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Poster 302 Hemiballism in Middle Cerebral Artery Stroke Improved by Conventional Rehabilitation Therapy: A Case Report
S258
Abstracts / PM R 8 (2016) S151-S332
Case/Program Description: This is a case of a 54-year-old man with a history of hypertension who presented to the emergency department due to sudden onset of atypical chest pain, nausea, abdominal pain, and back pain. Shortly after having the symptoms, he experienced bilateral lower limb weakness, numbness, and urinary and bowel incontinence. He denied being on anticoagulation or having any recent trauma. On examination, he was found to have 0/5 strength throughout his bilateral lower limbs. Patient was also found to have persistent priapism. Vitals were unremarkable except for hypertension of 162/95. After receiving dexamethasone, the patient regained marginal sensory and motor function. He was found to have a spinal epidural hematoma from T2-T6 on MRI, and was immediately taken to the operating room for laminectomy and hematoma evacuation. Visualization of the venous plexus did not reveal any abnormalities. There were no arteriovenous malformations identified on angiogram of the spinal arteries. Setting: Academic tertiary hospital. Results: Postoperatively, the patient was admitted to the acute neurosurgical services with continued physical and occupational therapy. By the time he was seen by the physiatrist consult on post-op day 5, the patient was ambulating 250ft with contact guard assist. Patient was discharged with home health care. Discussion: Spontaneous spinal epidural hematoma (SSEH) is a neurological emergency which typically presents as back pain with weakness to the limbs. In the case of this patient, he also presented with an atypical symptom of chest pain. Factors which contribute to SSEH, however, such as AVM, hemophilia, a recent anticoagulation use, did not present with this patient. Conclusions: As a rare neurological emergency, symptoms of SSEH may present as atypical chest pain, highlighting the importance of performing a thorough history and physical examination. Idiopathic cases of SSEH account for a large portion of cases, and its causes are not fully understood. While this patient presented with more severe findings, recognition of SSEH lead to a favorable outcome. Level of Evidence: Level V Poster 301 Newly Diagnosed Spinal Cord Injury Caused by Vertebra Osteomyelitis in a Patient with Complicated Traumatic Brain Injury: A Case Report Saiyun Hou, MD, PhD (Baylor College of Medicine, Houston, TX, United States), Monica Verduzco-Gutierrez, MD Disclosures: Saiyun Hou: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 62-year-old man with PMH of HTN, HLD, DM sustained TBI due to a motor vehicle accident with initial GCS of 3 improved to a 10 when admitted. He was found to have SDH and SAH shown on CT, which later got worse. Patient was not considered a candidate for any intervention. Patient was noted to have T4 and T6 mild body fracture, which was evaluated by neurosurgery and no intervention or brace were needed. His initial physical exam showed 2-3/5 RUE and 1/5 RLE, 3-4/5 LUE and LLE with normal tone. He was alert and oriented to person and place. His bowel and bladder were continent. His hospital course was complicated by one episode of sepsis and one episode of MRSA bacteremia for which patient was transferred to ICU and treated with antibiotics. He developed incontinent bladder and was unable to void when readmitted to rehabilitation center. His all extremities strength was worsening and bilateral lower extremities became flaccid. Then he spiked fever and had second episode of MRSA bacteremia, treated with antibiotics. He received stat spine MRI revealing pathologic fracture of the T4 vertebral body, with 75% loss of height, and encroachment of the posterior portion of the vertebral body into the spinal canal. AISA score was T6 AIS A. Setting: Tertiary care hospital. Results: Patient underwent emergency surgery of T3-4 laminectomy with T2-6 posterior spinal fusion, and 5 days later right transthoracic
T4 corpectomy and T3-T5 anterior arthrodesis. Intraoperative tissue culture showed positive MRSA. Biopsy of tissue was with no neoplasm. Discussion: This is the first reported case, to our knowledge, of newly diagnosed spinal cord injury caused by vertebra osteomyelitis following multiple episodes of bacteremia in a patient with complicated TBI. Conclusions: Multiple episodes of bacteremia increase risk of vertebra osteomyelitis leading to spinal cord injury although it is rare. TBI may delay an accurate diagnosis and prolong suffering. Close monitor of neurological change is key to lead to early and accurate diagnosis. Level of Evidence: Level V Poster 302 Hemiballism in Middle Cerebral Artery Stroke Improved by Conventional Rehabilitation Therapy: A Case Report Cora H. Brown, MD (Temple University Hospital, Philadelphia, Pennsylvania, United States), Alexander J. Feng, MD, Phillip Acevedo, MD, Ernesto Cruz, MD Disclosures: Cora Brown: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 85-year-old man presented with right hemiparesis and profound expressive aphasia of 1-hour duration. On neurological exam he had right facial paresis, right sided hemineglect, decreased coordination along with involuntary, rotatory flinging of right upper limb spreading to right lower limb. CT angiography of the head showed left middle cerebral artery (MCA) infarction with M1 branch occlusion. The patient was treated with intravenous tissue plasminogen activator (tPA) and thrombectomy of the M1 occlusion. After the treatment with tPA he showed improvement of the right hemiparesis but the aphasia and hemiballistic movements persisted. Due to the embolic nature of the stroke, he was treated with aspirin, coumadin, lovastatin and later transferred to acute stroke rehabilitation service. Setting: Acute stroke rehabilitation service. Results: After 2 weeks of proprioceptive neuromuscular facilitation (PNF) therapy, wearing right wrist and ankle weights, dynamic standing balance training, and Frenkel exercises the patient showed improvement of the hemiballistic movements, coordination and apraxia of the right hemiplegic limbs. He reached goals with transfer, activities of daily living (ADLs) and ambulation of 300 feet at modified independence. The expressive aphasia was reported at mild severity after speech-enhancing strategies. Discussion: Hemiballism is a rare symptom and described as involuntary, large-amplitude, rotatory movements of hemiparetic limbs. The etiology most commonly involves the subthalamic nucleus but any focal lesion located in the basal ganglia may cause hemiballism. Antipsychotics, sterotactic neurosurgery alone or in combination with physical therapy have been used to treat hemiballism in prior studies with variable time of functional recovery. Conclusions: Post-stroke hemiballism can significantly impair patients’ function. Medical therapy with antipsychotics for hemiballism may impede cognitive recovery in stroke patients while surgical intervention can cause unwanted complications. Our case proves that hemiballism can be improved in a short period of time with rehabilitation measures alone. Level of Evidence: Level V Poster 303 Bladder Distension Associated with Hypotension in a Patient with Tetraplegia after Spinal Cord Injury: A Case Report Saiyun Hou, MD, PhD (Baylor College of Medicine, Houston, TX, United States), Matthew Davis, MD Disclosures: Saiyun Hou: I Have No Relevant Financial Relationships To Disclose
Abstracts / PM R 8 (2016) S151-S332
Case/Program Description: This is a case of a 54-year-old man with a history of hypertension who presented to the emergency department due to sudden onset of atypical chest pain, nausea, abdominal pain, and back pain. Shortly after having the symptoms, he experienced bilateral lower limb weakness, numbness, and urinary and bowel incontinence. He denied being on anticoagulation or having any recent trauma. On examination, he was found to have 0/5 strength throughout his bilateral lower limbs. Patient was also found to have persistent priapism. Vitals were unremarkable except for hypertension of 162/95. After receiving dexamethasone, the patient regained marginal sensory and motor function. He was found to have a spinal epidural hematoma from T2-T6 on MRI, and was immediately taken to the operating room for laminectomy and hematoma evacuation. Visualization of the venous plexus did not reveal any abnormalities. There were no arteriovenous malformations identified on angiogram of the spinal arteries. Setting: Academic tertiary hospital. Results: Postoperatively, the patient was admitted to the acute neurosurgical services with continued physical and occupational therapy. By the time he was seen by the physiatrist consult on post-op day 5, the patient was ambulating 250ft with contact guard assist. Patient was discharged with home health care. Discussion: Spontaneous spinal epidural hematoma (SSEH) is a neurological emergency which typically presents as back pain with weakness to the limbs. In the case of this patient, he also presented with an atypical symptom of chest pain. Factors which contribute to SSEH, however, such as AVM, hemophilia, a recent anticoagulation use, did not present with this patient. Conclusions: As a rare neurological emergency, symptoms of SSEH may present as atypical chest pain, highlighting the importance of performing a thorough history and physical examination. Idiopathic cases of SSEH account for a large portion of cases, and its causes are not fully understood. While this patient presented with more severe findings, recognition of SSEH lead to a favorable outcome. Level of Evidence: Level V Poster 301 Newly Diagnosed Spinal Cord Injury Caused by Vertebra Osteomyelitis in a Patient with Complicated Traumatic Brain Injury: A Case Report Saiyun Hou, MD, PhD (Baylor College of Medicine, Houston, TX, United States), Monica Verduzco-Gutierrez, MD Disclosures: Saiyun Hou: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 62-year-old man with PMH of HTN, HLD, DM sustained TBI due to a motor vehicle accident with initial GCS of 3 improved to a 10 when admitted. He was found to have SDH and SAH shown on CT, which later got worse. Patient was not considered a candidate for any intervention. Patient was noted to have T4 and T6 mild body fracture, which was evaluated by neurosurgery and no intervention or brace were needed. His initial physical exam showed 2-3/5 RUE and 1/5 RLE, 3-4/5 LUE and LLE with normal tone. He was alert and oriented to person and place. His bowel and bladder were continent. His hospital course was complicated by one episode of sepsis and one episode of MRSA bacteremia for which patient was transferred to ICU and treated with antibiotics. He developed incontinent bladder and was unable to void when readmitted to rehabilitation center. His all extremities strength was worsening and bilateral lower extremities became flaccid. Then he spiked fever and had second episode of MRSA bacteremia, treated with antibiotics. He received stat spine MRI revealing pathologic fracture of the T4 vertebral body, with 75% loss of height, and encroachment of the posterior portion of the vertebral body into the spinal canal. AISA score was T6 AIS A. Setting: Tertiary care hospital. Results: Patient underwent emergency surgery of T3-4 laminectomy with T2-6 posterior spinal fusion, and 5 days later right transthoracic
T4 corpectomy and T3-T5 anterior arthrodesis. Intraoperative tissue culture showed positive MRSA. Biopsy of tissue was with no neoplasm. Discussion: This is the first reported case, to our knowledge, of newly diagnosed spinal cord injury caused by vertebra osteomyelitis following multiple episodes of bacteremia in a patient with complicated TBI. Conclusions: Multiple episodes of bacteremia increase risk of vertebra osteomyelitis leading to spinal cord injury although it is rare. TBI may delay an accurate diagnosis and prolong suffering. Close monitor of neurological change is key to lead to early and accurate diagnosis. Level of Evidence: Level V Poster 302 Hemiballism in Middle Cerebral Artery Stroke Improved by Conventional Rehabilitation Therapy: A Case Report Cora H. Brown, MD (Temple University Hospital, Philadelphia, Pennsylvania, United States), Alexander J. Feng, MD, Phillip Acevedo, MD, Ernesto Cruz, MD Disclosures: Cora Brown: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 85-year-old man presented with right hemiparesis and profound expressive aphasia of 1-hour duration. On neurological exam he had right facial paresis, right sided hemineglect, decreased coordination along with involuntary, rotatory flinging of right upper limb spreading to right lower limb. CT angiography of the head showed left middle cerebral artery (MCA) infarction with M1 branch occlusion. The patient was treated with intravenous tissue plasminogen activator (tPA) and thrombectomy of the M1 occlusion. After the treatment with tPA he showed improvement of the right hemiparesis but the aphasia and hemiballistic movements persisted. Due to the embolic nature of the stroke, he was treated with aspirin, coumadin, lovastatin and later transferred to acute stroke rehabilitation service. Setting: Acute stroke rehabilitation service. Results: After 2 weeks of proprioceptive neuromuscular facilitation (PNF) therapy, wearing right wrist and ankle weights, dynamic standing balance training, and Frenkel exercises the patient showed improvement of the hemiballistic movements, coordination and apraxia of the right hemiplegic limbs. He reached goals with transfer, activities of daily living (ADLs) and ambulation of 300 feet at modified independence. The expressive aphasia was reported at mild severity after speech-enhancing strategies. Discussion: Hemiballism is a rare symptom and described as involuntary, large-amplitude, rotatory movements of hemiparetic limbs. The etiology most commonly involves the subthalamic nucleus but any focal lesion located in the basal ganglia may cause hemiballism. Antipsychotics, sterotactic neurosurgery alone or in combination with physical therapy have been used to treat hemiballism in prior studies with variable time of functional recovery. Conclusions: Post-stroke hemiballism can significantly impair patients’ function. Medical therapy with antipsychotics for hemiballism may impede cognitive recovery in stroke patients while surgical intervention can cause unwanted complications. Our case proves that hemiballism can be improved in a short period of time with rehabilitation measures alone. Level of Evidence: Level V Poster 303 Bladder Distension Associated with Hypotension in a Patient with Tetraplegia after Spinal Cord Injury: A Case Report Saiyun Hou, MD, PhD (Baylor College of Medicine, Houston, TX, United States), Matthew Davis, MD Disclosures: Saiyun Hou: I Have No Relevant Financial Relationships To Disclose