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Poster 35 Use of Bromocriptine in Akinetic Mutism after Superior Sagittal Sinus Thrombosis with Hemorrhagic Venous Infarcts: A Case Report
Abstracts / PM R 7 (2015) S83-S222 spasticity levels, pain, sleep, fatigue, and quality of life between individuals receiving treatment with intrathecal versus oral baclofen. Design: Cross-sectional matched cohort survey study. Setting: Urban academic rehabilitation outpatient clinics. Participants: Adult patients with spasticity, treated with intrathecal or oral baclofen for at least 1 year, matched 1:1 for age, gender, and diagnosis. Interventions: Not applicable Main Outcome Measures: Surveys included the Penn Spasm Frequency Scale (PSFS), Brief Pain Inventory, Epworth Sleepiness Scale, Fatigue Severity Scale, Life Satisfaction Questionnaire, Diener Satisfaction with Life Scale. Results or Clinical Course: 62 matched subjects were enrolled. The mean (standard deviation, [SD]) age was 46 (11) years with a mean duration of intrathecal baclofen or oral baclofen treatment of 10.8 (5.8) and 12.1 (10.4) years, respectively. There were 40 (64%) males and 22 (36%) females. Primary diagnoses included spinal cord injury (SCI) (n¼38), cerebral palsy (n¼10), stroke (n¼10) and multiple sclerosis (n¼4). The mean (SD) dose of intrathecal and oral baclofen at the time of survey were 577 mcg (1429) and 86 mg (50), respectively. Patients receiving intrathecal compared to oral baclofen experienced significantly fewer [1.4 (0.9) vs. 2.4 (1.1)] and less severe [1.4 (0.9) vs. 2.2 (0.8)] spasms, respectively, as measured by the PSFS (P<.01; P<.01). There were no significant differences in pain, sleep, fatigue and quality of life between groups. Subanalysis of patients with SCI mirrored results of the entire study sample, with significant decreases in spasm frequency and severity associated with intrathecal compared to oral baclofen (P<.01; P<.01), but no other between group differences. Conclusion: Long-term treatment with intrathecal compared to oral baclofen is associated with reduced spasm frequency and severity.
Poster 35 Use of Bromocriptine in Akinetic Mutism after Superior Sagittal Sinus Thrombosis with Hemorrhagic Venous Infarcts: A Case Report Laura E. Black, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States), Priya V. Mhatre, MD Disclosures: L. E. Black: I Have No Relevant Financial Relationships To Disclose. Case Description: A 44-year-old woman initially presented to acute care with headaches and a third ventricle lesion that extended into the suprasellar cistern. She underwent bifrontal craniotomy with biopsy of the mass; pathology results showed pilocytic astrocytoma. Hospital course was complicated by superior sagittal sinus thrombosis with hemorrhagic venous infarcts in the bifrontal, callosal, and cingulated regions requiring decompressive hemicraniectomy. Postoperative imaging showed a new transverse venous sinus thrombosis. After her craniectomy, the patient only uttered short sentences and did not initiate movement, consistent with akinetic mutism. Setting: Acute inpatient rehabilitation (AIR) hospital. Results or Clinical Course: The patient was admitted to acute inpatient rehabilitation, where she initially uttered 1-2 word responses and required significant cuing to initiate speech and movement. She was started on bromocriptine and intensive speech therapy. Her initiation of speech improved, however, she remained impulsive and distractable. She was maintained on bromocriptine throughout her outpatient rehabilitation course with improvement in speech output and fluency. Discussion: Akinetic mutism is a disorder seen after frontal lobe lesions, specifically those that affect the cingulate gyrus, supplementary motor areas, and basal ganglia, and mesencephalic areas. Previous literature theorizes that the disorder is caused by damage to dopaminergic areas in these regions. Since this patient had hemorrhagic lesions affecting the bifrontal lobes and cingulated regions, bromocriptine may have improved dopaminergic transmission in these areas, resulting in clinical improvement.
S103
Conclusion: This is the first case of venous hemorrhagic infarcts resulting in akinetic mutism that improved with bromocriptine to our knowledge. Treatment with dopaminergic agonists may enhance rehabilitation outcomes in these patients.
Poster 36 AbobotulinumtoxinA (DysportÒ) in the Treatment of Adult Patients with Upper Limb Spasticity Due to Traumatic Brain Injury Michael W. O’Dell, MD (Weill Cornell Medical Center, New York, NY, United States), Heather W. Walker, MD, Steven R. Edgley, MD, Jean-Michel Gracies, MD, PhD, Fatma Gul, MD, Michael Wimmer, MD, Claire Vilain, MD, Allison Brashear, MD Disclosures: M. W. O’Dell: Consulting Fees or Other Remuneration e Ispen, Ottobach; Research Grants - Ipsen, SPR Objective: To determine the efficacy and safety of abobotulinumtoxinA 4 weeks after injection in patients with upper limb spasticity (ULS) caused by traumatic brain injury (TBI). Design: Sub-analysis in a randomized, placebo-controlled, doubleblind clinical trial. Setting: International, multicenter study. Participants: Twenty three of 243 (9.5%) hemiparetic patients with ULS caused by TBI. Interventions: In the initial treatment cycle, 14 subjects received abobotulinumtoxinA (500 U or 1000 U) and 9 received placebo, intramuscularly. Main Outcome Measures: Modified Ashworth Scale (MAS); Disability Assessment Scale (DAS); Tardieu scale (TS); Active range of motion (AROM); Physician Global Assessment (PGA), adverse events (AE). Results or Clinical Course: Mean age (SD) of the 23 patients was 35 (13) years and males represented 65%. They had suffered closed (74%) or penetrating brain injury (26%) 10 years (mean) earlier. The majority (74%) had previously been treated with botulinum toxin. Four weeks after injection, a higher proportion of patients treated with abobotulinumtoxinA compared to placebo were responders in terms of tone reduction (1 point improvement in MAS): 64% versus 22%. This improvement was accompanied by improvement in subjective function (1 grade decrease from baseline for the principal target of treatment on the DAS scale): 71% versus 22% for placebo. With abobotulinumtoxinA, the angle of catch (XV3 of the TS) improved in finger (+35 ), elbow (+22 ) and wrist (+12 ) flexors, resulting in a gain in active muscle extension of at least 5 (AROM). The overall clinical improvement (mean PGA score reaching at least grade 1) was higher with abobotulinumtoxinA versus placebo (93% versus 33%). 7 of 23 patients experienced a treatment emergent AE, none were unexpected. Conclusion: In this small sub-population of hemiparetic adults with ULS due to TBI, abobotulinumtoxinA improved muscle tone, spasticity, passive function and active movements). Efficacy and safety of abobotulinumtoxinA in patients with ULS after a TBI were consistent with the results observed for the total population (TBI and post-stroke patients) in this international placebo controlled study.
Poster 37 Physical Disability Function in Stroke Patients. Validation of the Spanish Language Version of the Stroke Impact Scale-16 Blanca Palomino Aguado, Chief of Section (Ramon Y Cajal Hospital, Madrid, Spain), Lorenzo Jimenez Cosmes, Physical Medicine and Rehabilitation, Jose Acosta Batlle, Radiologist, Pilar Sanchez Tarifa, Physical Medicine and Rehabilitation, Ma Elena Martinez Rodriguez, Physical Medicine and Rehabilitation, Maria Santos Oliete, Physical Medicine and Rehabilitation Disclosures: B. Palomino Aguado: I Have No Relevant Financial Relationships To Disclose.
Poster 35 Use of Bromocriptine in Akinetic Mutism after Superior Sagittal Sinus Thrombosis with Hemorrhagic Venous Infarcts: A Case Report Laura E. Black, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States), Priya V. Mhatre, MD Disclosures: L. E. Black: I Have No Relevant Financial Relationships To Disclose. Case Description: A 44-year-old woman initially presented to acute care with headaches and a third ventricle lesion that extended into the suprasellar cistern. She underwent bifrontal craniotomy with biopsy of the mass; pathology results showed pilocytic astrocytoma. Hospital course was complicated by superior sagittal sinus thrombosis with hemorrhagic venous infarcts in the bifrontal, callosal, and cingulated regions requiring decompressive hemicraniectomy. Postoperative imaging showed a new transverse venous sinus thrombosis. After her craniectomy, the patient only uttered short sentences and did not initiate movement, consistent with akinetic mutism. Setting: Acute inpatient rehabilitation (AIR) hospital. Results or Clinical Course: The patient was admitted to acute inpatient rehabilitation, where she initially uttered 1-2 word responses and required significant cuing to initiate speech and movement. She was started on bromocriptine and intensive speech therapy. Her initiation of speech improved, however, she remained impulsive and distractable. She was maintained on bromocriptine throughout her outpatient rehabilitation course with improvement in speech output and fluency. Discussion: Akinetic mutism is a disorder seen after frontal lobe lesions, specifically those that affect the cingulate gyrus, supplementary motor areas, and basal ganglia, and mesencephalic areas. Previous literature theorizes that the disorder is caused by damage to dopaminergic areas in these regions. Since this patient had hemorrhagic lesions affecting the bifrontal lobes and cingulated regions, bromocriptine may have improved dopaminergic transmission in these areas, resulting in clinical improvement.
S103
Conclusion: This is the first case of venous hemorrhagic infarcts resulting in akinetic mutism that improved with bromocriptine to our knowledge. Treatment with dopaminergic agonists may enhance rehabilitation outcomes in these patients.
Poster 36 AbobotulinumtoxinA (DysportÒ) in the Treatment of Adult Patients with Upper Limb Spasticity Due to Traumatic Brain Injury Michael W. O’Dell, MD (Weill Cornell Medical Center, New York, NY, United States), Heather W. Walker, MD, Steven R. Edgley, MD, Jean-Michel Gracies, MD, PhD, Fatma Gul, MD, Michael Wimmer, MD, Claire Vilain, MD, Allison Brashear, MD Disclosures: M. W. O’Dell: Consulting Fees or Other Remuneration e Ispen, Ottobach; Research Grants - Ipsen, SPR Objective: To determine the efficacy and safety of abobotulinumtoxinA 4 weeks after injection in patients with upper limb spasticity (ULS) caused by traumatic brain injury (TBI). Design: Sub-analysis in a randomized, placebo-controlled, doubleblind clinical trial. Setting: International, multicenter study. Participants: Twenty three of 243 (9.5%) hemiparetic patients with ULS caused by TBI. Interventions: In the initial treatment cycle, 14 subjects received abobotulinumtoxinA (500 U or 1000 U) and 9 received placebo, intramuscularly. Main Outcome Measures: Modified Ashworth Scale (MAS); Disability Assessment Scale (DAS); Tardieu scale (TS); Active range of motion (AROM); Physician Global Assessment (PGA), adverse events (AE). Results or Clinical Course: Mean age (SD) of the 23 patients was 35 (13) years and males represented 65%. They had suffered closed (74%) or penetrating brain injury (26%) 10 years (mean) earlier. The majority (74%) had previously been treated with botulinum toxin. Four weeks after injection, a higher proportion of patients treated with abobotulinumtoxinA compared to placebo were responders in terms of tone reduction (1 point improvement in MAS): 64% versus 22%. This improvement was accompanied by improvement in subjective function (1 grade decrease from baseline for the principal target of treatment on the DAS scale): 71% versus 22% for placebo. With abobotulinumtoxinA, the angle of catch (XV3 of the TS) improved in finger (+35 ), elbow (+22 ) and wrist (+12 ) flexors, resulting in a gain in active muscle extension of at least 5 (AROM). The overall clinical improvement (mean PGA score reaching at least grade 1) was higher with abobotulinumtoxinA versus placebo (93% versus 33%). 7 of 23 patients experienced a treatment emergent AE, none were unexpected. Conclusion: In this small sub-population of hemiparetic adults with ULS due to TBI, abobotulinumtoxinA improved muscle tone, spasticity, passive function and active movements). Efficacy and safety of abobotulinumtoxinA in patients with ULS after a TBI were consistent with the results observed for the total population (TBI and post-stroke patients) in this international placebo controlled study.
Poster 37 Physical Disability Function in Stroke Patients. Validation of the Spanish Language Version of the Stroke Impact Scale-16 Blanca Palomino Aguado, Chief of Section (Ramon Y Cajal Hospital, Madrid, Spain), Lorenzo Jimenez Cosmes, Physical Medicine and Rehabilitation, Jose Acosta Batlle, Radiologist, Pilar Sanchez Tarifa, Physical Medicine and Rehabilitation, Ma Elena Martinez Rodriguez, Physical Medicine and Rehabilitation, Maria Santos Oliete, Physical Medicine and Rehabilitation Disclosures: B. Palomino Aguado: I Have No Relevant Financial Relationships To Disclose.