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Poster 538 Normal Pressure Hydrocephalus Presenting with Cerebellar Stroke: A Case Report
S374
in resistive exercises. He also had some mild neck and right eye pain. The last chiropractic manipulation was on the day of presentation of symptoms. Computed tomography of the head and intra-cranial angiogram were negative and tissue plasminogen activator was administered. Further workup revealed right fronto-parietal acute infarction with complete occlusion of the right extra-cranial internal carotid artery consistent with dissection, right vertebral artery dissection and normal echocardiogram with no shunting. Cervical artery dissection (CAD) was treated conservatively with warfarin and aspirin. Setting: Acute rehabilitation hospital. Results or Clinical Course: After a 20-day stay in acute hospital setting, patient was transferred to an acute rehabilitation facility for a 9-day program including physical, occupational and speech therapy. At discharge, patient was mostly independent with self care activity, mobility and communication. Discussion: Chiropractic manipulations and possibly aggressive resistive exercises have contributed to CAD development. CAD accounts for about 2% of all ischemic strokes and represents 20% of ischemic stroke in adult under the age of 45 years. Manual chiropractic cervical spine manipulation may result in cerebral vascular accident from CAD. The vertebral artery is more susceptible to injury from excessive cervical rotation and extension manipulation due to its horizontal course compared to the extra-cranial internal carotid artery lying freely in neck soft tissues but vulnerable to compression against the cervical transverse processes or the bony mass. CAD treatment options are surgery, thrombolysis, anticoagulation or antiplatelet therapy. Conclusions: Stroke and CAD are uncommon in young adults. Chiropractic manipulation may result in CAD which may have a profound impact on quality of life. **Poster 537 Gait Apraxia After Bilateral Anterior Cerebral Artery Infarction: A Case Report and Literature Review. Fernanda Martins, PM&R Resident (University of São Paulo School of Medicine, San Paulo, Brazil); Liliana Jorge, MD. Disclosures: F. Martins, No Disclosures. Objective: Gait apraxia or frontal lobe ataxia is an established although rare clinical entity caused by anterior cerebral artery infarction. It represents only 1.3% of patients with ischemic stroke. The study aimed to review this condition and to report a clinical case of a subject with bifrontal infarction, and her functional outcome after rehabilitative management. Case Description: A 26-year-old woman presented with occlusion of the anterior cerebral artery following a neurosurgical complication of an aneurysm correction with subarachnoid hemorrhage. At functional evaluation, she presented gait apraxia characterized by poor control of truncal stability, impaired postural responses and astasia-abasia although simple active leg movements were possible while seated or lying. She underwent a rehabilitation program 11 months after her lesion due to social issues. Her inpatient multidisciplinary program length of stay was 6 weeks with observed functional improvement. Primary outcomes included: functional independence measure, Montreal Cognitive Assessment and 36-item short form health survey. Program Description: The inpatient rehabilitation program in-
PRESENTATIONS
cluded sessions of social advice, psychotherapy, speech/language therapy, each one twice a week, and daily sessions of physical and occupational therapy. Setting: Institute of Physical and Medicine Rehabilitation - Morumbi Unity. Results: Due to an abnormality within the anterior cerebral artery system, the patient infarction was on the supplementary motor regions of both hemispheres. She presented gait apraxia, not attributed to strict paresis. Conversely, the overlap of lack of behavioral initiative, negative affect, and insufficient motor control support the neural substrate of lesion of the dopaminergic mesocortical pathway. Discussion: This case report depicted a rare cause of gait impairment related to bifrontal infarction. So far, there are less than 50 cases reported. Rehabilitative management of this pathology is still challenging and the outcomes range from fair to unpredictible. However, this case report demonstrates functional improvement. Conclusions: Disorders of gait caused by frontal lobe lesions have complex clinical presentation and must be managed taking into account the poor outcome in long-term, due to progressive impairment. The rehabilitation program for these patients should be individualized for better results, as demonstrated by this case report. Poster 538 Normal Pressure Hydrocephalus Presenting with Cerebellar Stroke: A Case Report. Giselle Vivaldi, MD (NYU Medical Center, New York, NY, United States). Disclosures: G. Vivaldi, No Disclosures. Case Description: A 60-year-old white man presented to ED after a fall at home, with associated loss of consciousness and urinary incontinence. Patient had no past medical history. He had complaints of gait instability for 6 months. Upon arrival, he was alert and oriented to time, person, and place. Physical examination was remarkable for lower extremity weakness 4/5 bilaterally, impaired finger-to-nose coordination on right side, and unsteady gait. Noncontrast head CT scan showed an acute lacunar infarct involving the right cerebellar hemisphere, small vessel ischemic disease, and communicating hydrocephalus. Brain MRI demonstrated a small acute lacunar infact of the right cerebellar hemisphere, in addition to vetriculomegaly, consistent with normal pressure hydrocephalus (NPH). Setting: Tertiary care municipal hospital. Results or Clinical Course: Patient underwent lumbar puncture, which improved his gait. Once medically stable, patient was transferred to acute inpatient rehab. His therapist noted improved lower extremity strength, gait and coordination. Patient made significant gains in functional status, progressing from maximum assistance to contact guard assistance in transfers and ambulation. Further developments will be discussed. Discussion: To our knowledge, this is the first reported case of NPH and cerebellar stroke presenting simultaneously. The neurological signs presented by this patient (gait instability, one episode of urinary incontinence, lower extremity weakness, and right-sided dysmetria) were explained by imaging confirming both etiologies. Gait improved after lumbar puncture, as expected in NPH, however the deficits of the other disorder remained. Conclusions: NPH can present or be superimposed with a second disorder, in this case cerebellar stroke. When considering
PM&R
multiple etiologies, rehabilitation program must be tailored to address all issues present. Poster 539 Cryptic Hemorrhage Complicated by Epidural Hematoma. Hassan Akinbiyi, MD (Marianjoy Rehab Hospital, Wheaton, IL, United States); Disclosures: H. Akinbiyi, No Disclosures. Case Description: This case describes a previously healthy patient who presented to ER with acute headache, diplopia, and weakness. She was diagnosed with subarachnoid hemorrhage requiring external ventricular drain. Cerebral angiography showed no evidence of aneurysm. She was intubated for airway protection. After extubation she began to experience urinary retention requiring intermittent catheterization and complained of low back pain. She was further evaluated with lumbar spine MRI, which showed epidural hematoma at L2-L3 level. Setting: Single-center. Results or Clinical Course: Prior to discharge patient had resolution of both urinary retention and low back pain. Initial FIM Score:70. After 2 weeks of intensive therapy, including speech/ OT/PT the patient continued to improve with regard to mobility and gait dysfunction with discharge FIM Score:111. Discussion: This is the first reported case of cryptic hemorrhage complicated by epidural hematoma. In 1956, Crawford and Russell first coined the term “cryptic” vascular malformation in reference to small, clinically “latent” vascular lesions, some of which were angiographically occult, that resulted in either apoplectic cerebral hemorrhage or signs of a growing mass lesion. These lesions were pathologically diverse, consisting of arteriovenous malformations (AVMs), venous hamartoma, and are now called cavernous angiomas. Cryptic vascular malformations actually encompass a group of heterogenous malformations. The pathogenesis of cryptic vascular malformation is still unknown. Wilson has proposed that petechial hemorrhage leads to the development of cryptic vascular malformation. Conclusions: This is a unique case of patient with cryptic cerebral hemorrhage with extension to lumbar area, not reported in rehabilitation literature and it is important to raise awareness of physiatrists. Poster 540 Acute Bilateral Caudate Nucleus Infarction in a Patient With Atrial Fibrillation: A Case Report. Hector Delucca, (Albert Einstein/Montefiore, Bronx, NY, United States). Disclosures: H. Delucca, No Disclosures. Case Description: An 81-year-old woman with history of mild dementia and atrial fibrillation, not on anticoagulation due to fall risk, was brought to the hospital with altered mental status. The patient was at baseline prior to being found by her daughter on the floor. The daughter reported the patient as nonverbal, unresponsive, and unable to follow commands. At baseline, patient was intermittently oriented to place and time, and fully ambulatory without any assistance. She was able to perform most activities of daily living except for cooking. Daughter denied any prior falls, tonic-clonic movement, or urofecal incontinence. Examination showed patient was awake but inattentive, non-verbal, and did not respond to any commands. Eyes were midline and noted to be
Vol. 4, Iss. 10S, 2012
S375
symmetrical bilaterally without nystagmus or gaze deviation. Face was symmetric. Patient could not ambulate due to bilateral lower extremity weakness. She grimaced and withdrew to nailbed pressure. Deep tendon reflexes were 1⫹ throughout, and plantar reflexes were flexor bilaterally. A CT scan and magnetic resonance imaging of the brain demonstrated acute bilateral infarcts of the basal ganglia with involvement of caudate and centrum semiovale. Program Description: 81-year-old woman with atrial fibrillation and fall at home found to have acute bilateral caudate infarcts. Setting: Tertiary care hospital. Results or Clinical Course: The patient received aggressive therapy with gains in both function and cognition. Patient was subsequently discharged to subacute rehabilitation facility. Discussion: Bilateral caudate nuclei infarction is an extremely rare event with few reported cases of bilateral basal ganglia infarcts in the literature. Most cases have been secondary to intoxication, anatomical abnormality or mild head trauma. The unique aspect of this presentation is the lack of anticoagulation that likely resulted in embolic bilateral caudate infarcts. This presentation highlights the importance of anticoagulation on a patient with underlying atrial fibrillation for stroke prevention and stresses the need for multidisciplinary rehabilitation to improve patient’s functional status. Conclusions: Patients with atrial fibrillation should be anticoagulated for embolic stroke prevention. Poster 541 The Effect of Swimming Exercise on Cognitive Function in Cerebral Infarction Rats. In-Sung Choi, MD, PhD (Chonnam National University Medical School & Hospital, Gwangju city, Korea, Republic of); Jae-Young Han, MD; Jung-Kook Kim, MS; Sam-Gyu Lee, MD, PhD; Min-Keun Song, MD. Disclosures: I. Choi, No Disclosures. Objective: Most studies have used a treadmill exercise to find out the effect of regular aerobic exercise on the cognitive function. As some stroke patients cannot walk or control trunk movement easily, treadmill exercise would not be suitable for them. Swimming exercise is another type of aerobic exercise and is helpful for the improvement of motor weakness and balance in stroke patients. However, there is little basis on the effect of swimming exercise on the cognitive function in cerebral infarction rats. The aim of this study was to investigate the effect of regular swimming exercise on the cognitive function in cerebral infarction rats. Design: A prospective, experimental, group allocation design. Setting: An animal laboratory in the tertiary university hospital. Participants: Nineteen 10-week-old male Sprague-Dawley rats. Interventions: Rats were subjected to photothrombotic cerebral infarction on the left parietal lobe. All rats were randomly divided into 2 groups: control group (group A, n⫽10) and regular swimming exercise group (group B, free swimming, 10 minutes a day, 5 times a week, for 4 weeks, n⫽9). Main Outcome Measures: Escape latency was measured using Morris water maze test. The activity of superoxide dismutase (SOD) and the level of malondialdehyde (MDA) in the hippocampus were measured. Cresyl violet stain and immunohistochemistry for BDNF (brain derived neurotrophic factor) in the hippocampus were conducted. Results: After 4 weeks, escape latency was shorter in group B than in group A (P⬍.05). The activity of SOD was more increased in
in resistive exercises. He also had some mild neck and right eye pain. The last chiropractic manipulation was on the day of presentation of symptoms. Computed tomography of the head and intra-cranial angiogram were negative and tissue plasminogen activator was administered. Further workup revealed right fronto-parietal acute infarction with complete occlusion of the right extra-cranial internal carotid artery consistent with dissection, right vertebral artery dissection and normal echocardiogram with no shunting. Cervical artery dissection (CAD) was treated conservatively with warfarin and aspirin. Setting: Acute rehabilitation hospital. Results or Clinical Course: After a 20-day stay in acute hospital setting, patient was transferred to an acute rehabilitation facility for a 9-day program including physical, occupational and speech therapy. At discharge, patient was mostly independent with self care activity, mobility and communication. Discussion: Chiropractic manipulations and possibly aggressive resistive exercises have contributed to CAD development. CAD accounts for about 2% of all ischemic strokes and represents 20% of ischemic stroke in adult under the age of 45 years. Manual chiropractic cervical spine manipulation may result in cerebral vascular accident from CAD. The vertebral artery is more susceptible to injury from excessive cervical rotation and extension manipulation due to its horizontal course compared to the extra-cranial internal carotid artery lying freely in neck soft tissues but vulnerable to compression against the cervical transverse processes or the bony mass. CAD treatment options are surgery, thrombolysis, anticoagulation or antiplatelet therapy. Conclusions: Stroke and CAD are uncommon in young adults. Chiropractic manipulation may result in CAD which may have a profound impact on quality of life. **Poster 537 Gait Apraxia After Bilateral Anterior Cerebral Artery Infarction: A Case Report and Literature Review. Fernanda Martins, PM&R Resident (University of São Paulo School of Medicine, San Paulo, Brazil); Liliana Jorge, MD. Disclosures: F. Martins, No Disclosures. Objective: Gait apraxia or frontal lobe ataxia is an established although rare clinical entity caused by anterior cerebral artery infarction. It represents only 1.3% of patients with ischemic stroke. The study aimed to review this condition and to report a clinical case of a subject with bifrontal infarction, and her functional outcome after rehabilitative management. Case Description: A 26-year-old woman presented with occlusion of the anterior cerebral artery following a neurosurgical complication of an aneurysm correction with subarachnoid hemorrhage. At functional evaluation, she presented gait apraxia characterized by poor control of truncal stability, impaired postural responses and astasia-abasia although simple active leg movements were possible while seated or lying. She underwent a rehabilitation program 11 months after her lesion due to social issues. Her inpatient multidisciplinary program length of stay was 6 weeks with observed functional improvement. Primary outcomes included: functional independence measure, Montreal Cognitive Assessment and 36-item short form health survey. Program Description: The inpatient rehabilitation program in-
PRESENTATIONS
cluded sessions of social advice, psychotherapy, speech/language therapy, each one twice a week, and daily sessions of physical and occupational therapy. Setting: Institute of Physical and Medicine Rehabilitation - Morumbi Unity. Results: Due to an abnormality within the anterior cerebral artery system, the patient infarction was on the supplementary motor regions of both hemispheres. She presented gait apraxia, not attributed to strict paresis. Conversely, the overlap of lack of behavioral initiative, negative affect, and insufficient motor control support the neural substrate of lesion of the dopaminergic mesocortical pathway. Discussion: This case report depicted a rare cause of gait impairment related to bifrontal infarction. So far, there are less than 50 cases reported. Rehabilitative management of this pathology is still challenging and the outcomes range from fair to unpredictible. However, this case report demonstrates functional improvement. Conclusions: Disorders of gait caused by frontal lobe lesions have complex clinical presentation and must be managed taking into account the poor outcome in long-term, due to progressive impairment. The rehabilitation program for these patients should be individualized for better results, as demonstrated by this case report. Poster 538 Normal Pressure Hydrocephalus Presenting with Cerebellar Stroke: A Case Report. Giselle Vivaldi, MD (NYU Medical Center, New York, NY, United States). Disclosures: G. Vivaldi, No Disclosures. Case Description: A 60-year-old white man presented to ED after a fall at home, with associated loss of consciousness and urinary incontinence. Patient had no past medical history. He had complaints of gait instability for 6 months. Upon arrival, he was alert and oriented to time, person, and place. Physical examination was remarkable for lower extremity weakness 4/5 bilaterally, impaired finger-to-nose coordination on right side, and unsteady gait. Noncontrast head CT scan showed an acute lacunar infarct involving the right cerebellar hemisphere, small vessel ischemic disease, and communicating hydrocephalus. Brain MRI demonstrated a small acute lacunar infact of the right cerebellar hemisphere, in addition to vetriculomegaly, consistent with normal pressure hydrocephalus (NPH). Setting: Tertiary care municipal hospital. Results or Clinical Course: Patient underwent lumbar puncture, which improved his gait. Once medically stable, patient was transferred to acute inpatient rehab. His therapist noted improved lower extremity strength, gait and coordination. Patient made significant gains in functional status, progressing from maximum assistance to contact guard assistance in transfers and ambulation. Further developments will be discussed. Discussion: To our knowledge, this is the first reported case of NPH and cerebellar stroke presenting simultaneously. The neurological signs presented by this patient (gait instability, one episode of urinary incontinence, lower extremity weakness, and right-sided dysmetria) were explained by imaging confirming both etiologies. Gait improved after lumbar puncture, as expected in NPH, however the deficits of the other disorder remained. Conclusions: NPH can present or be superimposed with a second disorder, in this case cerebellar stroke. When considering
PM&R
multiple etiologies, rehabilitation program must be tailored to address all issues present. Poster 539 Cryptic Hemorrhage Complicated by Epidural Hematoma. Hassan Akinbiyi, MD (Marianjoy Rehab Hospital, Wheaton, IL, United States); Disclosures: H. Akinbiyi, No Disclosures. Case Description: This case describes a previously healthy patient who presented to ER with acute headache, diplopia, and weakness. She was diagnosed with subarachnoid hemorrhage requiring external ventricular drain. Cerebral angiography showed no evidence of aneurysm. She was intubated for airway protection. After extubation she began to experience urinary retention requiring intermittent catheterization and complained of low back pain. She was further evaluated with lumbar spine MRI, which showed epidural hematoma at L2-L3 level. Setting: Single-center. Results or Clinical Course: Prior to discharge patient had resolution of both urinary retention and low back pain. Initial FIM Score:70. After 2 weeks of intensive therapy, including speech/ OT/PT the patient continued to improve with regard to mobility and gait dysfunction with discharge FIM Score:111. Discussion: This is the first reported case of cryptic hemorrhage complicated by epidural hematoma. In 1956, Crawford and Russell first coined the term “cryptic” vascular malformation in reference to small, clinically “latent” vascular lesions, some of which were angiographically occult, that resulted in either apoplectic cerebral hemorrhage or signs of a growing mass lesion. These lesions were pathologically diverse, consisting of arteriovenous malformations (AVMs), venous hamartoma, and are now called cavernous angiomas. Cryptic vascular malformations actually encompass a group of heterogenous malformations. The pathogenesis of cryptic vascular malformation is still unknown. Wilson has proposed that petechial hemorrhage leads to the development of cryptic vascular malformation. Conclusions: This is a unique case of patient with cryptic cerebral hemorrhage with extension to lumbar area, not reported in rehabilitation literature and it is important to raise awareness of physiatrists. Poster 540 Acute Bilateral Caudate Nucleus Infarction in a Patient With Atrial Fibrillation: A Case Report. Hector Delucca, (Albert Einstein/Montefiore, Bronx, NY, United States). Disclosures: H. Delucca, No Disclosures. Case Description: An 81-year-old woman with history of mild dementia and atrial fibrillation, not on anticoagulation due to fall risk, was brought to the hospital with altered mental status. The patient was at baseline prior to being found by her daughter on the floor. The daughter reported the patient as nonverbal, unresponsive, and unable to follow commands. At baseline, patient was intermittently oriented to place and time, and fully ambulatory without any assistance. She was able to perform most activities of daily living except for cooking. Daughter denied any prior falls, tonic-clonic movement, or urofecal incontinence. Examination showed patient was awake but inattentive, non-verbal, and did not respond to any commands. Eyes were midline and noted to be
Vol. 4, Iss. 10S, 2012
S375
symmetrical bilaterally without nystagmus or gaze deviation. Face was symmetric. Patient could not ambulate due to bilateral lower extremity weakness. She grimaced and withdrew to nailbed pressure. Deep tendon reflexes were 1⫹ throughout, and plantar reflexes were flexor bilaterally. A CT scan and magnetic resonance imaging of the brain demonstrated acute bilateral infarcts of the basal ganglia with involvement of caudate and centrum semiovale. Program Description: 81-year-old woman with atrial fibrillation and fall at home found to have acute bilateral caudate infarcts. Setting: Tertiary care hospital. Results or Clinical Course: The patient received aggressive therapy with gains in both function and cognition. Patient was subsequently discharged to subacute rehabilitation facility. Discussion: Bilateral caudate nuclei infarction is an extremely rare event with few reported cases of bilateral basal ganglia infarcts in the literature. Most cases have been secondary to intoxication, anatomical abnormality or mild head trauma. The unique aspect of this presentation is the lack of anticoagulation that likely resulted in embolic bilateral caudate infarcts. This presentation highlights the importance of anticoagulation on a patient with underlying atrial fibrillation for stroke prevention and stresses the need for multidisciplinary rehabilitation to improve patient’s functional status. Conclusions: Patients with atrial fibrillation should be anticoagulated for embolic stroke prevention. Poster 541 The Effect of Swimming Exercise on Cognitive Function in Cerebral Infarction Rats. In-Sung Choi, MD, PhD (Chonnam National University Medical School & Hospital, Gwangju city, Korea, Republic of); Jae-Young Han, MD; Jung-Kook Kim, MS; Sam-Gyu Lee, MD, PhD; Min-Keun Song, MD. Disclosures: I. Choi, No Disclosures. Objective: Most studies have used a treadmill exercise to find out the effect of regular aerobic exercise on the cognitive function. As some stroke patients cannot walk or control trunk movement easily, treadmill exercise would not be suitable for them. Swimming exercise is another type of aerobic exercise and is helpful for the improvement of motor weakness and balance in stroke patients. However, there is little basis on the effect of swimming exercise on the cognitive function in cerebral infarction rats. The aim of this study was to investigate the effect of regular swimming exercise on the cognitive function in cerebral infarction rats. Design: A prospective, experimental, group allocation design. Setting: An animal laboratory in the tertiary university hospital. Participants: Nineteen 10-week-old male Sprague-Dawley rats. Interventions: Rats were subjected to photothrombotic cerebral infarction on the left parietal lobe. All rats were randomly divided into 2 groups: control group (group A, n⫽10) and regular swimming exercise group (group B, free swimming, 10 minutes a day, 5 times a week, for 4 weeks, n⫽9). Main Outcome Measures: Escape latency was measured using Morris water maze test. The activity of superoxide dismutase (SOD) and the level of malondialdehyde (MDA) in the hippocampus were measured. Cresyl violet stain and immunohistochemistry for BDNF (brain derived neurotrophic factor) in the hippocampus were conducted. Results: After 4 weeks, escape latency was shorter in group B than in group A (P⬍.05). The activity of SOD was more increased in