- Email: [email protected]
Poster 315: Unmasking Rehabilitation Potential in a Veteran with Bilateral Syndrome of Trephined: A Case Report
S232
Abstracts / PM R 9 (2017) S131-S290
Poster 315: Unmasking Rehabilitation Potential in a Veteran with Bilateral Syndrome of Trephined: A Case Report Logan McCool, DO (University of Minnesota, Minneapolis, Minnesota, United States), Neha P. James, DO, Mary Himmler, MD Disclosures: Logan McCool, DO: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A veteran who was involved in a moped accident with initial GCS of 8 and sustained multiple injuries including severe TBI with bilateral subdural hematomas and subarachnoid hemorrhages, bilateral basilar skull fractures, LeForte 3 fracture, and multiple other facial fractures. This veteran underwent bilateral craniectomies with abdominal skull flap placement. Veteran was enrolled in Emerging Consciousness Program about 1.5 months after bilateral craniectomy. Hospital course was complicated by neurostorming, infected bone flaps, tracheostomy placement, and 2 months of decerebrate posturing. Underwent bifrontal cranioplasty 3.5 months after craniectomy. Right temporal intraparenchymal and subdural hemorrhage noted intraoperatively. Setting: Tertiary care rehabilitation hospital. Results: Bilateral upper extremity extensor posturing persisted in the immediate post-cranioplasty period and gradually improved after bilateral cranioplasty. The veteran was classified as CRS-R 3 postoperatively and improved to CRS-R 19 approximately 1 month postoperatively. Seven months from the time of injury and 3 months from the time of bilateral cranioplasty, the veteran was ambulating with front wheeled walker and speaking in complete sentences. He is anticipating discharge home with family. Discussion: This is the first case, to our knowledge, of bilateral syndrome of trephined with 5 month follow up in acute inpatient rehabilitation. The Syndrome of Trephined (also known as Sunken Flap Syndrome) is a rare complication following large craniectomy that clinically manifests as severe headache, focal neural changes, seizures or cognitive changes. Syndrome of Trephined was first reported in 1977 and is thought to be a result of a negative pressure gradient between atmospheric and intracranial pressures. In a meta-analysis published in 2016, cranioplasty after onset of Syndrome of Trephined is reported to have improved neurological outcomes. Our case report suggests the important role cranioplasty may serve in unmasking rehabilitation potential. Conclusions: Physiatrists must recognize the importance of early cranioplasty in improving patients with the Syndrome of Trephined. Level of Evidence: Level V
Poster 316: Successive Recovery for Aphasia in the Bilingual Brain: A Case Report Priya B. Patel, DO (Mt Sinai Hlth Sys), Jeffrey S. Fine, MD Disclosures: Priya Patel: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 52-year-old right handed woman with medical history of hypertension and hyperlipidemia admitted following left thalamic stroke. Admission exam was notable for right hemiparesis, expressive and receptive aphasia, and dysphagia. CT head revealed left thalamic hemorrhage with midline shift and surrounding edema resulting in effacement of the third ventricle and dilatation of the right temporal horn. Hemorrhage was managed conservatively and patient was admitted to inpatient rehabilitation. Setting: Inpatient rehabilitation unit. Results: Upon rehabilitation admission, patient only spoke her native language of Bengali, but a dialect she learned in childhood, and per husband, she did not use for many years. As her edema resolved, her aphasia improved in a step-wise fashion. In several days, she started
speaking contemporary Bengali and increased comprehension to verbal commands in English. Subsequently, she was able to respond to basic questions in English with limited English proficiency, which was her baseline prior to stroke. Interestingly, edema resolution correlated with progressive step-wise recovery of successive languages. Discussion: Aphasia is commonly seen in stroke patients, especially those with damage to the left hemisphere, which is responsible for language function. Expressive aphasia (Broca’s area) presents as fragmented speech, but comprehension is intact. Receptive aphasia (Wernicke’s aphasia) presents as difficulty with comprehension, but fluent speech. This case demonstrates that patients with primary lesions distant to the language centers can still exhibit aphasia as a result of significant edema. Our patient demonstrates the importance of daily monitoring of communication ability, particularly in bilingual patients. Conclusions: This case highlights the importance of thorough history taking including cultural and linguistic background and its value in assessing the recovery of left hemisphere pathways in patients that are bilingual communicators. This information allowed us to clinically monitor resolving peri-hemorrhage edema and its effect on patient communication. Level of Evidence: Level V
Poster 317: T12 Schwannoma with Loculated Syrinx Extending to the Cervico-Medullary Junction: A Case Report Sanjay J. Digamber (Rush University Medical Center), Daniel Bunzol, MD Disclosures: Sanjay Digamber: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 35-year-old man presented with a 6month history of worsening bilateral lower extremity weakness. He has no past medical history and is originally from Guatemala. He works as a manual laborer and first noticed his symptoms while lifting boxes at work. He also developed urinary retention and constipation with bowel movements every 4 days. He reports abnormal sensation from the umbilucus and below. The patient had no upper extremity symptoms and he was completely independent with all activities of daily living and gait prior to onset. His weakness progressed to the point where he required the use of a rolling walker to ambulate. At this point he decided to see a physician. Imaging showed a T12 intradural and intramedullary mass arising from the conus medullaris with loculated syrinx extending from T12 to the cervico-medullary junction. Neurosurgery evaluated patient and he underwent T10-11 laminectomy with tumor resection. Setting: Acute Inpatient Rehabilitation. Results: His lower extremity weakness improved over the course of his rehab stay. His right lower extremity was 1/5 for hip flexion, 2/5 for knee extension, and 4/5 for plantarflexion and dorsiflexion on admission. On the left he was 3+/5 for hip flexion and 4-/5 throughout. Over his rehab stay he was 4+/5 throughout the left extremity and 5/5 on the right. Ambulating 10 feet with walker on admission and beyond 230 feet through rehab course. Discussion: This patient showed significant progress with prompt management and intensive therapy. His lower extremities improved significantly and he had no upper extremity symptoms throughout his hospital course. His constipation has resolved and sensation below T10 has improved. Conclusions: Young and otherwise healthy patients with extensive loculated syringomyelia throughout the spinal cord may present with no upper extremity symptoms. With timely surgical management and prompt transfer to rehab these patients can show dramatic improvement. Level of Evidence: Level V
Abstracts / PM R 9 (2017) S131-S290
Poster 315: Unmasking Rehabilitation Potential in a Veteran with Bilateral Syndrome of Trephined: A Case Report Logan McCool, DO (University of Minnesota, Minneapolis, Minnesota, United States), Neha P. James, DO, Mary Himmler, MD Disclosures: Logan McCool, DO: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A veteran who was involved in a moped accident with initial GCS of 8 and sustained multiple injuries including severe TBI with bilateral subdural hematomas and subarachnoid hemorrhages, bilateral basilar skull fractures, LeForte 3 fracture, and multiple other facial fractures. This veteran underwent bilateral craniectomies with abdominal skull flap placement. Veteran was enrolled in Emerging Consciousness Program about 1.5 months after bilateral craniectomy. Hospital course was complicated by neurostorming, infected bone flaps, tracheostomy placement, and 2 months of decerebrate posturing. Underwent bifrontal cranioplasty 3.5 months after craniectomy. Right temporal intraparenchymal and subdural hemorrhage noted intraoperatively. Setting: Tertiary care rehabilitation hospital. Results: Bilateral upper extremity extensor posturing persisted in the immediate post-cranioplasty period and gradually improved after bilateral cranioplasty. The veteran was classified as CRS-R 3 postoperatively and improved to CRS-R 19 approximately 1 month postoperatively. Seven months from the time of injury and 3 months from the time of bilateral cranioplasty, the veteran was ambulating with front wheeled walker and speaking in complete sentences. He is anticipating discharge home with family. Discussion: This is the first case, to our knowledge, of bilateral syndrome of trephined with 5 month follow up in acute inpatient rehabilitation. The Syndrome of Trephined (also known as Sunken Flap Syndrome) is a rare complication following large craniectomy that clinically manifests as severe headache, focal neural changes, seizures or cognitive changes. Syndrome of Trephined was first reported in 1977 and is thought to be a result of a negative pressure gradient between atmospheric and intracranial pressures. In a meta-analysis published in 2016, cranioplasty after onset of Syndrome of Trephined is reported to have improved neurological outcomes. Our case report suggests the important role cranioplasty may serve in unmasking rehabilitation potential. Conclusions: Physiatrists must recognize the importance of early cranioplasty in improving patients with the Syndrome of Trephined. Level of Evidence: Level V
Poster 316: Successive Recovery for Aphasia in the Bilingual Brain: A Case Report Priya B. Patel, DO (Mt Sinai Hlth Sys), Jeffrey S. Fine, MD Disclosures: Priya Patel: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 52-year-old right handed woman with medical history of hypertension and hyperlipidemia admitted following left thalamic stroke. Admission exam was notable for right hemiparesis, expressive and receptive aphasia, and dysphagia. CT head revealed left thalamic hemorrhage with midline shift and surrounding edema resulting in effacement of the third ventricle and dilatation of the right temporal horn. Hemorrhage was managed conservatively and patient was admitted to inpatient rehabilitation. Setting: Inpatient rehabilitation unit. Results: Upon rehabilitation admission, patient only spoke her native language of Bengali, but a dialect she learned in childhood, and per husband, she did not use for many years. As her edema resolved, her aphasia improved in a step-wise fashion. In several days, she started
speaking contemporary Bengali and increased comprehension to verbal commands in English. Subsequently, she was able to respond to basic questions in English with limited English proficiency, which was her baseline prior to stroke. Interestingly, edema resolution correlated with progressive step-wise recovery of successive languages. Discussion: Aphasia is commonly seen in stroke patients, especially those with damage to the left hemisphere, which is responsible for language function. Expressive aphasia (Broca’s area) presents as fragmented speech, but comprehension is intact. Receptive aphasia (Wernicke’s aphasia) presents as difficulty with comprehension, but fluent speech. This case demonstrates that patients with primary lesions distant to the language centers can still exhibit aphasia as a result of significant edema. Our patient demonstrates the importance of daily monitoring of communication ability, particularly in bilingual patients. Conclusions: This case highlights the importance of thorough history taking including cultural and linguistic background and its value in assessing the recovery of left hemisphere pathways in patients that are bilingual communicators. This information allowed us to clinically monitor resolving peri-hemorrhage edema and its effect on patient communication. Level of Evidence: Level V
Poster 317: T12 Schwannoma with Loculated Syrinx Extending to the Cervico-Medullary Junction: A Case Report Sanjay J. Digamber (Rush University Medical Center), Daniel Bunzol, MD Disclosures: Sanjay Digamber: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 35-year-old man presented with a 6month history of worsening bilateral lower extremity weakness. He has no past medical history and is originally from Guatemala. He works as a manual laborer and first noticed his symptoms while lifting boxes at work. He also developed urinary retention and constipation with bowel movements every 4 days. He reports abnormal sensation from the umbilucus and below. The patient had no upper extremity symptoms and he was completely independent with all activities of daily living and gait prior to onset. His weakness progressed to the point where he required the use of a rolling walker to ambulate. At this point he decided to see a physician. Imaging showed a T12 intradural and intramedullary mass arising from the conus medullaris with loculated syrinx extending from T12 to the cervico-medullary junction. Neurosurgery evaluated patient and he underwent T10-11 laminectomy with tumor resection. Setting: Acute Inpatient Rehabilitation. Results: His lower extremity weakness improved over the course of his rehab stay. His right lower extremity was 1/5 for hip flexion, 2/5 for knee extension, and 4/5 for plantarflexion and dorsiflexion on admission. On the left he was 3+/5 for hip flexion and 4-/5 throughout. Over his rehab stay he was 4+/5 throughout the left extremity and 5/5 on the right. Ambulating 10 feet with walker on admission and beyond 230 feet through rehab course. Discussion: This patient showed significant progress with prompt management and intensive therapy. His lower extremities improved significantly and he had no upper extremity symptoms throughout his hospital course. His constipation has resolved and sensation below T10 has improved. Conclusions: Young and otherwise healthy patients with extensive loculated syringomyelia throughout the spinal cord may present with no upper extremity symptoms. With timely surgical management and prompt transfer to rehab these patients can show dramatic improvement. Level of Evidence: Level V