- Email: [email protected]
Cardioembolic Stroke with Visual Deficit in a Patient who is a Bilateral Hand Amputee: A Case Report
S280
addition to PO Baclofen to treat spasticity, the patient was also fitted with a dynamic left-upper-extremity splint to gradually stretch the arm and relieve the elbow contracture. Modifying, bilateral ankle-foot orthoses were used for 2 hours a day during bed rest to maintain range of motion and prevent contractures. Discussion: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC Virus (JCV), activated during immunosuppression. It is characterized by subacute neurological decline that typically results in progressive weakness, sensory loss, dysarthria, ataxia, hemianopsia, and cognitive impairment. Despite the progression of this disease, rehabilitation therapy with our patient shows the possibility of improved function after certain decline. After approximately 4 weeks of acute inpatient rehabilitation, our patient showed improvements with dynamic sitting, bed mobility, feeding, transferring, ambulation across level surfaces, wheelchair propulsion, and static standing balance. Conclusions: While likely under-reported, to the best of the authors’ knowledge, we describe the first case of functional improvement in a patient with PML after inpatient rehabilitation. This case also highlights the importance of how increased functional ability can increase patient safety and decrease caretaker burden. Poster 407 Occlusion of the Artery of Percheron Causing Bilateral Thalamic Stroke: A Case Report. Craig Best, DO (Rush University Medical Center, Chicago, IL, United States); Chirag M. Shah, MD. Disclosures: C. Best, No Disclosures: I Have Nothing To Disclose. Case Description: A 59-year-old man with a history of anxiety and insomnia presented with altered mental status (AMS). Neurologic exam revealed a lethargic patient with an upward gaze palsy, right mydriasis, and unsteady gait. Motor, sensory, and reflex exam of the extremities was normal. Laboratory testing revealed urine drug screen positive for benzodiazepines (known prescription for alprazolam); remaining pertinent laboratory evaluation was negative. MRI brain revealed acute ischemic process of basal paramedian thalamic nuclei due to occlusion of the artery of Percheron (AOP). CTA head & neck suggested mild atherosclerotic disease of the distal basilar artery and proximal left posterior cerebral artery (PCA). During acute hospital stay, patient experienced ongoing AMS, alteration of sleep-wake cycle, hypersomnolence, agitation, anxiety, obsessive-compulsive behavior, and paranoia. Program Description: Case Study. Setting: Tertiary Care Center. Results or Clinical Course: During patient’s acute inpatient rehabilitation course, he demonstrated perseverative speech, distractibility, disinhibition (e.g. inappropriate sexual comments), obsessive-compulsive and paranoid behavior, and hypersomnolence. Cranial nerve, motor, sensory, and reflex exam was unremarkable. Neuropsychology evaluation revealed mild-moderate memory impairment and poor verbal fluency, even though the patient scored well on attention and executive functioning. These were unexpected findings given his behavioral presentation. Findings suggested thalamic structures affected by the stroke were associated with orbitofrontal cortical circuits without involvement of dorsolateral prefrontal circuits.
PRESENTATIONS
Discussion: The medial thalamus is usually supplied by the paramedian arteries arising from the first segment (P1) of the PCA bilaterally. In the case described, occlusion of the AOP, a common trunk arising from one of the P1 segments providing bilateral distribution, resulted in bilateral infarctions of the medial aspects of the thalamus. Typical presentation of bilateral thalamic stroke is a triad of AMS, memory impairment, and vertical gaze palsy. AOP infarcts account for 0.1-0.3% of all ischemic strokes and 22-35% of all thalamic infarcts. Conclusions: Bilateral thalamic stroke is a rare entity requiring interdisciplinary rehabilitation with particular focus on cognitive evaluation and treatment. Poster 408 Irreversible Spinal Cord Injury Following Intrathecal Chemotherapy: A Case Report. Amy H. Ng, MD (UT MD Anderson Cancer Center, Houston, TX, United States). Disclosures: A. H. Ng, No Disclosures: I Have Nothing To Disclose. Case Description: A 37-year-old right-handed man with T-cell lymphoma initially diagnosed in 2009 went into complete remission following EPOCH chemotherapy. Subsequent disease recurrence with CNS involvement prompted administration of intrathecal chemotherapy with methotrexate and cytarabine and radiation to the brain and spine. The disease progressed during this therapy, and lenalidomide was added to his treatment regimen. During this therapy, he developed weakness of the bilateral lower extremities, which progressed to complete paresis and urinary retention. Setting: Inpatient rehabilitation in a cancer specialty hospital. Results or Clinical Course: Approximately a week after the addition of lenalidomide to his intrathecal cytarabine chemotherapy regimen, the patient developed paraplegia. MRI of the spine showed enhancement at T4-5 and T6-T9, and a follow-up MRI two months later showed progression of the enhancement. Multiple CSF samples showed no malignant cells, and no infection was found. His paresis was thought to be due to the radiation and intrathecal chemotherapy with the addition of lenalidomide. Treatment with high-dose steroids did not improve his neurologic status. Conclusions: Little is known about the mechanism by which intrathecal chemotherapy causes neurologic complications. There are no reported cases of lenalidomide in addition to intrathecal chemotherapy causing spinal cord injury in the recent literature. This case highlights the susceptibility of the spinal cord to damage by chemotherapy and radiation therapy. Poster 409 Cardioembolic Stroke with Visual Deficit in a Patient who is a Bilateral Hand Amputee: A Case Report. Louis Ostola, MD (Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States); Ronald S. Taylor, MD. Disclosures: L. Ostola, No Disclosures: I Have Nothing To Disclose. Case Description: This patient was admitted for respiratory distress and atrial fibrillation with rapid ventricular rate. On day 2 of admission she suffered a cardioembolic stroke. CT brain showed findings consistent with multiple emboli scattered throughout multiple vascular distributions, likely as a result of atrial fibrillation.
PM&R
Complicating matters was her history of a bilateral transradial amputation due to a work injury in 1988. Prior to admission she lived alone and was independent with basic and advanced activities of daily living (ADLs) using bilateral body powered prostheses with voluntary opening hand hooks. She was proficient enough with their use that she continued to be a one half pack per day smoker. Setting: Tertiary Care Hospital. Results or Clinical Course: The main goal of therapy was to help the patient return to her baseline status with ADLs. The major barrier was her left visual field deficit causing double vision. This was addressed with taping her glasses, which helped with the double vision, but resulted in a loss of depth perception and difficulty donning her prostheses. Over time, her vision gradually improved and she was able to accommodate for her residual visual deficits. She was discharged home with her daughter at a standby assist level given increased time to complete tasks. Discussion: To our knowledge there are no documented cases of visual deficit from cardioembolic stroke in a bilateral hand amputee. As stroke survival rates increase we are faced with unique co-morbidities that affect function. Conclusions: As survival rates for both stroke and amputation increase we need to be prepared to address the challenges of both to keep our patients as functional and independent as we can. Poster 410 Rehabilitation of an Eighteen-Year-Old Male with a Severe Traumatic Brain Injury Complicated by Sinking Skin Flap Syndrome: A Case Report. Mary E. Russell, DO, MS (Baylor College of Medicine, Houston, TX, United States); Monica E. Crump, MD. Disclosures: M. E. Russell, No Disclosures: I Have Nothing To Disclose. Case Description: The patient is an 18-year-old male who presented to an outside hospital after a self-inflicted gunshot wound to the head for which the patient underwent emergent hemicraniectomy and decompression. Patient had ventriculoperitoneal shunt placement for hydrocephalus on hospital day 22. He presented to our inpatient rehabilitation hospital 28 days after injury. Patient was making great strides during his rehabilitation course and progressed from total assistance to minimal assistance with ADLs and transfers. However, six weeks into his rehabilitation stay, patient became extremely limited by pain from positional headaches. Multiple medications for pain, including norco, gabapentin and topiramate were started for headaches presumed to be secondary to an overdraining shunt. The shunt was adjusted and headaches improved slightly. Patient began to digress with therapies and was noted to have increasing lethargy, decreased responsiveness, increased spasticity and irretractable nausea and vomiting. Head CT done during week seven of inpatient rehabilitation showed an increase in the sunken in appearance of the brain with increased left to right subfalcine herniation. Patient was transferred to an acute care hospital to expedite cranioplasty given neurologic deterioration from sinking skin flap syndrome. Program Description: 18-year-old male with severe neurological deficits secondary to a gunshot wound to the head. Setting: Rehabilitation hospital. Results or Clinical Course: Three months after injury, patient had shown significant improvement before neurologic deterioration secondary to sinking skin flap syndrome. It is uncertain what
Vol. 5, Iss. 9S, 2013
S281
deficits may remain after cranioplasty. Patient was discharged to a post-acute brain injury rehabilitation program. Further developments will be discussed. Discussion: Sinking skin flap syndrome is a serious and unusual complication of hemicraniectomy after traumatic brain injury and should be considered given neurologic deterioration in the setting of subfalcine herniation in a patient with hydrocephalus managed with a ventriculoperitoneal shunt. Conclusions: Sinking skin flap syndrome is an unusual neurological complication of hemicraniectomy in the traumatic brain injury population. Poster 411 Recurrent Miller Fisher Variant of Guillain-Barré Syndrome: A Case Report. Hannah A. Shoval (New York Presbyterian Hospital of Columbia and Cornell, New York, NY, United States); Allyson A. Shrikhande, MD. Disclosures: H. A. Shoval, No Disclosures: I Have Nothing To Disclose. Case Description: AF, a 33-year-old woman, presented with a second episode of Guillain-Barre syndrome Miller Fisher variant (MFS) 12 years after her first episode. She reported numbness of the hands and feet, "lazy" left eye and ataxic gait starting 10 days after an upper respiratory illness. Brain magnetic resonance imaging showed enhancement of bilateral cranial nerve seven. Patient’s GQ1b antibody was positive. Electromyography showed sensorimotor demyelinating peripheral neuropathy. AF required mechanical ventilation and a percutaneous endoscopic gastrostomy (PEG). Exam showed absent reflexes and near complete paralysis retaining only the ability to raise her left eyebrow and move her right toes. AF had unreactive pupils, no blink to threat, complete opthalmoplegia and absent gag. AF was treated with intravenous immunoglobulin. Methadone and clonazepam started for anxiety and pain. Metoprolol started for tachycardia to the 150’s secondary to dysautonomia. Gabapentin started for neuropathic pain. AF improved and after one month was admitted to inpatient rehabilitation unit (IRU). Setting: Tertiary care hospital. Results or Clinical Course: In the IRU, AF was decannulated and underwent a trial of void successfully. Metoprolol was decreased; methadone discontinued. Re-empowering AF was crucial given her prior inability to communicate. Therapists encouraged, physicians explained medication choices carefully, and psychiatry supported with psychotherapy. After 21/2 weeks, AF ambulated 800 feet independently and was modified independent with activities of daily living. AF passed a modified barium swallow and advanced to a regular diet. Discussion: MFS is characterized by ataxia, areflexia and ophthalmoplegia. Recurrence does not exclude the diagnosis. It is mostly an acute self-limiting condition but can progress rapidly and close monitoring is critical. Early mobilization including ranging extremities is important. Admission to IRU enables a multi-disciplinary team approach with physical and occupational therapists, speech and language pathologists, supportive counseling and close medical surveillance. This can re-empower the patient for an efficient transition to home. Conclusions: The effects of MFS can be devastating for patients and correct diagnosis is critical. IRU is a valuable resource for transitioning to a home setting.
addition to PO Baclofen to treat spasticity, the patient was also fitted with a dynamic left-upper-extremity splint to gradually stretch the arm and relieve the elbow contracture. Modifying, bilateral ankle-foot orthoses were used for 2 hours a day during bed rest to maintain range of motion and prevent contractures. Discussion: Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the JC Virus (JCV), activated during immunosuppression. It is characterized by subacute neurological decline that typically results in progressive weakness, sensory loss, dysarthria, ataxia, hemianopsia, and cognitive impairment. Despite the progression of this disease, rehabilitation therapy with our patient shows the possibility of improved function after certain decline. After approximately 4 weeks of acute inpatient rehabilitation, our patient showed improvements with dynamic sitting, bed mobility, feeding, transferring, ambulation across level surfaces, wheelchair propulsion, and static standing balance. Conclusions: While likely under-reported, to the best of the authors’ knowledge, we describe the first case of functional improvement in a patient with PML after inpatient rehabilitation. This case also highlights the importance of how increased functional ability can increase patient safety and decrease caretaker burden. Poster 407 Occlusion of the Artery of Percheron Causing Bilateral Thalamic Stroke: A Case Report. Craig Best, DO (Rush University Medical Center, Chicago, IL, United States); Chirag M. Shah, MD. Disclosures: C. Best, No Disclosures: I Have Nothing To Disclose. Case Description: A 59-year-old man with a history of anxiety and insomnia presented with altered mental status (AMS). Neurologic exam revealed a lethargic patient with an upward gaze palsy, right mydriasis, and unsteady gait. Motor, sensory, and reflex exam of the extremities was normal. Laboratory testing revealed urine drug screen positive for benzodiazepines (known prescription for alprazolam); remaining pertinent laboratory evaluation was negative. MRI brain revealed acute ischemic process of basal paramedian thalamic nuclei due to occlusion of the artery of Percheron (AOP). CTA head & neck suggested mild atherosclerotic disease of the distal basilar artery and proximal left posterior cerebral artery (PCA). During acute hospital stay, patient experienced ongoing AMS, alteration of sleep-wake cycle, hypersomnolence, agitation, anxiety, obsessive-compulsive behavior, and paranoia. Program Description: Case Study. Setting: Tertiary Care Center. Results or Clinical Course: During patient’s acute inpatient rehabilitation course, he demonstrated perseverative speech, distractibility, disinhibition (e.g. inappropriate sexual comments), obsessive-compulsive and paranoid behavior, and hypersomnolence. Cranial nerve, motor, sensory, and reflex exam was unremarkable. Neuropsychology evaluation revealed mild-moderate memory impairment and poor verbal fluency, even though the patient scored well on attention and executive functioning. These were unexpected findings given his behavioral presentation. Findings suggested thalamic structures affected by the stroke were associated with orbitofrontal cortical circuits without involvement of dorsolateral prefrontal circuits.
PRESENTATIONS
Discussion: The medial thalamus is usually supplied by the paramedian arteries arising from the first segment (P1) of the PCA bilaterally. In the case described, occlusion of the AOP, a common trunk arising from one of the P1 segments providing bilateral distribution, resulted in bilateral infarctions of the medial aspects of the thalamus. Typical presentation of bilateral thalamic stroke is a triad of AMS, memory impairment, and vertical gaze palsy. AOP infarcts account for 0.1-0.3% of all ischemic strokes and 22-35% of all thalamic infarcts. Conclusions: Bilateral thalamic stroke is a rare entity requiring interdisciplinary rehabilitation with particular focus on cognitive evaluation and treatment. Poster 408 Irreversible Spinal Cord Injury Following Intrathecal Chemotherapy: A Case Report. Amy H. Ng, MD (UT MD Anderson Cancer Center, Houston, TX, United States). Disclosures: A. H. Ng, No Disclosures: I Have Nothing To Disclose. Case Description: A 37-year-old right-handed man with T-cell lymphoma initially diagnosed in 2009 went into complete remission following EPOCH chemotherapy. Subsequent disease recurrence with CNS involvement prompted administration of intrathecal chemotherapy with methotrexate and cytarabine and radiation to the brain and spine. The disease progressed during this therapy, and lenalidomide was added to his treatment regimen. During this therapy, he developed weakness of the bilateral lower extremities, which progressed to complete paresis and urinary retention. Setting: Inpatient rehabilitation in a cancer specialty hospital. Results or Clinical Course: Approximately a week after the addition of lenalidomide to his intrathecal cytarabine chemotherapy regimen, the patient developed paraplegia. MRI of the spine showed enhancement at T4-5 and T6-T9, and a follow-up MRI two months later showed progression of the enhancement. Multiple CSF samples showed no malignant cells, and no infection was found. His paresis was thought to be due to the radiation and intrathecal chemotherapy with the addition of lenalidomide. Treatment with high-dose steroids did not improve his neurologic status. Conclusions: Little is known about the mechanism by which intrathecal chemotherapy causes neurologic complications. There are no reported cases of lenalidomide in addition to intrathecal chemotherapy causing spinal cord injury in the recent literature. This case highlights the susceptibility of the spinal cord to damage by chemotherapy and radiation therapy. Poster 409 Cardioembolic Stroke with Visual Deficit in a Patient who is a Bilateral Hand Amputee: A Case Report. Louis Ostola, MD (Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States); Ronald S. Taylor, MD. Disclosures: L. Ostola, No Disclosures: I Have Nothing To Disclose. Case Description: This patient was admitted for respiratory distress and atrial fibrillation with rapid ventricular rate. On day 2 of admission she suffered a cardioembolic stroke. CT brain showed findings consistent with multiple emboli scattered throughout multiple vascular distributions, likely as a result of atrial fibrillation.
PM&R
Complicating matters was her history of a bilateral transradial amputation due to a work injury in 1988. Prior to admission she lived alone and was independent with basic and advanced activities of daily living (ADLs) using bilateral body powered prostheses with voluntary opening hand hooks. She was proficient enough with their use that she continued to be a one half pack per day smoker. Setting: Tertiary Care Hospital. Results or Clinical Course: The main goal of therapy was to help the patient return to her baseline status with ADLs. The major barrier was her left visual field deficit causing double vision. This was addressed with taping her glasses, which helped with the double vision, but resulted in a loss of depth perception and difficulty donning her prostheses. Over time, her vision gradually improved and she was able to accommodate for her residual visual deficits. She was discharged home with her daughter at a standby assist level given increased time to complete tasks. Discussion: To our knowledge there are no documented cases of visual deficit from cardioembolic stroke in a bilateral hand amputee. As stroke survival rates increase we are faced with unique co-morbidities that affect function. Conclusions: As survival rates for both stroke and amputation increase we need to be prepared to address the challenges of both to keep our patients as functional and independent as we can. Poster 410 Rehabilitation of an Eighteen-Year-Old Male with a Severe Traumatic Brain Injury Complicated by Sinking Skin Flap Syndrome: A Case Report. Mary E. Russell, DO, MS (Baylor College of Medicine, Houston, TX, United States); Monica E. Crump, MD. Disclosures: M. E. Russell, No Disclosures: I Have Nothing To Disclose. Case Description: The patient is an 18-year-old male who presented to an outside hospital after a self-inflicted gunshot wound to the head for which the patient underwent emergent hemicraniectomy and decompression. Patient had ventriculoperitoneal shunt placement for hydrocephalus on hospital day 22. He presented to our inpatient rehabilitation hospital 28 days after injury. Patient was making great strides during his rehabilitation course and progressed from total assistance to minimal assistance with ADLs and transfers. However, six weeks into his rehabilitation stay, patient became extremely limited by pain from positional headaches. Multiple medications for pain, including norco, gabapentin and topiramate were started for headaches presumed to be secondary to an overdraining shunt. The shunt was adjusted and headaches improved slightly. Patient began to digress with therapies and was noted to have increasing lethargy, decreased responsiveness, increased spasticity and irretractable nausea and vomiting. Head CT done during week seven of inpatient rehabilitation showed an increase in the sunken in appearance of the brain with increased left to right subfalcine herniation. Patient was transferred to an acute care hospital to expedite cranioplasty given neurologic deterioration from sinking skin flap syndrome. Program Description: 18-year-old male with severe neurological deficits secondary to a gunshot wound to the head. Setting: Rehabilitation hospital. Results or Clinical Course: Three months after injury, patient had shown significant improvement before neurologic deterioration secondary to sinking skin flap syndrome. It is uncertain what
Vol. 5, Iss. 9S, 2013
S281
deficits may remain after cranioplasty. Patient was discharged to a post-acute brain injury rehabilitation program. Further developments will be discussed. Discussion: Sinking skin flap syndrome is a serious and unusual complication of hemicraniectomy after traumatic brain injury and should be considered given neurologic deterioration in the setting of subfalcine herniation in a patient with hydrocephalus managed with a ventriculoperitoneal shunt. Conclusions: Sinking skin flap syndrome is an unusual neurological complication of hemicraniectomy in the traumatic brain injury population. Poster 411 Recurrent Miller Fisher Variant of Guillain-Barré Syndrome: A Case Report. Hannah A. Shoval (New York Presbyterian Hospital of Columbia and Cornell, New York, NY, United States); Allyson A. Shrikhande, MD. Disclosures: H. A. Shoval, No Disclosures: I Have Nothing To Disclose. Case Description: AF, a 33-year-old woman, presented with a second episode of Guillain-Barre syndrome Miller Fisher variant (MFS) 12 years after her first episode. She reported numbness of the hands and feet, "lazy" left eye and ataxic gait starting 10 days after an upper respiratory illness. Brain magnetic resonance imaging showed enhancement of bilateral cranial nerve seven. Patient’s GQ1b antibody was positive. Electromyography showed sensorimotor demyelinating peripheral neuropathy. AF required mechanical ventilation and a percutaneous endoscopic gastrostomy (PEG). Exam showed absent reflexes and near complete paralysis retaining only the ability to raise her left eyebrow and move her right toes. AF had unreactive pupils, no blink to threat, complete opthalmoplegia and absent gag. AF was treated with intravenous immunoglobulin. Methadone and clonazepam started for anxiety and pain. Metoprolol started for tachycardia to the 150’s secondary to dysautonomia. Gabapentin started for neuropathic pain. AF improved and after one month was admitted to inpatient rehabilitation unit (IRU). Setting: Tertiary care hospital. Results or Clinical Course: In the IRU, AF was decannulated and underwent a trial of void successfully. Metoprolol was decreased; methadone discontinued. Re-empowering AF was crucial given her prior inability to communicate. Therapists encouraged, physicians explained medication choices carefully, and psychiatry supported with psychotherapy. After 21/2 weeks, AF ambulated 800 feet independently and was modified independent with activities of daily living. AF passed a modified barium swallow and advanced to a regular diet. Discussion: MFS is characterized by ataxia, areflexia and ophthalmoplegia. Recurrence does not exclude the diagnosis. It is mostly an acute self-limiting condition but can progress rapidly and close monitoring is critical. Early mobilization including ranging extremities is important. Admission to IRU enables a multi-disciplinary team approach with physical and occupational therapists, speech and language pathologists, supportive counseling and close medical surveillance. This can re-empower the patient for an efficient transition to home. Conclusions: The effects of MFS can be devastating for patients and correct diagnosis is critical. IRU is a valuable resource for transitioning to a home setting.