S230 S290
Poster 309:
A Rare Cause of Ischemic Stroke in the Absence of
Classical Risk Factors in an Otherwise Healthy 34-
Year Old: A Case Report
Justin A. Raper, MD (Albert Einstein College of Medicine),
Francis J. Lopez, MD
Disclosures:
Justin Raper: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 34-year-old Asian woman presented to
the emergency department after an acute episode of confusion and
speech difficulty. On initial evaluation she was disoriented, aphasic,
had left-sided facial asymmetry, right-sided extremity weakness, and
numbness. Urinary toxicology was negative. Computed tomography
(CT), magnetic resonance imaging/angiogram (MRI/MRA), and carotid
ultrasound were performed which confirmed an ischemic stroke. She
was started on Aspirin, Plavix, and Lipitor, and transferred to acute
inpatient rehab for further diagnostic investigation and functional
optimization. Hematology recommended a hypercoagulable work-up.
In collaboration with Neurology, advanced imaging was integrated with
the entire clinical picture, resulting in a diagnosis of Moyamoya
disease.
Setting:
Community Hospital.
Results:
MRI/MRA showed acute infarcts in the left anterior and left
middle cerebral arteries with corresponding flow restriction. Carotid
Ultrasound was negative for stenosis. Hypercoagulable work-up
including Factor 5 Leiden, Protein C/S, Anti-Cardiolipin, Sickle Cell,
Janus Kinase 2, Beta 2 glycoprotein were negative.
Discussion:
Moyamoya disease is a rare progressive cerebrovascular
condition with an incidence of less than 1 in 100,000 in the United
States. It most often occurs in children, but can also affect young
adults in their thirties. Its etiology is believed to involve a genetic
component which causes cerebrovascular stenosis and abnormal
collateral blood vessels. These collaterals are fragile and may lead to
hemorrhagic stroke. Prognosis depends on age and extent of ischemia;
but the patient’s neurological status at the time of treatment is the
most important prognostic factor. Medical management thus far has
proven ineffective. Treatment is primarily surgical using encephalo-
duroarteriosynangiosis or encephalomyosynangiosis with the goal of
revascularization across the blockage.
Conclusions:
Although rare in the United States, Moyamoya disease
should be considered as a possible differential in young patients
lacking classical risk factors for stroke. Since medical management has
proven ineffective, a correct diagnosis is critical so patients may un-
dergo revascularization surgery.
Level of Evidence:
Level V
Poster 310:
Functional Recovery of a Patient with an Invasive
Sacral Giant Cell Tumor and Debilitating Pain: A Case
Report
Sarah A. Mihalov, MD (Rehabilitation Institute of Chicago /
Northwestern University Feinberg School of Medicine),
Alan S. Anschel, MD
Disclosures:
Sarah Mihalov: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 53-year-old woman with sacral giant
cell tumor (GCT). The patient initially presented with severe, right,
back and leg pain without weakness requiring morphine-equivalent-
daily-dose (MEDD) of 232 mg plus gabapentin for pain control. Imaging
demonstrated a sacral and hemipelvic mass; biopsy confirmed diag-
nosis of GCT. Oncology began denosumab treatment. Within 1 month,
her MEDD was 0 mg. Within 6 months, she discontinued gabapentin. At
9 months, her back pain recurred, requiring a MEDD of 238 mg. On
exam, she then exhibited right ankle dorsiflexion weakness and right
gastrocnemius muscle atrophy without pathological reflexes or
changes in bowel or bladder. Repeat imaging demonstrated lytic tumor
in the right hemisacrum and in the right S1 and S2 roots. She under-
went tumor debulking with spine stabilization with an uncomplicated
postoperative course. Post-operative-day-one (POD1), she required
moderate assistance for bed mobility and minimal assistance for
ambulation. She transferred to acute inpatient rehabilitation on POD 4
on a MEDD of 330 mg plus gabapentin for pain control.
Setting:
Inpatient rehabilitation hospital.
Results:
The patient completed a comprehensive rehabilitation pro-
gram for 7 days. Her Functional Independence Measure (FIM) score
improved from 71 on admission to 105 on discharge with a FIM effi-
ciency of 5.6. Her 6-minute-walk (6MW) improved from 501feet with
close supervision and rolling walker (RW) to 857 feet with distant su-
pervision and RW. At discharge, her MEDD score was 48 mg plus
gabapentin. She discharged home with outpatient therapy and
improved her 6MW to 1604 ft with complete independence.
Discussion:
GCT is a rare primary bone tumor that is locally aggres-
sive, benign, and rarely affects the sacrum. This case uniquely dem-
onstrates a sacral GCT with neurologic compromise and debilitating
pain treated successfully with multidisciplinary interventions,
including rehabilitation, which is rarely discussed in the GCT
literature.
Conclusions:
Patients with complex surgical interventions after
invasive sacral GCT can make significant functional gains and recovery
in acute inpatient rehabilitation.
Level of Evidence:
Level V
Poster 311:
Management of Lower Extremity Dyskinesia with the
Dopamine Agonist Ropinirole in a Patient with
Multiple Sclerosis and an Intrathecal Baclofen Pump:
A Case Report
Maria G. Martinez, MD (Syracuse VA Medical Center NY, Syracuse, NY,
United States), Gizelda T. Casella, MD PhD, Kristen Franklin, Pharm D,
Claudine A. Ward, MD
Disclosures:
Maria G. Martinez, MD: I Have No Relevant Financial
Relationships To Disclose
Case/Program Description:
A 66-year-old woman with primary pro-
gressive multiple sclerosis (MS)
e
diagnosed at age 38
e
causing severe
spasticity in the limbs and trunk with occasional diaphragmatic spasms
affecting her ability to breathe. She also presented with bilateral
lower extremity (BLE) dyskinesia. The patient underwent intrathecal
baclofen (ITB) pump implantation. Despite excellent control of the
limb/trunk spasticity and complete resolution of the diaphragmatic
spasms, dyskinesia of BLE persisted. She was thus started on
Ropinirole.
Setting:
Outpatient clinic at a VA Medical Center.
Results:
BLE dyskinesia resolved completely once her dose was
titrated up to 0.75 mg at bedtime. After a few weeks on ITB and
Ropinirole, the patient wished to taper off Ropinirole. When she
decreased to 0.25 mg at bedtime, the dyskinesia in her BLE re-
emerged. Ropinirole was increased back to 0.75 mg and the dyskinesia
once again resolved.
Discussion:
Dyskinesia is an uncommon finding in patients with MS and
may become a treatment challenge especially when associated with
severe spasticity. One must carefully differentiate between uncon-
trolled spasticity and dyskinetic movements in order to treat accord-
ingly. Optimal control of spasticity was not sufficient to treat this
patient’s dyskinesia and only when Ropinirole was added, did she
achieve good control. Ropinirole is a potent nonergoline dopamine
agonist specific for D2 and D3 receptor subtypes, possibly within the
caudate and putamen in the brain and may be used to treat dyskinetic-
type movements. Tapering of Ropinirole preceded the recurrence of
dyskinesia of BLE and increasing the dose again extinguished the
abnormal movement.
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Abstracts / PM R 9 (2017) S131-S290