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the bilateral crus cerebri, the left basal ganglia, and scattered areas in
the subcortical white matter. Treatment with traditional neuro-
stimulants resulted in minimal change. He was started on zolpidem 3
months after injury. An increase in arousal and participation was seen
within 15 minutes of the first dose, and lasted up to an hour. Dosing
was gradually increased to 15 mg six times a day, administered every 2
hours. He also had previously received a test dose of lorazepam with
no effect on arousal.
Setting:
Inpatient Rehabilitation Hospital.
Results:
This patient demonstrated a transient increase in arousal,
attention, and participation on zolpidem. His Coma Recovery Scale
e
Revised (CRS-R) score improved from 13 to 20 over the 6-week titration
of zolpidem. He was discharged on zolpidem 15 mg every 2-hours six
times per day without adverse effects.
Discussion:
High, frequent doses of zolpidem in this patient with
disorder of consciousness was well-tolerated. Zolpidem’s effect on
arousal may be due to selective binding to the omega- 1 site of the
GABA A receptor. This patient’s lack of response to lorazepam is
consistent with previous reports of no change in arousal after use of
non-selective GABA agonists in patients with disorders of
consciousness.
Conclusions:
To our knowledge, this is the first reported case of
frequent, high dose use of zolpidem to improve arousal following TBI.
Zolpidem may increase arousal in select patients with disorder of
consciousness after brain injury. Patients may be able to tolerate
higher doses and frequencies than previously reported without adverse
effects.
Level of Evidence:
Level V
Poster 334:
Hashimoto Encephalopathy: Cognitive Advancement:
A Case Report
Ka Hoi Hui, MD (Baylor College of Medicine, Houston, Texas, United
States), Mohammad A. Issa, MD, Craig DiTommaso, MD
Disclosures:
Ka Hoi Hui, MD: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 61-year-old woman with hypothyroid-
ism and 3-month history of progressive confusion and memory loss
presented with seizure. During her hospitalization, patient underwent
extensive work up over the course of 1 month which excluded neo-
plasms, metabolic, infectious, and rheumatologic etiologies. She was
found to have elevated antithyroid antibodies in her serum and CSF.
She was eventually diagnosed with Hashimoto Thyroiditis. Patient was
started on steroids and had improvement in cognition and regression of
thalamic signal abnormalities on MRI. The patient was then admitted
to the inpatient rehabilitation unit for 15 days with emphasis on
improving her cognitive deficits using external aids and rote learning in
addition to starting her on Donepezil.
Setting:
Hospital-based acute rehabilitation unit.
Results:
After completion of 15 days of inpatient rehabilitation pa-
tient demonstrated improvement in her FIM scores compared to
baseline. Her FIM scores improved from 3 to 5 for memory and problem
solving, 4 to 6 for expression, 5 to 6 for comprehension and social
interaction, 1 to 6 for ambulation, 4 to 6 for transfer, 4 to 6 for lower
extremity dressing, and 5 to 6 for upper extremity dressing.
Discussion:
Hashimoto encephalopathy is an uncommon clinical
diagnosis associated with Hashimoto thyroiditis. It is a diagnosis of
exclusion based on presence of antithyroid antibodies, neurological
symptoms, and a positive response to immunotherapy. Current liter-
ature has limited information regarding cognitive and motor recovery
with rehabilitation for patients with Hashimoto encephalopathy.
Conclusions:
External aids and rote learning may promote cognitive
recovery in patients with clinical diagnosis of Hashimoto encephalop-
athy. Patients may also benefit from interdisciplinary rehabilitation to
improve mobility and self-care skills.
Level of Evidence:
Level V
Poster 335:
Heterotopic Ossification Extending into the
Supraclavicular Notch with Resulting Shoulder Pain
and Weakness in an Adult Man post Traumatic Spinal
Cord Injury: A Case Report
Austin L. Albright, MD (University of Virginia Physical Medicine)
Disclosures:
Austin Albright: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient presented to the AIRH setting
after sustaining a traumatic C5 ASIA Impairment Scale - A SCI resulting
from a 55 mph motor vehicle collision. He would develop severe left
shoulder somatic and neuropathic pain, as well as external rotational
weakness early in his rehabilitation course. CT ultimately would
confirm the diagnosis of heterotopic ossification of a left clavicular
fracture extending into the left supraclavicular notch with resulting
suprascapular nerve compression. EMG/NCS would confirm a concur-
rent suprascapular neuropathy with resulting complete functional
denervation. Multiple attempts to achieve appropriate analgesia were
made including: Oral Analgesics (NSAIDs, Gabapentin, Cymbalta, Opi-
oids), Topical Analgesics (Capsaicin, Lidoderm Patches, Fentanyl
Patches), Desensitization Techniques, and a Series of Nerve Blocks.
Surgical intervention was also considered at that time. Ultimately, his
left shoulder pain would improve with medical management and
without need for surgical intervention.
Setting:
Acute Inpatient Rehabilitation Hospital (AIRH).
Results:
At 6 years post presentation, the patient continues to
demonstrate improved left shoulder pain resulting from his hetero-
topic ossification extending into his supraclavicular notch with
resulting suprascapular neuropathy. His course has been and is
complicated by multiple other concurrent somatic and neuropathic
pain complaints resulting from his underlying SCI. Currently his pain is
subjectively well managed with oral gabapentin, oral acetaminophen,
and topical diclofenac.
Discussion:
This case demonstrates the complexities associated with
diagnosing and treating musculoskeletal and neuropathic pain com-
plaints in the SCI population.
Conclusions:
Suprascapular nerve palsy should be considered in the
differential diagnosis for cervical level SCI’s with concurrent clavicular
fracture presenting with shoulder pain.
Level of Evidence:
Level V
Poster 336:
Delayed Cryptogenic Functional Decline After
Craniectomy with Immediate Improvement After
Cranioplasty: A Case Report
Deborah A. Hudleston, MD (Univ of Minnesota, Minneapolis, MN,
United States)
Disclosures:
Deborah Hudleston: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
Patient: 24-year-old man with severe
traumatic brain injury (TBI). The patient was hospitalized on the
inpatient rehabilitation unit from post-op week 3 through post-op
week 10 after open bifrontal parietal bicoronal hemicraniectomies for
significantly increased intracranial swelling and pressure. Eight weeks
postoperatively he began to decline in function, with a 62% reduction
in total ADL FIM scores from post-op week 8 to week 10. Workup for the
etiology of his decline in function was unremarkable. He was trans-
ferred to the neurosurgery service at 10 weeks post-op for planned
cranioplasty. On post-op day 1 after cranioplasty he was noted to have
improved communication and safety awareness such that he no longer
needed a safety assistant for the first time in 10 weeks. He was
participating in therapies and readmitted to the acute rehabilitation
unit on post-op day 2.
Setting:
Major metropolitan area level 1 trauma center.
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Abstracts / PM R 9 (2017) S131-S290