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Poster 292 Cerebellar Cognitive Affective Syndrome Secondary to Metastatic Cerebellar Vermis Mass: A Case Report
PM&R
Results or Clinical Course: Electrodiagnostic study revealed severe peripheral axonal neuropathy affecting only the sensory fibers. There was electrodiagnostic evidence of chronic peripheral neuropathy of the right femoral nerve which was possibly related to a previous abdominal surgery. The patient had some improvement of her functional status with therapies. Discussion: Weakness and incoordination were unusual presentations of the underlying sensory neuropathy. What further complicated this case was the right thigh numbness, which was a manifestation of the unilateral femoral neuropathy. Electrodiagnostic evaluation was essential for the accurate diagnosis of this patient’s complicated condition. Differential diagnosis of sensory peripheral neuropathy includes medication toxicities, paraneoplastic ganglionopathies, metabolic factors, nutritional deficiencies, hereditary neuropathies, immunologically mediated diseases and infections. Oxaliplatin is a third-generation platinum based chemotherapeutic agent. In contrast to other drugs, it can cause acute peripheral nerve hyperexcitability by affecting sodium channels. Chronic neuropathy is due to a direct toxic effect of Oxaliplatin on the sensory nerves. Conclusions: We describe a patient with chronic severe Oxaliplatin induced sensory polyneuropathy. Awareness of this complication is of utmost importance for the rehabilitation professional to provide the patient with a timely and accurate diagnosis along with supportive treatment. Poster 292 Cerebellar Cognitive Affective Syndrome Secondary to Metastatic Cerebellar Vermis Mass: A Case Report. Craig Best, DO (Rush University Medical Center, Chicago, IL, United States); Sri Ranjini Muthukrishnan, MD. Disclosures: C. Best, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 47-year-old man with history of pelvic malignancy, hypertension, hyperlipidemia, and diabetes mellitus presented with headache, vertigo, and gait abnormalities. Magnetic resonance imaging revealed cerebellar vermis mass for which resection was performed. Pathology revealed poorly differentiated metastatic neuroendocrine carcinoma. No further chemotherapy was recommended by Medical Oncology; radiation therapy was recommended by Radiation Oncology. Physiatry examination revealed deficits in orientation, immediate and short-term recall, and emotional lability; vertical nystagmus with all eye movements; normal strength and light touch sensation and symmetric muscle stretch reflexes; no dysmetria or dysdiadochokinesia was noted though gait was ataxic. Neuropsychiatry evaluation noted dysnomia, deficits of executive function, avolition, and personality changes, including increased anger and agitation. In the setting of cerebellar lesion, a diagnosis of cerebellar cognitive affective syndrome for which sertraline was initiated. Setting: Tertiary Care Hospital. Results or Clinical Course: The patient completed a course of acute rehabilitation including physical, occupational, and speech therapy. At time of discharge, he was able to ambulate 200 feet with walker at modified independent level and was at supervision to modified independent for activities of daily living. Finally, his emotional lability and agitation were noted to improve; however, his memory remained poor at time of discharge home with family and 24 hour supervision.
Vol. 6, Iss. 9S, 2014
S287
Discussion: Cerebellar cognitive affective syndrome is characterized by disturbances of executive functioning, impaired spatial cognition, personality changes, and linguistic difficulties which lead to an overall worsening of intellectual function. Lesions of the posterior lobe and/or vermis of the cerebellum are more likely to result in cognitive impairment and behavioral changes. Anatomical and functional neuroimaging studies have revealed complex neural circuitry explaining the cerebellum’s role in high order cognitive and behavioral function. Conclusions: Cerebellar cognitive affective syndrome is a rare though important entity and must be kept in mind when aiding in the the rehabilitation of those patients with cerebellar lesions.
Poster 293 Acute Inpatient Rehabilitation of a Patient with Both Incomplete Tetraplegia and Lower Extremity Amputation. Samantha Mendelson (James A Haley VA Medical Center, Tampa, FL, United States); Allan Alcantara, RN; Larry Kelleher, DO. Disclosures: S. Mendelson, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To describe a unique case and acknowledge acute inpatient rehabilitation needs of a patient with an incomplete spinal cord injury and BKA can be addressed simultaneously. Case Description: This is a 40-year-old man who presented with left lower extremity thromboembolic disease, requiring a below the knee amputation. Six months later he developed lower extremity weakness and neuropathic pain in his midback and distally. A MRI revealed a T3 extramedullary plasmacytoma. He was treated with radiotherapy and steroids, and his symptoms stabilized. He was then diagnosed with T3 AIS B incomplete paraplegia. He applied to multiple inpatient rehabilitation centers, but was denied admission based on his need for both amputee and spinal cord injury rehabilitation. He was accepted and admitted to our acute inpatient spinal cord injury rehabilitation unit with the goal of addressing both components of his new disability. Program Description: During his rehabilitation course, he did undergo a setback when he developed new onset thoracic neuropathic pain. A repeat ASIA examination showed a worsening condition to C4 ASIA D, with plasmacytoma extension shown on MRI into the posterior arch of the T3 vertebrae leading to spinal instability. He underwent tumor debulking, T3 corpectomy and fusion of T1-5. Postoperatively he made slow but steady gains and was treated by our multidisciplinary team including physical therapy, occupational therapy, prosthetics, recreational therapy, psychology, dietary and vocational therapy. He was fitted for a custom below the knee amputee prosthesis. Setting: Inpatient Spinal Cord Injury Rehabilitation Unit. Results or Clinical Course: He continues to progress with his therapies, with the attainable long term goals of modified independence for activities of daily living and community ambulation with BKA prosthesis. Discussion: This case report demonstrates an unusual pair of comorbidities that were both benefitted by comprehensive interdisciplinary inpatient rehabilitation. Our patient ultimately showed gains in motor and overall function, despite his multiple medical setbacks.
Results or Clinical Course: Electrodiagnostic study revealed severe peripheral axonal neuropathy affecting only the sensory fibers. There was electrodiagnostic evidence of chronic peripheral neuropathy of the right femoral nerve which was possibly related to a previous abdominal surgery. The patient had some improvement of her functional status with therapies. Discussion: Weakness and incoordination were unusual presentations of the underlying sensory neuropathy. What further complicated this case was the right thigh numbness, which was a manifestation of the unilateral femoral neuropathy. Electrodiagnostic evaluation was essential for the accurate diagnosis of this patient’s complicated condition. Differential diagnosis of sensory peripheral neuropathy includes medication toxicities, paraneoplastic ganglionopathies, metabolic factors, nutritional deficiencies, hereditary neuropathies, immunologically mediated diseases and infections. Oxaliplatin is a third-generation platinum based chemotherapeutic agent. In contrast to other drugs, it can cause acute peripheral nerve hyperexcitability by affecting sodium channels. Chronic neuropathy is due to a direct toxic effect of Oxaliplatin on the sensory nerves. Conclusions: We describe a patient with chronic severe Oxaliplatin induced sensory polyneuropathy. Awareness of this complication is of utmost importance for the rehabilitation professional to provide the patient with a timely and accurate diagnosis along with supportive treatment. Poster 292 Cerebellar Cognitive Affective Syndrome Secondary to Metastatic Cerebellar Vermis Mass: A Case Report. Craig Best, DO (Rush University Medical Center, Chicago, IL, United States); Sri Ranjini Muthukrishnan, MD. Disclosures: C. Best, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Case Description: A 47-year-old man with history of pelvic malignancy, hypertension, hyperlipidemia, and diabetes mellitus presented with headache, vertigo, and gait abnormalities. Magnetic resonance imaging revealed cerebellar vermis mass for which resection was performed. Pathology revealed poorly differentiated metastatic neuroendocrine carcinoma. No further chemotherapy was recommended by Medical Oncology; radiation therapy was recommended by Radiation Oncology. Physiatry examination revealed deficits in orientation, immediate and short-term recall, and emotional lability; vertical nystagmus with all eye movements; normal strength and light touch sensation and symmetric muscle stretch reflexes; no dysmetria or dysdiadochokinesia was noted though gait was ataxic. Neuropsychiatry evaluation noted dysnomia, deficits of executive function, avolition, and personality changes, including increased anger and agitation. In the setting of cerebellar lesion, a diagnosis of cerebellar cognitive affective syndrome for which sertraline was initiated. Setting: Tertiary Care Hospital. Results or Clinical Course: The patient completed a course of acute rehabilitation including physical, occupational, and speech therapy. At time of discharge, he was able to ambulate 200 feet with walker at modified independent level and was at supervision to modified independent for activities of daily living. Finally, his emotional lability and agitation were noted to improve; however, his memory remained poor at time of discharge home with family and 24 hour supervision.
Vol. 6, Iss. 9S, 2014
S287
Discussion: Cerebellar cognitive affective syndrome is characterized by disturbances of executive functioning, impaired spatial cognition, personality changes, and linguistic difficulties which lead to an overall worsening of intellectual function. Lesions of the posterior lobe and/or vermis of the cerebellum are more likely to result in cognitive impairment and behavioral changes. Anatomical and functional neuroimaging studies have revealed complex neural circuitry explaining the cerebellum’s role in high order cognitive and behavioral function. Conclusions: Cerebellar cognitive affective syndrome is a rare though important entity and must be kept in mind when aiding in the the rehabilitation of those patients with cerebellar lesions.
Poster 293 Acute Inpatient Rehabilitation of a Patient with Both Incomplete Tetraplegia and Lower Extremity Amputation. Samantha Mendelson (James A Haley VA Medical Center, Tampa, FL, United States); Allan Alcantara, RN; Larry Kelleher, DO. Disclosures: S. Mendelson, No Disclosures: I Have No Relevant Financial Relationships to Disclose. Objective: To describe a unique case and acknowledge acute inpatient rehabilitation needs of a patient with an incomplete spinal cord injury and BKA can be addressed simultaneously. Case Description: This is a 40-year-old man who presented with left lower extremity thromboembolic disease, requiring a below the knee amputation. Six months later he developed lower extremity weakness and neuropathic pain in his midback and distally. A MRI revealed a T3 extramedullary plasmacytoma. He was treated with radiotherapy and steroids, and his symptoms stabilized. He was then diagnosed with T3 AIS B incomplete paraplegia. He applied to multiple inpatient rehabilitation centers, but was denied admission based on his need for both amputee and spinal cord injury rehabilitation. He was accepted and admitted to our acute inpatient spinal cord injury rehabilitation unit with the goal of addressing both components of his new disability. Program Description: During his rehabilitation course, he did undergo a setback when he developed new onset thoracic neuropathic pain. A repeat ASIA examination showed a worsening condition to C4 ASIA D, with plasmacytoma extension shown on MRI into the posterior arch of the T3 vertebrae leading to spinal instability. He underwent tumor debulking, T3 corpectomy and fusion of T1-5. Postoperatively he made slow but steady gains and was treated by our multidisciplinary team including physical therapy, occupational therapy, prosthetics, recreational therapy, psychology, dietary and vocational therapy. He was fitted for a custom below the knee amputee prosthesis. Setting: Inpatient Spinal Cord Injury Rehabilitation Unit. Results or Clinical Course: He continues to progress with his therapies, with the attainable long term goals of modified independence for activities of daily living and community ambulation with BKA prosthesis. Discussion: This case report demonstrates an unusual pair of comorbidities that were both benefitted by comprehensive interdisciplinary inpatient rehabilitation. Our patient ultimately showed gains in motor and overall function, despite his multiple medical setbacks.