S232 S290
Poster 315:
Unmasking Rehabilitation Potential in a Veteran with
Bilateral Syndrome of Trephined: A Case Report
Logan McCool, DO (University of Minnesota, Minneapolis, Minnesota,
United States), Neha P. James, DO, Mary Himmler, MD
Disclosures:
Logan McCool, DO: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A veteran who was involved in a moped
accident with initial GCS of 8 and sustained multiple injuries including
severe TBI with bilateral subdural hematomas and subarachnoid
hemorrhages, bilateral basilar skull fractures, LeForte 3 fracture, and
multiple other facial fractures. This veteran underwent bilateral cra-
niectomies with abdominal skull flap placement. Veteran was enrolled
in Emerging Consciousness Program about 1.5 months after bilateral
craniectomy. Hospital course was complicated by neurostorming,
infected bone flaps, tracheostomy placement, and 2 months of
decerebrate posturing. Underwent bifrontal cranioplasty 3.5 months
after craniectomy. Right temporal intraparenchymal and subdural
hemorrhage noted intraoperatively.
Setting:
Tertiary care rehabilitation hospital.
Results:
Bilateral upper extremity extensor posturing persisted in the
immediate post-cranioplasty period and gradually improved after
bilateral cranioplasty. The veteran was classified as CRS-R 3 post-
operatively and improved to CRS-R 19 approximately 1 month post-
operatively. Seven months from the time of injury and 3 months from
the time of bilateral cranioplasty, the veteran was ambulating with
front wheeled walker and speaking in complete sentences. He is
anticipating discharge home with family.
Discussion:
This is the first case, to our knowledge, of bilateral syn-
drome of trephined with 5 month follow up in acute inpatient reha-
bilitation. The Syndrome of Trephined (also known as Sunken Flap
Syndrome) is a rare complication following large craniectomy that
clinically manifests as severe headache, focal neural changes, seizures
or cognitive changes. Syndrome of Trephined was first reported in 1977
and is thought to be a result of a negative pressure gradient between
atmospheric and intracranial pressures. In a meta-analysis published in
2016, cranioplasty after onset of Syndrome of Trephined is reported to
have improved neurological outcomes. Our case report suggests the
important role cranioplasty may serve in unmasking rehabilitation
potential.
Conclusions:
Physiatrists must recognize the importance of early
cranioplasty in improving patients with the Syndrome of Trephined.
Level of Evidence:
Level V
Poster 316:
Successive Recovery for Aphasia in the Bilingual Brain:
A Case Report
Priya B. Patel, DO (Mt Sinai Hlth Sys), Jeffrey S. Fine, MD
Disclosures:
Priya Patel: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 52-year-old right handed woman with
medical history of hypertension and hyperlipidemia admitted
following left thalamic stroke. Admission exam was notable for right
hemiparesis, expressive and receptive aphasia, and dysphagia. CT
head revealed left thalamic hemorrhage with midline shift and sur-
rounding edema resulting in effacement of the third ventricle and
dilatation of the right temporal horn. Hemorrhage was managed
conservatively and patient was admitted to inpatient rehabilitation.
Setting:
Inpatient rehabilitation unit.
Results:
Upon rehabilitation admission, patient only spoke her native
language of Bengali, but a dialect she learned in childhood, and per
husband, she did not use for many years. As her edema resolved, her
aphasia improved in a step-wise fashion. In several days, she started
speaking contemporary Bengali and increased comprehension to ver-
bal commands in English. Subsequently, she was able to respond to
basic questions in English with limited English proficiency, which was
her baseline prior to stroke. Interestingly, edema resolution correlated
with progressive step-wise recovery of successive languages.
Discussion:
Aphasia is commonly seen in stroke patients, especially
those with damage to the left hemisphere, which is responsible for
language function. Expressive aphasia (Broca’s area) presents as
fragmented speech, but comprehension is intact. Receptive aphasia
(Wernicke’s aphasia) presents as difficulty with comprehension, but
fluent speech. This case demonstrates that patients with primary le-
sions distant to the language centers can still exhibit aphasia as a
result of significant edema. Our patient demonstrates the importance
of daily monitoring of communication ability, particularly in bilingual
patients.
Conclusions:
This case highlights the importance of thorough history
taking including cultural and linguistic background and its value in
assessing the recovery of left hemisphere pathways in patients that
are bilingual communicators. This information allowed us to clinically
monitor resolving peri-hemorrhage edema and its effect on patient
communication.
Level of Evidence:
Level V
Poster 317:
T12 Schwannoma with Loculated Syrinx Extending to
the Cervico-Medullary Junction: A Case Report
Sanjay J. Digamber (Rush University Medical Center), Daniel Bunzol,
MD
Disclosures:
Sanjay Digamber: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 35-year-old man presented with a 6-
month history of worsening bilateral lower extremity weakness. He
has no past medical history and is originally from Guatemala. He
works as a manual laborer and first noticed his symptoms while
lifting boxes at work. He also developed urinary retention and
constipation with bowel movements every 4 days. He reports
abnormal sensation from the umbilucus and below. The patient
had no upper extremity symptoms and he was completely inde-
pendent with all activities of daily living and gait prior to onset.
His weakness progressed to the point where he required the use of
a rolling walker to ambulate. At this point he decided to see a
physician. Imaging showed a T12 intradural and intramedullary
mass arising from the conus medullaris with loculated syrinx
extending from T12 to the cervico-medullary junction. Neurosur-
gery evaluated patient and he underwent T10-11 laminectomy with
tumor resection.
Setting:
Acute Inpatient Rehabilitation.
Results:
His lower extremity weakness improved over the course of his
rehab stay. His right lower extremity was 1/5 for hip flexion, 2/5 for
knee extension, and 4/5 for plantarflexion and dorsiflexion on
admission. On the left he was 3+/5 for hip flexion and 4-/5 throughout.
Over his rehab stay he was 4+/5 throughout the left extremity and 5/5
on the right. Ambulating 10 feet with walker on admission and beyond
230 feet through rehab course.
Discussion:
This patient showed significant progress with prompt
management and intensive therapy. His lower extremities improved
significantly and he had no upper extremity symptoms throughout his
hospital course. His constipation has resolved and sensation below T10
has improved.
Conclusions:
Young and otherwise healthy patients with extensive
loculated syringomyelia throughout the spinal cord may present with
no upper extremity symptoms. With timely surgical management and
prompt transfer to rehab these patients can show dramatic
improvement.
Level of Evidence:
Level V
S232
Abstracts / PM R 9 (2017) S131-S290