if the 51 years old patient has left sided hemiparesis and left facial palsy, peripheral type with headache and dizziness and suspection is stroke, where can be the lesion? H/o of DM and HTN for about 10 years
left sided hemiparesis and peripheral facial palsy
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The first thought to me is that perhaps this is not truly a LMN 7th palsy. Common things being common facial palsies can be subtle and are often mistaken as LMN when in fact they are UMN putting the lesion in this case either in the RMCA or given his history the Right internal capsule due to his intracranial atherosclerotic disease.
If it is in fact a TRUE LMN seven with Left hemiparesis the localization becomes more tricky. You have to consider other etiologies in this case such as a demyelinating process, autoimmune disorder, etc. etc. You can develop what appears to be a LMN 7th nerve palsy with lower pontine lacunes but this is exceedingly rare and would give you contralateral hemiparesis.
Hope it helps
If it is in fact a TRUE LMN seven with Left hemiparesis the localization becomes more tricky. You have to consider other etiologies in this case such as a demyelinating process, autoimmune disorder, etc. etc. You can develop what appears to be a LMN 7th nerve palsy with lower pontine lacunes but this is exceedingly rare and would give you contralateral hemiparesis.
Hope it helps
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You have to image his pons. "Peripheral" VII palsies can be central if they involve the nucleus or fascicle of the 7th nerve. You would expect crossed weakness with a pontine infarct(face on one side, body on the other), but if he had a more midline perforator this can cause a midline infarct that hit both the descending motor tracts on one side and the motor nucleus/fascicle of 7 on the other. It's also possible he had multiple perforators affected from a basilar abnormality.
Not a classic case by any means and certainly not 100% localizing, but small vessel disease risk factors and collateral symptoms of "dizziness" (? vertigo) make small vessel posterior circulation disease worrisome.
MRI/MRA head & neck are how I would proceed...
Due to the crossed innervation of the forehead/upper face in most people, an anterior circulation cause would have to affect both motor corticies involving the facial fibers--not impossible, but certainly rare.
All this is assuming the facial weakness is of a peripheral pattern as you implied; some people will mistake mild weakness of eye closure as involvement of the upper face, but I've seen enough strokes with orbicularis oris affected to know this is not true. Only if they cannot raise their eyebrow, wrinkle their forehead, ect. do I consider it a definite 7th nerve/nucleus lesion.
Not a classic case by any means and certainly not 100% localizing, but small vessel disease risk factors and collateral symptoms of "dizziness" (? vertigo) make small vessel posterior circulation disease worrisome.
MRI/MRA head & neck are how I would proceed...
Due to the crossed innervation of the forehead/upper face in most people, an anterior circulation cause would have to affect both motor corticies involving the facial fibers--not impossible, but certainly rare.
All this is assuming the facial weakness is of a peripheral pattern as you implied; some people will mistake mild weakness of eye closure as involvement of the upper face, but I've seen enough strokes with orbicularis oris affected to know this is not true. Only if they cannot raise their eyebrow, wrinkle their forehead, ect. do I consider it a definite 7th nerve/nucleus lesion.
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I agree with other posters that this is likely a R hemispheric stroke, as there is often partial involvement of the orbicularis oculi / forehead with UMN lesions. One way to confirm a LMN lesion of CN VII is to test taste sensation. With most LMN CN VII lesions, patients lose taste sensation on one half of the tongue. I would often go get sugar and salt from the cafeteria as a resident to test taste sensation in ED patients with incomplete Bell's just to make sure I wasn't missing a stroke.
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Better not use too much sugar if he's diabetic 
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In the real world, you're probably really seeing a R MCA stroke (ie mistaking the UMN CNVII lesion for a LMN lesion).
For academic purposes, you can localize this constellation of findings to the left pons (catching the fasicle of CNVII) exactly like one of the above posters astutely mentioned.
Further down the differential lie the more exotic and ever popular suspects like the immunological, infectious, or neoplastic etiologies. Given your limited supplied history, one must presume cerebrovascular disease until proven otherwise and check an MRI/A.
For academic purposes, you can localize this constellation of findings to the left pons (catching the fasicle of CNVII) exactly like one of the above posters astutely mentioned.
Further down the differential lie the more exotic and ever popular suspects like the immunological, infectious, or neoplastic etiologies. Given your limited supplied history, one must presume cerebrovascular disease until proven otherwise and check an MRI/A.
