S239 S290
Results:
He had a 7 day second acute rehab admission after which his
total ADL FIM score increased by 275% over his total ADL FIM score prior
to cranioplasty.
Discussion:
Syndrome of the Trephined (SoT), or Sinking Skin Flap
Syndrome (SSS) is a disorder of delayed neurological deterioration that
occurs in patients with large cranial defects following craniectomy. It
is not well-known amongst physiatrists but has implications for patient
evaluation and management.
Conclusions:
SoT/SSS, is a potential complication of large craniec-
tomies that can develop during the course of acute rehabilitation and
may explain otherwise cryptogenic declines in function.
Level of Evidence:
Level V
Poster 337:
Medical and Functional Recovery in Neurologic Rehabilitation
of Central Nervous System Toxoplasmosis: A Case Report
Surein Theivakumar
Disclosures:
Surein Theivakumar: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 42-year-old healthy man presented to
acute care hospital with 5-month history of progressive confusion, 25
pound weight loss, and night sweats. In addition, he reported
decreased function in his left arm for 6 weeks. Upon workup, patient
was found to have positive HIV-1 antibody and antigen as well as
brain MRI consistent with toxoplasmosis. Cervical spine MRI showed
large intramedullary mass from C1 to C7. Toxoplasmosis was
confirmed with cerebral spinal fluid polymerase chain reaction as
well as IgG antibody. For toxoplasmosis, patient was treated with
Bactrim, steroid taper, and keppra. Patient was admitted to acute
inpatient rehabilitation for 16-day course to improve functional
deficits in cognition, activities of daily living, and ambulation. Upon
arrival to acute inpatient rehabilitation, patient started on highly
active antiretroviral therapy (HAART). EEG was performed showing
no seizure like activity, thus keppra and steroids tapered off. In
addition, patient continued on Bactrim, weekly azithromycin, and
Genvoya for management of HIV treatment/prophylaxis and treat-
ment of central nervous system toxoplasmosis throughout rehabili-
tation stay and upon discharge.
Setting:
Acute inpatient rehabilitation facility.
Results:
By the end of the 16-day rehabilitation course, patient
showed significant improvement both medically and functionally.
Repeat MRI of brain and cervical spine showed significant improvement
of toxoplasmosis lesions. In addition, patient showed a large
improvement in FIM scores when comparing initial and discharge
therapy evaluations. The comparison of MRIs and FIM scores compar-
isons will be discussed.
Discussion:
There are a few case reports that also show good func-
tional outcome of CNS toxoplasmosis when patients are undergoing
appropriate medical treatment. However, more studies involving
rehabilitation and medical courses are needed to support further
support early neurologic rehabilitation.
Conclusions:
Neurologic rehabilitation provides promising medical
and functional recovery for central nervous system toxoplasmosis,
however more studies are required to further support early rehabili-
tation courses for these patients.
Level of Evidence:
Level V
Poster 338:
Brown-Sequard Syndrome due to Ischemia from a
Vertebral Artery Occlusion: A Case Report
Mayya Gorbal, MD (Albert Einstein Col of Med), Edward Alexeev, MD,
Shayan Senthelal, MD, Maria A. Jouvin-Castro, MD
Disclosures:
Mayya Gorbal: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 42-year-old African-American man with
a past medical history of recurrent anterior and posterior circulation
cerebral infarcts and right subclavian vein occlusion who presented
with sudden onset of right hemiplegia. Physical exam was notable for
flaccid paralysis of the right upper and lower extremities and
decreased sensation to pinprick and temperature on the left below the
C4 sensory level, consistent with a right Brown-Sequard syndrome. MRI
brain showed no acute infarcts. MRA of the head, neck and chest
showed a new complete lack of flow within the right vertebral artery
and thoracic vasculature ectasia with areas of aneurysm. MRI of the
cervical spine without contrast was remarkable for intramedullary
spinal cord signal abnormality from the level of C2 to C6. MRI of the
cervical and thoracic spine with contrast showed edema compatible
with spinal cord ischemia. Hypercoagulable, autoimmune and vascu-
litis workups were unrevealing and the patient remained hemiplegic
on the right side. He was then discharged to acute inpatient rehabil-
itation for physical and functional optimization.
Setting:
Acute Inpatient Rehabilitation Facility.
Results:
The patient had a challenging neuromuscular rehabilitation
course. He actively participated in a comprehensive therapy regimen
and was only able to regain minimal strength of his right lower ex-
tremity at time of discharge while his right upper extremity remained
plegic. Following discharge, he developed right sided spasticity
managed with baclofen under the care of physiatrists.
Discussion:
Brown-Sequard syndrome is a spinal cord lesion charac-
terized by ipsilateral weakness and loss of proprioception and
contralateral loss of pain and temperature sensation. We present a
case of this relatively uncommon condition manifesting in a patient
with a medical history suggestive of a vasculopathy of unclear
etiology.
Conclusions:
Vertebral artery occlusion can manifest in the setting of
a diffuse vasculopathy and play a critical role in the development of
spinal cord ischemia, resulting in decreased patient function.
Level of Evidence:
Level V
Poster 339:
Ptosis, Diagnosis, Neurosarcoidosis: A Case Report
Brian P. Golden, DO (Nassau University Medical Center, East Meadow,
NY, United States), Ketan Patel, Resident Physician, Yousaf Chowdhry,
MD, Lyn D. Weiss, MD
Disclosures:
Brian Golden: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 25-year-old man presented to the
emergency room with bilateral ptosis, generalized weakness and fa-
tigue. He was discharged with no treatment. Three days later, the
patient presented with progressively worsening symptoms and un-
steady gait. He denied any recent travel or illnesses. On exam he was
found to be extremely lethargic, had an ataxic gait, and cranial nerve
palsies. An infectious etiology was initially ruled out, and the differ-
ential diagnosis was narrowed to myasthenia gravis (MG), Guillain-
Barre Syndrome (GBS), or multiple sclerosis (MS). He was started on
bedside therapy, and his treatment course consisted of intravenous
(IV) hydration, IV Immunoglobulin, and cholinesterase inhibitors.
Setting:
Tertiary care teaching hospital.
Results:
The CT head was negative, and lumbar puncture showed
oligoclonal bands and elevated proteins in the cerebrospinal fluid
(CSF). Magnetic resonance imaging (MRI) brain showed increased signal
intensity in the brainstem, basal ganglia, and cortex. Electrodiagnostic
testing (EDx), including repetitive nerve stimulation, needle electro-
myography, nerve conduction studies, and F waves were performed
and were normal, concluding that there was no EDx evidence of GBS,
MG, myopathy, or peripheral neuropathy.
Discussion:
IV steroids were started for suspected neurosarcoidosis as
evidenced by bilateral cranial nerve palsies, high protein in CSF, and
possible inflammation. The patient had significant improvement in
symptoms and function after a trial of high dose steroids, further
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Abstracts / PM R 9 (2017) S131-S290