Poster 313: Klüver-Bucy Syndrome After Facial Gunshot Wound: A Case Report

Abstracts / PM R 9 (2017) S131-S290 Conclusions: Ropinirole was fundamental to control dyskinesia in this patient with MS and well controlled spasticity. Level of Evidence: Level V Poster 312: Rare Cause of Ulnar Neuropathy in an 18-Year-Old Musician: A Case Report Brennan Boettcher, DO (Mayo Clinic, Rochester, MN, United States), Terin Euerle, MD, Eric J. Sorenson, MD Disclosures: Brennan Boettcher: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 18-year-old right handed female musician presented for evaluation of left hand weakness, first noted 19 months prior while trying to play bar cords on her guitar and subsequently difficulty flattening her hand for a hand scanner in the airport. More recently, she noted hypothenar atrophy in the hand. She had no numbness or other neurologic complaints. She was evaluated elsewhere with electromyography (EMG) which was concerning for a C8 radiculopathy. Cervical spine advanced imaging was normal. Exam revealed left hypothenar atrophy, ulnar clawing, positive Froment’s sign, and severe weakness of the hypothenar and interosseous muscles but no thenar weakness. Sensory exam was normal. Tinel’s in the left forearm was positive, but negative at the ulnar groove and carpal tunnel. Setting: Quaternary care academic center. Results: Nerve conduction studies demonstrated low left ulnar motor amplitude with prominent dispersion and conduction block between the elbow and wrist as well as low amplitude ulnar sensory response. The dorsal ulnar cutaneous and medial antebrachial cutaneous sensory responses were normal. Needle EMG demonstrated chronic neurogenic changes in the ulnar muscles of the hand with sparse fibrillation potentials. Proximal ulnar, medial cord and C8/T1 innervated muscles were normal. Ultrasound of the ulnar nerve demonstrated a focal nerve enlargement in the mid-forearm and loss of fascicular architecture. MRI showed segmental fascicular enlargement, T2 hyperintensity and enhancement of the ulnar nerve with associated muscular denervation changes, suggestive of perineurioma. Discussion: A perineurioma is a rare cause of a peripheral mononeuropathy. Knowledge of this condition and imaging findings are essential for accurate diagnosis. Perineuriomas are slow growing tumors arising from perineural cells demonstrating fusiform fascicular enlargement and intense gadolinium enhancement. Conclusions: Consultation with a peripheral nerve neurosurgeon and peripheral nerve neurologist resulted in a plan for continued observation and repeat imaging with no role for surgery. Level of Evidence: Level V Poster 313: ¨ver-Bucy Syndrome After Facial Gunshot Wound: Klu A Case Report Henry S. York, MD (Univ of Maryland School of Medicine, Baltimore, Maryland, United States), Ryan McCarter IV, MS Disclosures: Henry S. York, MD: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This 25-year-old man with history of ADHD and childhood seizures sustained a self-inflicted gunshot wound to the right-side of his face resulting in bi-frontal temporal lobe contusions, right globe rupture and extrusion, extra-axial hemorrhage, and bilateral Le Fort III and zygomatic arch fractures that obliterated his bilateral orbital floors and optic nerves. His Glasgow Coma Scale score was 5T on arrival to the acute hospital where the above fractures were repaired and his right eye was enucleated; he was diagnosed with cortical blindness. Because of his significant functional deficits, he participated in Comprehensive Inpatient Brain Injury Rehabilitation,

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where he displayed inappropriate sexual behaviors, hyperphagia, and profound anterograde and retrograde amnesia, symptoms consistent with Klu ¨ver-Bucy syndrome. The patient made sufficient progress such that he could perform mobility and activities of daily living with close supervision and verbal cues. He was discharged home but continued to have moderate-severe cognitive, communication, and memory deficits. Setting: Rehabilitation hospital. Results: One year post-injury, his residual memory and cognition has improved. The patient remains significantly overweight (306 pounds), but it is stable. He continues to be followed by a team of physicians for multiple secondary medical conditions. Discussion: Klu ¨vereBucy syndrome results from bilateral lesions of the medial temporal lobe including the amygdaloid nucleus and can present with hyperphagia, hypersexuality, hyperorality, visual agnosia, and docility. It is rare for humans to display all of the above symptoms but three or more are necessary for diagnosis. The most common symptoms in humans are placidity, hyperorality, and dietary changes. Only two other cases of Klu ¨ver-Bucy syndrome after a gunshot wound to the head are described in the literature. Conclusions: Klu ¨ver-Bucy syndrome is rare but can be seen in individuals with penetrating traumatic brain injuries. Provider awareness of all the features of Klu ¨ver-Bucy syndrome can help patients obtain appropriate consultation and guidance. Level of Evidence: Level V Poster 314: Challenging Cases of Ultrasound Guided Baclofen Pump Refills: A Case Series Jesse N. Charnoff, MD (University of Miami/Jackson Memorial, Miami, FL, United States), Diana Molinares Mejia, MD, Armen Derian, MD, Seema R. Khurana, DO Disclosures: Jesse N. Charnoff, MD: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Ultrasound is a valuable tool in performing minimally invasive procedures such as joint injections. The current gold standard in intrathecal baclofen pump refills is the use of a template. Templates are sufficient in many cases, however in certain cases their use may be limited due to several factors that make pump refills difficult. These include obesity, pump tilting or migration. Introduction of ultrasound in these cases decreased the difficulty of locating of the reservoir port, decreased procedure time, and improved patient satisfaction. This case series describes a novel technique to refill intrathecal pumps using ultrasound guidance. Setting: Outpatient spasticity clinic. Results: Patients reported that in comparison to the template method, ultrasound guidance was less traumatic. In all cases, the needle was inserted in the correct location on the first attempt. The patients reported increased satisfaction with the use of ultrasound. Discussion: The utility of using ultrasound to assist in refilling intrathecal baclofen pump reservoirs has not been studied. In our three cases we found that ultrasound guidance is beneficial for both patients and physicians. In difficult cases of intrathecal pump refills, ultrasound may help physicians perform more effectively and efficiently. The patient may benefit from fewer needle-sticks, because the pump can be visualized throughout the procedure. Conclusions: Ultrasound guidance improves the accuracy of intrathecal pump refills, particularly in difficult cases where the reservoir port may not be as easily identified using templates or palpation guidance. This novel technique involves the use of a marking pen in order to avoid any sterile gel penetrating the abdomen with the needle advanced under ultrasound directly. By marking the site first, then inserting the needle after sterilization, we penetrated the pump reservoir with 100% accuracy. Further studies will compare ultrasound guidance to the traditional template and blind, palpation based techniques. Level of Evidence: Level V