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Sudden Hemiparesis While Stretching- A Case Report
PM&R
Setting: Tertiary care center. Results or Clinical Course: Therapy for range of motion, positioning and splinting was provided in the hospital and he was discharged home with Neurology outpatient follow-up. He was later rehospitalized due to complications of immobility. Discussion: PMA is a form of motor neuron disease distinguished from amyotrophic lateral sclerosis (ALS) by lack of UMN findings. It accounts for 2.5-11% of all cases of motor neuron disease and has a better prognosis than ALS due to slower progression and longer survival. Conclusions: Patients with chronic SCI can have decreased function due to aging or a syrinx. As providers who manage SCI patients, this extremely unusual case should remind us that these patients are also at risk for new neurologic problems greatly impacting function and quality of life. They need to be investigated thoroughly and quickly so management and prognosis can be discussed. Poster 382 Sudden Hemiparesis While Stretching- A Case Report. Jennifer Gomez, MD (Montefiore Medical Center, Bronx, NY, United States); Michelle Stern, MD. Disclosures: J. Gomez, No Disclosures: I Have Nothing To Disclose. Case Description: A 37-year-old man with no past medical history presented to the emergency department with acute leftsided weakness. Patient reported performing home neck stretches when symptoms began. He had completed an upper trapezius stretch (described tipping his head to the right and increasing the stretch with his right hand) when he experienced sudden loss of sensation on his left side and dizziness followed by left-sided hemiparesis. Pertinent physical findings included left upper and lower extremity flaccidity with manual motor strength of 0/5, hyporeflexia, decrease vibration on left side and decrease temperature and pinprick on right side and urinary retention. Cervical spine MRI positive for cord edema from C2-C4, mild posterior disk bulge at C5-6. Patient initially scheduled for surgical intervention; however when results of brain MRI showed scattered bilateral cerebellum and occipital infarcts, surgery was cancelled. Based on clinical findings the diagnosis of vertebral artery dissection with thromboembolism and resultant cerebellar and cervical cord infarct was made. On admission to the acute inpatient rehabilitation, his functional status was maximal assistance and unable to ambulate. Setting: Tertiary care hospital. Results or Clinical Course: Patient completed a 6 week acute rehab program. His functional status improved to independence with transfers and ambulated 150 feet with left AFO. Discussion: Vertebral artery dissection is a common cause of ischemic stroke in younger patients. Typical presentation involves neurological deficits associated with vertebra-basilar circulation infarcts. However, it is uncommon for patients to present with symptoms associated with cervical spine involvement. Abnormalities in the vasculature are usually identified with either MRI or vascular duplex. In situations where imaging studies fail to present vascular findings, the clinical presentation and history of presenting illness must be considered. Conclusions: Cervical cord infarction is an atypical presentation for vertebral artery dissection. To our knowledge no prior cases
Vol. 5, Iss. 9S, 2013
S271
have been documented where a stretching exercise resulted in both cerebral and cervical spinal cord infarction with a Brown-Séquard presentation. Poster 383 Spontaneous Perirenal Hemorrhage from Renal Capsular Artery in Cauda Equina Syndrome: A Case Report. Hyun Seok, MD, PhD (Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea). Disclosures: H. Seok, No Disclosures: I Have Nothing To Disclose. Case Description: A 57-year-old man, who has been diagnosed with cauda equina syndrome(CES) due to L3 burst fracture 3 months ago, presented with fever and chill. His diagnosis was acute pyelonephritis(APN) due to neurogenic bladder. After the treatment of APN, he was transferred to the department of rehabilitation medicine for the management of CES. Because of large post voiding residual urine volume, he did self catheterization after voiding. But he presented with fever and chills again, and recurrent APN was diagnosed. On the third day of antibiotic treatment, he presented with acute abdominal pain and hypovolemic shock. Abdominal CT and angiography showed left APN and perirenal hematoma d/t left renal capsular artery bleeding. Setting: Tertiary care university hospital. Results or Clinical Course: After embolization of left renal capsular artery, there was no more active bleeding. Hematoma causing abdominal pain was removed by surgery. Voiding cystourethrogram showed no vesicoureteral reflux. Urodynamic study revealed areflexic neurogenic bladder. He was transfered to secondary hospital with self clean intermittent catheterization for voiding. Discussion: In this case, rupture of renal cortex or subcortical artery was not found. It is postulated that communication between cortical and subcortical arteries caused APN to spread over cortical artery and vascular erosion. Conclusions: Since APN due to neurogenic bladder can lead to critical complication such as perirenal hemorrhage, physician must concentrate attention on early diagnosis and treatment of UTI, and management of neurogenic bladder after cauda equina injury. Poster 384 A Rare Case of Coccidioidomycosis Spinal Meningitis Resulting in Paraplegia: A Case Report. Jared Myers, DO (Loma Linda University Medical Center, Loma Linda, CA, United States); Scott Strum, MD; Murray Brandstater, MD. Disclosures: J. Myers, No Disclosures: I Have Nothing To Disclose. Case Description: A 35-year-old man with history of Coccidioidomycosis spinal meningitis (CSM) presents with myelopathy. Program Description: Patient was first diagnosed and treated for CSM in 2006 after presenting with 1 month history of headache and fever. The patient began having progressive lower extremity weakness in 2010 and was found on imaging and cerebral spinal fluid microscopy to have recurrent Coccidioidomycosis arachnoiditis localized at the thoracolumbar junction. Patient underwent neurosurgical decompression and was placed on lifelong oral Fluconazole. His weakness improved and he was ambulatory until
Setting: Tertiary care center. Results or Clinical Course: Therapy for range of motion, positioning and splinting was provided in the hospital and he was discharged home with Neurology outpatient follow-up. He was later rehospitalized due to complications of immobility. Discussion: PMA is a form of motor neuron disease distinguished from amyotrophic lateral sclerosis (ALS) by lack of UMN findings. It accounts for 2.5-11% of all cases of motor neuron disease and has a better prognosis than ALS due to slower progression and longer survival. Conclusions: Patients with chronic SCI can have decreased function due to aging or a syrinx. As providers who manage SCI patients, this extremely unusual case should remind us that these patients are also at risk for new neurologic problems greatly impacting function and quality of life. They need to be investigated thoroughly and quickly so management and prognosis can be discussed. Poster 382 Sudden Hemiparesis While Stretching- A Case Report. Jennifer Gomez, MD (Montefiore Medical Center, Bronx, NY, United States); Michelle Stern, MD. Disclosures: J. Gomez, No Disclosures: I Have Nothing To Disclose. Case Description: A 37-year-old man with no past medical history presented to the emergency department with acute leftsided weakness. Patient reported performing home neck stretches when symptoms began. He had completed an upper trapezius stretch (described tipping his head to the right and increasing the stretch with his right hand) when he experienced sudden loss of sensation on his left side and dizziness followed by left-sided hemiparesis. Pertinent physical findings included left upper and lower extremity flaccidity with manual motor strength of 0/5, hyporeflexia, decrease vibration on left side and decrease temperature and pinprick on right side and urinary retention. Cervical spine MRI positive for cord edema from C2-C4, mild posterior disk bulge at C5-6. Patient initially scheduled for surgical intervention; however when results of brain MRI showed scattered bilateral cerebellum and occipital infarcts, surgery was cancelled. Based on clinical findings the diagnosis of vertebral artery dissection with thromboembolism and resultant cerebellar and cervical cord infarct was made. On admission to the acute inpatient rehabilitation, his functional status was maximal assistance and unable to ambulate. Setting: Tertiary care hospital. Results or Clinical Course: Patient completed a 6 week acute rehab program. His functional status improved to independence with transfers and ambulated 150 feet with left AFO. Discussion: Vertebral artery dissection is a common cause of ischemic stroke in younger patients. Typical presentation involves neurological deficits associated with vertebra-basilar circulation infarcts. However, it is uncommon for patients to present with symptoms associated with cervical spine involvement. Abnormalities in the vasculature are usually identified with either MRI or vascular duplex. In situations where imaging studies fail to present vascular findings, the clinical presentation and history of presenting illness must be considered. Conclusions: Cervical cord infarction is an atypical presentation for vertebral artery dissection. To our knowledge no prior cases
Vol. 5, Iss. 9S, 2013
S271
have been documented where a stretching exercise resulted in both cerebral and cervical spinal cord infarction with a Brown-Séquard presentation. Poster 383 Spontaneous Perirenal Hemorrhage from Renal Capsular Artery in Cauda Equina Syndrome: A Case Report. Hyun Seok, MD, PhD (Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea). Disclosures: H. Seok, No Disclosures: I Have Nothing To Disclose. Case Description: A 57-year-old man, who has been diagnosed with cauda equina syndrome(CES) due to L3 burst fracture 3 months ago, presented with fever and chill. His diagnosis was acute pyelonephritis(APN) due to neurogenic bladder. After the treatment of APN, he was transferred to the department of rehabilitation medicine for the management of CES. Because of large post voiding residual urine volume, he did self catheterization after voiding. But he presented with fever and chills again, and recurrent APN was diagnosed. On the third day of antibiotic treatment, he presented with acute abdominal pain and hypovolemic shock. Abdominal CT and angiography showed left APN and perirenal hematoma d/t left renal capsular artery bleeding. Setting: Tertiary care university hospital. Results or Clinical Course: After embolization of left renal capsular artery, there was no more active bleeding. Hematoma causing abdominal pain was removed by surgery. Voiding cystourethrogram showed no vesicoureteral reflux. Urodynamic study revealed areflexic neurogenic bladder. He was transfered to secondary hospital with self clean intermittent catheterization for voiding. Discussion: In this case, rupture of renal cortex or subcortical artery was not found. It is postulated that communication between cortical and subcortical arteries caused APN to spread over cortical artery and vascular erosion. Conclusions: Since APN due to neurogenic bladder can lead to critical complication such as perirenal hemorrhage, physician must concentrate attention on early diagnosis and treatment of UTI, and management of neurogenic bladder after cauda equina injury. Poster 384 A Rare Case of Coccidioidomycosis Spinal Meningitis Resulting in Paraplegia: A Case Report. Jared Myers, DO (Loma Linda University Medical Center, Loma Linda, CA, United States); Scott Strum, MD; Murray Brandstater, MD. Disclosures: J. Myers, No Disclosures: I Have Nothing To Disclose. Case Description: A 35-year-old man with history of Coccidioidomycosis spinal meningitis (CSM) presents with myelopathy. Program Description: Patient was first diagnosed and treated for CSM in 2006 after presenting with 1 month history of headache and fever. The patient began having progressive lower extremity weakness in 2010 and was found on imaging and cerebral spinal fluid microscopy to have recurrent Coccidioidomycosis arachnoiditis localized at the thoracolumbar junction. Patient underwent neurosurgical decompression and was placed on lifelong oral Fluconazole. His weakness improved and he was ambulatory until