S231 S290
Conclusions:
Ropinirole was fundamental to control dyskinesia in this
patient with MS and well controlled spasticity.
Level of Evidence:
Level V
Poster 312:
Rare Cause of Ulnar Neuropathy in an 18-Year-Old
Musician: A Case Report
Brennan Boettcher, DO (Mayo Clinic, Rochester, MN, United States),
Terin Euerle, MD, Eric J. Sorenson, MD
Disclosures:
Brennan Boettcher: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
An 18-year-old right handed female
musician presented for evaluation of left hand weakness, first noted 19
months prior while trying to play bar cords on her guitar and subse-
quently difficulty flattening her hand for a hand scanner in the airport.
More recently, she noted hypothenar atrophy in the hand. She had no
numbness or other neurologic complaints. She was evaluated else-
where with electromyography (EMG) which was concerning for a C8
radiculopathy. Cervical spine advanced imaging was normal. Exam
revealed left hypothenar atrophy, ulnar clawing, positive Froment’s
sign, and severe weakness of the hypothenar and interosseous muscles
but no thenar weakness. Sensory exam was normal. Tinel’s in the left
forearm was positive, but negative at the ulnar groove and carpal
tunnel.
Setting:
Quaternary care academic center.
Results:
Nerve conduction studies demonstrated low left ulnar motor
amplitude with prominent dispersion and conduction block between
the elbow and wrist as well as low amplitude ulnar sensory response.
The dorsal ulnar cutaneous and medial antebrachial cutaneous sensory
responses were normal. Needle EMG demonstrated chronic neurogenic
changes in the ulnar muscles of the hand with sparse fibrillation po-
tentials. Proximal ulnar, medial cord and C8/T1 innervated muscles
were normal. Ultrasound of the ulnar nerve demonstrated a focal
nerve enlargement in the mid-forearm and loss of fascicular archi-
tecture. MRI showed segmental fascicular enlargement, T2 hyper-
intensity and enhancement of the ulnar nerve with associated
muscular denervation changes, suggestive of perineurioma.
Discussion:
A perineurioma is a rare cause of a peripheral mono-
neuropathy. Knowledge of this condition and imaging findings are
essential for accurate diagnosis. Perineuriomas are slow growing tu-
mors arising from perineural cells demonstrating fusiform fascicular
enlargement and intense gadolinium enhancement.
Conclusions:
Consultation with a peripheral nerve neurosurgeon and
peripheral nerve neurologist resulted in a plan for continued obser-
vation and repeat imaging with no role for surgery.
Level of Evidence:
Level V
Poster 313:
Klu¨ver-Bucy Syndrome After Facial Gunshot Wound:
A Case Report
Henry S. York, MD (Univ of Maryland School of Medicine, Baltimore,
Maryland, United States), Ryan McCarter IV, MS
Disclosures:
Henry S. York, MD: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
This 25-year-old man with history of
ADHD and childhood seizures sustained a self-inflicted gunshot wound
to the right-side of his face resulting in bi-frontal temporal lobe con-
tusions, right globe rupture and extrusion, extra-axial hemorrhage,
and bilateral Le Fort III and zygomatic arch fractures that obliterated
his bilateral orbital floors and optic nerves. His Glasgow Coma Scale
score was 5T on arrival to the acute hospital where the above fractures
were repaired and his right eye was enucleated; he was diagnosed with
cortical blindness. Because of his significant functional deficits, he
participated in Comprehensive Inpatient Brain Injury Rehabilitation,
where he displayed inappropriate sexual behaviors, hyperphagia, and
profound anterograde and retrograde amnesia, symptoms consistent
with Klu¨ver-Bucy syndrome. The patient made sufficient progress such
that he could perform mobility and activities of daily living with close
supervision and verbal cues. He was discharged home but continued to
have moderate-severe cognitive, communication, and memory
deficits.
Setting:
Rehabilitation hospital.
Results:
One year post-injury, his residual memory and cognition has
improved. The patient remains significantly overweight (306 pounds),
but it is stable. He continues to be followed by a team of physicians for
multiple secondary medical conditions.
Discussion:
Klu¨ver
e
Bucy syndrome results from bilateral lesions of
the medial temporal lobe including the amygdaloid nucleus and can
present with hyperphagia, hypersexuality, hyperorality, visual
agnosia, and docility. It is rare for humans to display all of the above
symptoms but three or more are necessary for diagnosis. The most
common symptoms in humans are placidity, hyperorality, and dietary
changes. Only two other cases of Klu¨ver-Bucy syndrome after a gun-
shot wound to the head are described in the literature.
Conclusions:
Klu¨ver-Bucy syndrome is rare but can be seen in in-
dividuals with penetrating traumatic brain injuries. Provider aware-
ness of all the features of Klu¨ver-Bucy syndrome can help patients
obtain appropriate consultation and guidance.
Level of Evidence:
Level V
Poster 314:
Challenging Cases of Ultrasound Guided Baclofen Pump
Refills: A Case Series
Jesse N. Charnoff, MD (University of Miami/Jackson Memorial, Miami,
FL, United States), Diana Molinares Mejia, MD, Armen Derian, MD,
Seema R. Khurana, DO
Disclosures:
Jesse N. Charnoff, MD: I Have No Relevant Financial
Relationships To Disclose
Case/Program Description:
Ultrasound is a valuable tool in perform-
ing minimally invasive procedures such as joint injections. The current
gold standard in intrathecal baclofen pump refills is the use of a
template. Templates are sufficient in many cases, however in certain
cases their use may be limited due to several factors that make pump
refills difficult. These include obesity, pump tilting or migration.
Introduction of ultrasound in these cases decreased the difficulty of
locating of the reservoir port, decreased procedure time, and
improved patient satisfaction. This case series describes a novel
technique to refill intrathecal pumps using ultrasound guidance.
Setting:
Outpatient spasticity clinic.
Results:
Patients reported that in comparison to the template
method, ultrasound guidance was less traumatic. In all cases, the
needle was inserted in the correct location on the first attempt. The
patients reported increased satisfaction with the use of ultrasound.
Discussion:
The utility of using ultrasound to assist in refilling intra-
thecal baclofen pump reservoirs has not been studied. In our three
cases we found that ultrasound guidance is beneficial for both patients
and physicians. In difficult cases of intrathecal pump refills, ultrasound
may help physicians perform more effectively and efficiently. The
patient may benefit from fewer needle-sticks, because the pump can
be visualized throughout the procedure.
Conclusions:
Ultrasound guidance improves the accuracy of intra-
thecal pump refills, particularly in difficult cases where the reservoir
port may not be as easily identified using templates or palpation guid-
ance. This novel technique involves the use of a marking pen in order to
avoid any sterile gel penetrating the abdomen with the needle advanced
under ultrasound directly. By marking the site first, then inserting the
needle after sterilization, we penetrated the pump reservoir with 100%
accuracy. Further studies will compare ultrasound guidance to the
traditional template and blind, palpation based techniques.
Level of Evidence:
Level V
S231
Abstracts / PM R 9 (2017) S131-S290