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Poster 117 Eight-and-a-Half Syndrome as a Sequela of Pontine Hemorrhage: A Case Report
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Abstracts / PM R 7 (2015) S83-S222
by admission and discharge functional independence measure (FIM). Clinical characteristics including age, sex, race, marital status, stroke risk factors, stroke site, and discharge destination were recorded. The association between serum BDNF level and stroke functional outcomes was assessed using Pearson’s correlation analysis. Results or Clinical Course: The mean serum BDNF level was 22.609.87ng/ml (range, 5.22-44.83ng/ml). Pearson’s correlation analysis showed that the lower serum BDNF level was associated with less marital family support (r¼0.316, P¼.047), lower FIM motor subscore on admission (r¼0.338, P¼.033) and discharge (r¼0.355, P¼.025) and lower total FIM score on discharge (r¼0.363, P¼.021). Stroke patients with lower serum BDNF level were more likely to be discharged to skilled nursing facility (r¼-0.407, P¼.009). Conclusion: Serum BDNF level was associated with functional outcomes as measured by FIM and discharge destination within 2 month of the onset of stroke. BDNF may serve as a prognostic biomarker for functional recovery and may be used as a surrogate marker to evaluate the responsiveness to targeted neurorestorative therapies. Larger scale studies are warranted to confirm these results.
Poster 117 Eight-and-a-Half Syndrome as a Sequela of Pontine Hemorrhage: A Case Report Rebecca R. Shoemaker (Rehabilitation Institute of Michigan- DMC, Detroit, MI, United States), Maria Humayun, MD Disclosures: R. R. Shoemaker: I Have No Relevant Financial Relationships To Disclose. Case Description: A 52-year-old man presented with eight-and-ahalf syndrome and was found to have a left dorsal pontine hemorrhage as demonstrated on magnetic resonance imaging. He had a past medical history significant for human immunodeficiency virus (HIV) and deep vein thromboses secondary to antiphospholipid syndrome. On initial examination he was found to have left conjugate gaze palsy and partial deviation of gaze in the right eye. Additional findings included a left facial droop and right upper extremity weakness. On later evaluation by ophthalmology he was discovered to have intranuclear ophthalmoplegia of the left eye, torsional nystagmus and 20/50 visual acuity bilaterally. He also had multiple episodes of hallucinations thought to be secondary to narcotics which required antipsychotic medication administration as well as a bedside sitter. When medically stable he was admitted to the neurosciences unit to address the deficits resulting from his pontine hemorrhage. Setting: Inpatient rehabilitation facility Results or Clinical Course: The rehabilitation course was complicated by continued hallucinations, insomnia and visual complaints including diplopia and blurred vision that further complicated his progression in therapy sessions. His right upper extremity strength improved but his ophthalmic symptoms did not. Further developments will be discussed. Discussion: Eight-and-a-half syndrome is a relatively rare disorder that results from a lower pontine tegmentum lesion and presents with unilateral intranuclear ophthalmoplegia, horizontal gaze palsy and lower motor neuron cranial nerve seven palsy. The only remaining horizontal eye movement is abduction of the eye contralateral to the lesion. Nystagmus is often present. Vertical eye movements are preserved. Possible ophthalmological symptoms include diplopia, oscillopsia and blurred vision which may spontaneously resolve but are occasionally persistent and difficult to manage. Conclusion: The ophthalmologic symptoms of the relatively rare eight-and-a-half syndrome following a pontine lesion may be
persistent and crippling in nature and impact the progression of therapy in the rehabilitation stage.
Poster 118 Prolonged Treatment of Paroxysmal Sympathetic Hyperactivity Limits Functional Gains: A Case Report Tomasz Chec, BS (Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States), Ziva Petrin, MD, Matthew B. Sonagere, DO, Kristofer J. Feeko, DO Disclosures: T. Chec: I Have No Relevant Financial Relationships To Disclose. Case Description: A 35-year-old man with a past medical history of hypertension initially presented with non-traumatic type A aortic dissection, complicated by ischemic stroke of the left anterior, left middle, and right posterior cerebral artery, and subsequent cerebral edema treated with a left decompressive hemicraniectomy. He had a complicated hospital course with ventilator-dependent respiratory failure requiring tracheostomy and PEG tube placement. He remained minimally conscious, with recurrent episodes of agitation, fevers, hypertension, tachycardia, diaphoresis and posturing, eventually recognized as paroxysmal sympathetic hyperactivity (PSH). Episodes persisted despite a regimen of quetiapine, clonidine, propranolol, fentanyl, diazepam and bromocriptine. He was discharged to a long-term care facility at a dependent level unable to follow commands. Setting: Tertiary care acute hospital followed by acute inpatient rehabilitation. Results or Clinical Course: He required multiple acute hospital care admissions for numerous infections with fever, tachycardia, and hypertension treated as persistent PSH. Following transmetatarsal amputation 21 months after initial injury, he was admitted to acute inpatient rehabilitation and weaned off bromocriptine, diazepam, and fentanyl without further evidence of sympathetic hyperactivity. He progressed from dependent functional status to improved levels of consciousness with consistent orientation and reliable verbalization. After 3 weeks of rehabilitation he was decannulated, tolerated a soft mechanical diet, followed 3 step commands, directed care for dressing and bathing, supervision for feeding and discharged home with family. Discussion: PSH is a syndrome of transient increases in heart rate, blood pressure, respiratory rate, temperature, and diaphoresis in the setting of severe acquired brain injury. Resolution can be obscured by coexisting infections. Anatomical localization, duration and triggers are still being elucidated. Further insight into resolution of PSH and weaning off medication is needed. Conclusion: Prolonged and inappropriate treatment for PSH, if unrecognized, can limit rehabilitation. Withdrawal of sedating medications can result in significant functional gains.
Poster 119 An Analysis of Early and Late Response to Foot Drop Stimulation in Persons with Stroke Kristina M. Quirolgico, MD (New York Presbyterian Hospital - Columbia and Cornell, New York, NY, United States), Ashley Giambrone, PhD, Ziyad Ayyoub, MD, Steven R. Edgley, MD, Kari Dunning, PT, PhD, Keith McBride, MPT, DPT, Michael W. O’Dell, MD Disclosures: K. M. Quirolgico: Research Grants - Bioness Objective: To identify variables predicting an early (ER) versus late responder (LR) to foot drop stimulation (FDS) in persons with stroke. Design: Secondary analysis of data from FASTEST clinical trial. Setting: Multicenter clinical trial. Participants: Ninety-nine subjects (48.5% female, age¼60.712.4y, time post-stroke¼4.8+5.3y), with foot drop and a comfortable gait
Abstracts / PM R 7 (2015) S83-S222
by admission and discharge functional independence measure (FIM). Clinical characteristics including age, sex, race, marital status, stroke risk factors, stroke site, and discharge destination were recorded. The association between serum BDNF level and stroke functional outcomes was assessed using Pearson’s correlation analysis. Results or Clinical Course: The mean serum BDNF level was 22.609.87ng/ml (range, 5.22-44.83ng/ml). Pearson’s correlation analysis showed that the lower serum BDNF level was associated with less marital family support (r¼0.316, P¼.047), lower FIM motor subscore on admission (r¼0.338, P¼.033) and discharge (r¼0.355, P¼.025) and lower total FIM score on discharge (r¼0.363, P¼.021). Stroke patients with lower serum BDNF level were more likely to be discharged to skilled nursing facility (r¼-0.407, P¼.009). Conclusion: Serum BDNF level was associated with functional outcomes as measured by FIM and discharge destination within 2 month of the onset of stroke. BDNF may serve as a prognostic biomarker for functional recovery and may be used as a surrogate marker to evaluate the responsiveness to targeted neurorestorative therapies. Larger scale studies are warranted to confirm these results.
Poster 117 Eight-and-a-Half Syndrome as a Sequela of Pontine Hemorrhage: A Case Report Rebecca R. Shoemaker (Rehabilitation Institute of Michigan- DMC, Detroit, MI, United States), Maria Humayun, MD Disclosures: R. R. Shoemaker: I Have No Relevant Financial Relationships To Disclose. Case Description: A 52-year-old man presented with eight-and-ahalf syndrome and was found to have a left dorsal pontine hemorrhage as demonstrated on magnetic resonance imaging. He had a past medical history significant for human immunodeficiency virus (HIV) and deep vein thromboses secondary to antiphospholipid syndrome. On initial examination he was found to have left conjugate gaze palsy and partial deviation of gaze in the right eye. Additional findings included a left facial droop and right upper extremity weakness. On later evaluation by ophthalmology he was discovered to have intranuclear ophthalmoplegia of the left eye, torsional nystagmus and 20/50 visual acuity bilaterally. He also had multiple episodes of hallucinations thought to be secondary to narcotics which required antipsychotic medication administration as well as a bedside sitter. When medically stable he was admitted to the neurosciences unit to address the deficits resulting from his pontine hemorrhage. Setting: Inpatient rehabilitation facility Results or Clinical Course: The rehabilitation course was complicated by continued hallucinations, insomnia and visual complaints including diplopia and blurred vision that further complicated his progression in therapy sessions. His right upper extremity strength improved but his ophthalmic symptoms did not. Further developments will be discussed. Discussion: Eight-and-a-half syndrome is a relatively rare disorder that results from a lower pontine tegmentum lesion and presents with unilateral intranuclear ophthalmoplegia, horizontal gaze palsy and lower motor neuron cranial nerve seven palsy. The only remaining horizontal eye movement is abduction of the eye contralateral to the lesion. Nystagmus is often present. Vertical eye movements are preserved. Possible ophthalmological symptoms include diplopia, oscillopsia and blurred vision which may spontaneously resolve but are occasionally persistent and difficult to manage. Conclusion: The ophthalmologic symptoms of the relatively rare eight-and-a-half syndrome following a pontine lesion may be
persistent and crippling in nature and impact the progression of therapy in the rehabilitation stage.
Poster 118 Prolonged Treatment of Paroxysmal Sympathetic Hyperactivity Limits Functional Gains: A Case Report Tomasz Chec, BS (Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States), Ziva Petrin, MD, Matthew B. Sonagere, DO, Kristofer J. Feeko, DO Disclosures: T. Chec: I Have No Relevant Financial Relationships To Disclose. Case Description: A 35-year-old man with a past medical history of hypertension initially presented with non-traumatic type A aortic dissection, complicated by ischemic stroke of the left anterior, left middle, and right posterior cerebral artery, and subsequent cerebral edema treated with a left decompressive hemicraniectomy. He had a complicated hospital course with ventilator-dependent respiratory failure requiring tracheostomy and PEG tube placement. He remained minimally conscious, with recurrent episodes of agitation, fevers, hypertension, tachycardia, diaphoresis and posturing, eventually recognized as paroxysmal sympathetic hyperactivity (PSH). Episodes persisted despite a regimen of quetiapine, clonidine, propranolol, fentanyl, diazepam and bromocriptine. He was discharged to a long-term care facility at a dependent level unable to follow commands. Setting: Tertiary care acute hospital followed by acute inpatient rehabilitation. Results or Clinical Course: He required multiple acute hospital care admissions for numerous infections with fever, tachycardia, and hypertension treated as persistent PSH. Following transmetatarsal amputation 21 months after initial injury, he was admitted to acute inpatient rehabilitation and weaned off bromocriptine, diazepam, and fentanyl without further evidence of sympathetic hyperactivity. He progressed from dependent functional status to improved levels of consciousness with consistent orientation and reliable verbalization. After 3 weeks of rehabilitation he was decannulated, tolerated a soft mechanical diet, followed 3 step commands, directed care for dressing and bathing, supervision for feeding and discharged home with family. Discussion: PSH is a syndrome of transient increases in heart rate, blood pressure, respiratory rate, temperature, and diaphoresis in the setting of severe acquired brain injury. Resolution can be obscured by coexisting infections. Anatomical localization, duration and triggers are still being elucidated. Further insight into resolution of PSH and weaning off medication is needed. Conclusion: Prolonged and inappropriate treatment for PSH, if unrecognized, can limit rehabilitation. Withdrawal of sedating medications can result in significant functional gains.
Poster 119 An Analysis of Early and Late Response to Foot Drop Stimulation in Persons with Stroke Kristina M. Quirolgico, MD (New York Presbyterian Hospital - Columbia and Cornell, New York, NY, United States), Ashley Giambrone, PhD, Ziyad Ayyoub, MD, Steven R. Edgley, MD, Kari Dunning, PT, PhD, Keith McBride, MPT, DPT, Michael W. O’Dell, MD Disclosures: K. M. Quirolgico: Research Grants - Bioness Objective: To identify variables predicting an early (ER) versus late responder (LR) to foot drop stimulation (FDS) in persons with stroke. Design: Secondary analysis of data from FASTEST clinical trial. Setting: Multicenter clinical trial. Participants: Ninety-nine subjects (48.5% female, age¼60.712.4y, time post-stroke¼4.8+5.3y), with foot drop and a comfortable gait