residence was divided into 16 areas based 45–49 399 (10.9) 1596 (10.9)
on administrative district. These regions were regrouped into 50–54 459 (12.5) 1836 (12.5)
55–59 442 (12.1) 1768 (12.1)
urban (Seoul, Busan, Daegu, Incheon, Gwangju, Daejeon, 60–64 349 (9.5) 1396 (9.5)
and Ulsan) and rural (Gyeonggi, Gangwon, Chungcheong- 65–69 323 (8.8) 1292 (8.8)
buk, Chungcheongnam, Jeollabuk, Jeollanam, Gyeongsang- 70–74 223 (6.1) 892 (6.1)
buk, Gyeongsangnam, and Jeju) areas. Charlson comorbidity 75–79 142 (3.9) 568 (3.9)
index (CCI) was used for 16 comorbidities as the continuous 80–84 73 (2.0) 292 (2.0)
85+ 23 (0.6) 92 (0.6)
variable (0 [no comorbidity] through 28 [multiple comorbidi- Sex 1.000
ties] except for cerebral vascular disease [23]. Male 1698 (46.4) 6792 (46.4)
Female 1960 (53.6) 7840 (53.6)
Income 1.000
2.4. Statistical analyses
1 (lowest) 557 (15.2) 2228 (15.2)
2 500 (13.7) 2000 (13.7)
Chi-square tests were used to compare the rates of the 3 628 (17.2) 2512 (17.2)
general characteristics between the Bell’s palsy and control 4 833 (22.8) 3332 (22.8)
groups. The stratified Cox proportional hazard models were 5 (highest) 1140 (31.2) 4560 (31.2)
used to analyze Hazard ratios (HRs) of Bell’s palsy for hem- Region of residence 1.000
Urban 1672 (45.7) 6688 (45.7)
orrhagic stroke and ischemic stroke. In these analyses, crude
Rural 1986 (54.3) 7944 (54.3)
(simple) and adjusted (for CCI score) models were used, and CCI <0.001∗
95% confidence intervals (CIs) were calculated. In these anal- 0 1110 (30.3) 6323 (43.2)
yses, age, sex, income, and region of residence were stratified. 1 376 (10.3) 1360 (9.3)
Kaplan-Meier analysis and Log-rank test was used. For the 2 507 (13.9) 1717 (11.7)
≥3 1665 (45.5) 5232 (35.8)
subgroup analyses, we divided the participants by age (< 50
Hemorrhagic stroke 27 (0.7) 78 (0.5) 0.142
years old, and ≥ 50 years old), sex (men and women), and Ischemic stroke 110 (3.0) 234 (1.6) <0.001∗
each time period after the onset of Bell’s palsy (≤ 1 year, 1
CCI: Charlson Comorbidity index except for cerebral vascular diseases.
to 2 years, 2 to 3years, > 3years). Break point of age was ∗ Chi-square test. Significance at P < 0.05.
determined in the median value. Two-tailed analyses were
conducted, and P values less than 0.05 were regarded as in-
dicative of significance. The results were statistically analyzed 0.001) compared to controls, which is contrast to hemor-
using SPSS v. 21.0 (IBM, Armonk, NY, USA). rhagic stroke (P = 0.141) (Fig. 2). In the subgroup analy-
ses, for ischemic stroke, the adjusted HRs were 1.92 (95%
3. Results CI = 0.89–4.16, P = 0.099), 1.73 (95% CI = 1.36–2.21,
P < 0.001), 1.72 (95% CI = 1.23–2.40, P < 0.001), and
The mean follow-up of ischemic stroke and hemorrhagic 1.76 (95% CI = 1.27–2.43, P < 0.001) in < 50 years old,
stroke were 59.3months (Standard deviation [SD] = 39.9 ≥ 50 years old, men and women subgroup, respectively. On
months) and 59.9months (SD = 39.9 months), respectively. the other hand, none of the adjusted HR was significant for
The prevalence of hemorrhagic stroke in the Bell’s palsy hemorrhagic stroke in Bell’s palsy patients (Table 3).
group (0.7% [27/3658] was similar to that in the control In the subgroup analyses according to time after Bell’s
group (0.5% [78/14,632], P = 0.142), whereas the preva- palsy, the adjusted HRs for ischemic stroke in patients with
lence of ischemic stroke was significantly higher in the Bell’s Bell’s palsy were significantly higher when the follow-up pe-
palsy group (3.0% [110/3658] than in the control group (1.6% riods were ≤ 2 years. The adjusted HRs were 3.41 (95%
[234/14,632], P < 0.001, Table 1). The demographic charac- CI = 2.23–5.22, P < 0.001) and 2.64 (95% CI = 1.51–4.60,
teristics of the patients in the two groups were identical due P < 0.001) in patients with follow-up periods of ≤ 1 year
to the matching procedure (P = 1.000). and 1 to 2 years, respectively (Table 4).
The adjusted HRs for ischemic stroke was 1.74 (95%
CI = 1.38–2.10) in the Bell’s palsy group (P < 0.001).
The adjusted HRs for hemorrhagic stroke was 1.19 (95% 4. Discussion
CI = 0.76–1.87, P = 0.437) in the Bell’s palsy group (Ta-
Although the pathophysiology of Bell’s palsy remains
ble 2). Kaplan-Meier graph revealed a significant higher cu-
enigmatic, it is widely accepted that neurotropic viral infec-
mulative incidence of ischemic stroke in Bell’s palsy (P <

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 S.-Y. Lee, J.-S. Lim and D.J. Oh et al. / Auris Nasus Larynx 48 (2021) 194–200 197

Table 2. Crude and adjusted hazard ratios (95% confidence interval) of Bell’s palsy for hemorrhagic stroke and ischemic stroke.

Characteristics Hemorrhagic stroke Ischemic stroke

Crude† P-value Adjusted† , ‡ P-value Crude† P-value Adjusted† , ‡ P-value
Bell’s palsy 1.37 (0.88–2.12) 0.162 1.19 (0.76–1.87) 0.437 1.94 (1.55–2.44) <0.001∗ 1.74 (1.38–2.19) <0.001∗
Control 1.00 1.00 1.00 1.00
∗ Cox-proportional hazard regression model, Significance at P < 0.05.
† Stratified model for age, sex, income, and region of residence.
‡ Adjusted model for Charlson Comorbidity index except for cerebral vascular diseases.

Fig. 2. Kaplan-Meier survival analysis according to stroke type (a) Kaplan-Meier survival analysis of hemorrhagic stroke in both Bell’s palsy and control. (b)
Kaplan-Meier survival analysis of ischemic stroke in both Bell’s palsy and control. For events that occurred within 30 days (i.e., stroke after Bell’s palsy), it
was plotted based on 0 month.

Table 3. Subgroup analysis of crude and adjusted hazard ratios (95% confidence interval) of Bell’s palsy for hemorrhagic stroke and ischemic
stroke according to age and sex.

Characteristics Hemorrhagic stroke Ischemic stroke

Crude† P-value Adjusted† , ‡ P-value Crude† P-value Adjusted† , ‡ P-value
Age < 50 years old (n = 8120)
Bell’s palsy 2.50 (0.82–7.64) 0.108 1.41 (0.39–5.03) 0.600 2.20 (1.05–4.59) 0.036∗ 1.92 (0.89–4.16) 0.099
Control 1.00 1.00 1.00 1.00
Age ≥ 50 years old (n = 10,170)
Bell’s palsy 1.24 (0.77–2.00) 0.381 1.12 (0.69–1.82) 0.646 1.92 (1.51–2.44) <0.001∗ 1.73 (1.36–2.21) <0.001∗
Control 1.00 1.00 1.00 1.00
Men (n = 8490)
Bell’s palsy 1.39 (0.74–2.61) 0.309 1.30 (0.69–2.48) 0.418 1.95 (1.41–2.70) <0.001∗ 1.72 (1.23–2.40) 0.001∗
Control 1.00 1.00 1.00 1.00
Women (n = 9800)
Bell’s palsy 1.35 (0.74–2.47) 0.335 1.10 (0.59–2.06) 0.758 1.94 (1.41–2.67) <0.001∗ 1.76 (1.27–2.43) 0.001∗
Control 1.00 1.00 1.00 1.00
∗ Cox-proportional hazard regression model, Significance at P < 0.05.
† Stratified model for age, sex, income, and region of residence.
‡ Adjusted model for Charlson Comorbidity index except for cerebral vascular diseases.

tion with herpes simplex virus (HSV) and varicella zoster
virus (VZV) or reactivation of a latent virus might play a
causative role in the development of Bell’s palsy [24,25].
During the pathologic process of Bell’s palsy, these viruses
travel along efferent nerve fibers to cerebral and temporal
arteries upon their reactivation in the geniculate ganglion
[26,27]. The replication of these viruses can induce inflam-
mation in the cerebral and temporal arteries, which result
in atherosclerotic plaque formation and vascular endothelial
malfunction [28,29]. These effects may eventually lead to
stroke due to cerebrovascular remodeling. VZV DNA and its
pathogens could contribute to vasculopathy in intracerebral
arteries or extracerebral temporal arteries and consequently
result in stroke corresponding to the ischemic area [30,31]. In
addition to VZV, HSV has been identified as a potent cause of
stroke in some cases by unraveling the significant expression
of HSV-specific immunoglobulin M antibodies [32]. Given a
significant association exists between infectious burden of the
herpes virus family and stroke [33,34], this putative associ-
ation may contribute to an increased risk of stroke in Bell’s
palsy patients.

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Table 4. Subgroup analysis of crude and adjusted hazard ratios (95% confidence interval) of Bell’s palsy for hemorrhagic stroke and ischemic
stroke from index dates.

Characteristics Hemorrhagic stroke Ischemic stroke

Crude† P-value Adjusted† , ‡ P-value Crude† P-value Adjusted† , ‡ P-value
≤ 1 year
Bell’s palsy 1.47 (0.62–3.51) 0.380 1.43 (0.60–3.42) 0.419 3.83 (2.52–5.81) <0.001∗ 3.41 (2.23–5.22) <0.001∗
Control 1.00 1.00 1.00 1.00
1–2 year
Bell’s palsy 1.50 (0.40–5.65) 0.549 1.06 (0.25–4.50) 0.941 2.71 (1.56–4.71) <0.001∗ 2.64 (1.51–4.60) 0.001∗
Control 1.00 1.00 1.00 1.00
2–3 year
Bell’s palsy 1.43 (0.46–4.50) 0.583 1.16 (0.35–3.81) 0.807 1.56 (0.82–2.97) 0.171 1.18 (0.59–2.35) 0.633
Control 1.00 1.00 1.00 1.00
> 3 years
Bell’s palsy 1.27 (0.68–2.38) 0.450 1.09 (0.57–2.06) 0.796 1.12 (0.76–1.65) 0.638 1.00 (0.67–1.48) 0.985
Control 1.00 1.00 1.00 1.00
∗ Cox-proportional hazard regression model, Significance at P < 0.05.
† Stratified model for age, sex, income, and region of residence.
‡ Adjusted model for Charlson Comorbidity index except for cerebral vascular diseases.

In Bell’s palsy patients, viral infection or the reactivation
of a latent virus can also induce demyelination of the fa-
cial nerve via provoking autoimmune responses against nerve
myelin, especially in the facial nerve [24]. Notably, patients
with Bell’s palsy often manifest an elevated level of circulat-
ing inflammatory cytokines such as interleukin-1 and tumor
necrosis factor-alpha that facilitate inflammation via leukocyte
migration into the vascular wall [35]. Based on neurotropic-
virus-induced vasculopathy, the accumulation of circulating
inflammatory cytokines in Bell’s palsy patients may promote
perivascular inflammation and thrombotic formation in the
cerebrovascular system, and these effects may eventually lead
to stroke [36].
In this study, there is no association of Bell’s palsy with
hemorrhagic stroke. Although neurotropic viruses can induce
cerebrovascular rupture that contributes to the development
of hemorrhagic stroke [37], only limited information on the
causative association between Bell’s palsy and hemorrhagic
stroke is available at present. Given that hemorrhagic stroke
has a higher mortality risk than ischemic stroke [9,10], the im-
mediate onset and irreversibility of hemorrhagic stroke might
contribute to the low degree of association with Bell’s palsy
over a long follow-up period. In addition, the relatively small
number of hemorrhagic stroke cases might have led to de-
creased statistical power.
In the subgroup analyses, Bell’s palsy appeared to have
a differential risk of ischemic stroke, depending on age.
The risk of ischemic stroke was higher in patients aged
< 50 (HR = 1.92, CI = 0.89–4.16) than in patients aged
≥ 50 years (HR = 1.73, CI = 1.36–2.21). This finding is
inconsistent with the previous notion that the incidence of
stroke is known to increase with age [38], probably due
to the different methodologies used. A higher possibility
of ischemic stroke, especially in elderly patients, may be
attributed to the shared systemic inflammatory profiles be-
tween Bell’s palsy and stroke [39]. Although the risk of
stroke is higher in females after 55 years of age [38], our
results indicated a similar risk of ischemic stroke regardless
of gender. It awaits further confirmation.
We also found that the association between Bell’s palsy
and ischemic stroke was significant only within 2 years of
the onset of Bell’s palsy, and this association became sta-
tistically insignificant as duration from the onset of Bell’s
palsy increased. Consistent with the present study, a previ-
ous population-based case-control study demonstrated that a
substantial number of patients with Bell’s palsy suffered from
stroke within 6 months [14]. Several risk factors for stroke
have been reported, such as old age, hypertension and coro-
nary artery disease. However, most of these risk factors are
chronic conditions that cannot act as specific predictors for
acute stroke [13]. Based on a meta-analysis study, herpes
zoster, which can cause manifestations following neurotropic
virus activation, is an established risk factor for stroke, es-
pecially shortly after infection [40]. Given this, the higher
occurrence of stroke, especially within 2 years after Bell’s
palsy, may be attributable to the spread of the viral infection
or to immune responses associated with Bell’s palsy itself
rather than with its risk factors. Thus, prompt surveillance
during the early period after Bell’s palsy may enhance cere-
bral resuscitation for patients with ischemic stroke.
The present study has several advantages, as in our pre-
vious studies utilizing the HIRA-NSC [41-43]. The present
study used representative data from a large population, which
was verified in a previous study [20]. Because the NHIS data
cover all citizens of Korea, without exceptions, no participants
were lost during follow-up. The control group was randomly
selected, with matching of demographics to avoid confound-
ing effects. An adjusted hazard model was used to further
minimize the impact of confounders. Notably, we enrolled
only participants who received the diagnosis for Bell’s palsy
≥ 2 times via ambulatory visits for the same episode with
steroid treatment to improve the accuracy of the diagnoses.
Due to the validated study population and the control group
adjusted for predisposing factors, the present results improved

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 S.-Y. Lee, J.-S. Lim and D.J. Oh et al. / Auris Nasus Larynx 48 (2021) 194–200
on the previous findings on the risk of stroke in patients with
Bell’s palsy.
However, the present study has certain limitations. First,
Lee et al. reported that adjusted HR for stroke was 2.02-
fold higher in patients with Bell’s palsy than in controls dur-
ing a 3-year follow-up [14]. The most noteworthy finding of
the study was that steroid administration markedly attenuated
the risk of stroke [14]. Although this study did not evalu-
ate the risk of stroke according to the presence of steroid
treatment, we showed an inconsistent result by demonstrating
a significantly higher risk of ischemic stroke despite steroid
administration. Accordance with this study, steroid treatment
in Bell’s palsy did not significantly reduce the risk of periph-
eral arterial occlusive disease based on a large cohort study
[44]. Although Bell’s palsy treatment usually requires a short
course of steroid medication for up to 14 days after the onset
of symptoms [45], this short-term use of steroid medication
might not alter virus vasculopathy or systemic inflammation.
However, no consensus exists on the implication of steroid
treatment for Bell’s palsy patients in reducing stroke; thus,
more information will be necessary in this regard. Second,
despite the cohort study design, we could not exclude the ef-
fects of possible confounders that may precipitate both Bell’s
palsy and stroke. Information with regard to additional sus-
pected risk factors for stroke, such as smoking, alcohol con-
sumption, and obesity, were not available in the insurance
database [13]. Moreover, it was difficult to match participants
with respect to atrial fibrillation or use of medications, despite
the large size of this population-based cohort study, because
strict matching based on these characteristics increased the
dropout rate of the subjects due to a lack of control partici-
pants. Additionally, matching the use of medications accord-
ing to duration was difficult due to heterogeneous medication
profiles, including factors such as doses and drug companies.
5. Conclusion
Based on a large population-based case-control study in
Korea, there is an association of Bell’s palsy with ischemic
stroke but not with hemorrhagic stroke.
Declaration of Competing Interest
There are no competing interests for any author.
Funding
This work was supported in part by a research grant
(NRF-2018-R1D1A1A0-2085328) from the National Re-
search Foundation (NRF) of Korea.
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