S229 S290
Poster 306:
Beyond Saturday Night: A Case Series of Radial
Neuropathy in the Arm Diagnosed by Ultrasound in
Conjunction with Electrodiagnosis
Austin C. Myers, MD MBA (Vidant Rehab Ctr/East Carolina Univ/Brod),
Eric Morrison, MD, MSc, John Norbury, MD, Siena Ona, MD
Disclosures:
Austin Myers: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Three patients presented for evaluation
of wrist drop. Patient 1 was a 15-year-old boy who awoke with a wrist
drop and numbness following surgical repair of a humerus fracture.
Patient 2 was a 58-year-old woman who awoke with wrist drop asso-
ciated with a bruise on her triceps and no history of trauma. Patient 3
was a 61-year-old man who awoke with a wrist drop following crutch
use and recent weight loss.
Setting:
Outpatient EMG Clinic.
Results:
Patient 1 had reduced radial motor and sensory amplitudes
on nerve conduction studies (NCS); Neuromuscular ultrasound (NMUS)
revealed a surgical screw impinging on the nerve at the spiral groove.
Patient 2 had normal radial NCS and reduced recruitment in the
extensor digitorum communis; NMUS revealed increased hypo-
echogenicity and caliber of the radial nerve at the exit of the spiral
groove in direct contact with a hematoma. Patient 3 had reduced
amplitude of the radial motor response with a normal radial sensory
response, NMUS showed increased nerve swelling at the spiral groove
on ultrasound.
Discussion:
Radial neuropathy at the spiral groove (Saturday Night
Palsy) can be a challenging diagnosis based on electrodiagnosis alone
because mild lesions can result in normal nerve conduction studies and
severe lesions result in non-localizing axon loss pathology. Addition-
ally, fascicular sparing can lead to erroneous localization (such as in
case 3 where the lesion is at the spiral groove, but sensory fibers were
spared). NMUS also revealed radial nerve pathology in this case series
that has not been described previously in the literature (non-traumatic
hematoma in case 2).
Conclusions:
Neuromuscular ultrasound can be a powerful compli-
ment to electrodiagnosis in localizing radial neuropathies and deter-
mining etiology.
Level of Evidence:
Level V
Poster 307:
Non-Rhythmic Recurrent Shaking After Right Basal
Ganglia Stroke: A Case Report
Aaron A. Hanyu-Deutmeyer, DO (Marianjoy Rehab Hosp),
Padma K. Srigiriraju, MD
Disclosures:
Aaron Hanyu-Deutmeyer: My spouse/partner has a rela-
tionship with Allergan Speakers bureau, My spouse/partner has a
relationship with Allergan provided Botox for injection
Case/Program Description:
A 73-year-old female patient with history
of prior stroke with residual left sided weakness presented to the ED
with “spasms” on her left side. She was noted to have non-rhythmic
shaking movements that lasted 2-5 seconds that would then recur
every 10-30 seconds. EEG showed no evidence of seizure, but MRI
showed evidence of acute infarct in the right basal ganglia.
Setting:
Tertiary care center and acute rehabilitation hospital.
Results:
Recurrent movements were captured on EEG with no evi-
dence of epileptiform activity. The patient was diagnosed with hem-
ichorea-hemiballism as a result of the basal ganglia stroke. Her
rehabilitation course was further complicated by residual deficits from
a previous stroke, and cerebral amyloid angiopathy with micro-
hemorrhages on MRI. The patient’s hemiballism was most apparent
during periods of stress, but she showed significant improvement in her
hemiballism with standard therapies. The patient made slow but
sustained progress, improving from a total assist to contact guard
assist at the time of discharge.
Discussion:
Hemiballism-hemichorea is an extremely rare neurolog-
ical condition with an incidence of 0.45/100000. It is caused by a
decrease in activity in the subthalamic nucleus most often from
stroke. However, due to this patient’s presentation and prior deficits,
stroke was not initially part of the differential diagnosis. This patient
had significant risk factors for stroke including diabetes, age, hyper-
tension. While able to participate in standard therapies for stroke,
medically due to her cerebral amyloid angiopathy, the risk of hemor-
rhage had to be carefully weighed against the risk of recurrent
ischemia.
Conclusions:
Post-stroke hemiballism-hemichorea causes profound
effects to a patient’s function. With an initial presentation that can
appear significantly different from a typical stroke, the spastic
movements can cause not only physical and emotional distress to the
patient but potentially continued long term deficits if not properly
identified and treated as a stroke.
Level of Evidence:
Level V
Poster 308:
West Nile Virus Encephalitis in an Immunosuppressed Patient
Who Presents to Rehabilitation: A Case Report
Joseph A. Wong, MD (George Washington University School of Med,
Edison, New Jersey, United States), Brian D. Greenwald, MD, FAAPMR
Disclosures:
Joseph Wong: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 50-year-old woman status-post renal
transplantation and diagnosed with West Nile virus (WNV) encepha-
litis. Patient is status-post renal transplantation 13 years ago with
chronic rejection and maintained on immunosuppressive therapy who
initially presented with fever, abdominal pain, and lethargy that
quickly progressed to severe encephalopathy. Laboratory studies
revealed severe anemia and uremia, with no improvement of mental
status after urgent hemodialysis. Lumbar puncture revealed lym-
phocytic pleocytosis, and an exhaustive infectious work-up revealed
a positive WNV polymerase chain reaction test. Magnetic resonance
imaging of the brain showed acute cerebellitis. Management was
supportive with the intention to minimize immunosuppressive ther-
apy while trying to maintain the allograft transplant. Patient was
transferred to an acute inpatient brain trauma unit for comprehen-
sive rehabilitation.
Setting:
Academic acute inpatient rehabilitation facility.
Results:
Initial rehabilitation evaluation demonstrated impaired
arousal and inconsistent one-step command following. Maximum
assistance, verbal and tactile cues were required for sitting balance.
Patient displayed ataxic dysarthria, aphasia, persistent vertical
nystagmus, neuromuscular and motor impairments. The patient was
provided with comprehensive medical support and interdisciplinary
inpatient rehabilitation. Despite her ongoing medical complexities,
she showed significant improvements during her rehabilitation course.
Discussion:
WNV encephalitis presents in less than one percent of all
people infected with a ten percent mortality rate. Research suggests
that immunocompromised subjects may have a prolonged period of
viremia, depressed humoral response, increased severity and exten-
sion of pathology, and higher mortality rates. Limited case reports also
suggest the effectiveness of immunosuppression reduction without the
compromise of allograft outcomes. This case report adds to the dearth
of literature regarding treatment, rehabilitation, and outcomes of
immunocompromised patients with WNV encephalitis.
Conclusions:
This case presents the acute rehabilitation course of a
patient with WNV encephalitis, a diagnosis rarely seen in immuno-
compromised patients.
Level of Evidence:
Level V
S229
Abstracts / PM R 9 (2017) S131-S290