S241 S290
Case/Program Description:
A 61-year-old woman with a history of
chronic back pain and radiculopathy presented with acute onset
bilateral lower extremity (BLE) numbness, weakness, and urinary
retention. Exam revealed BLE paraparesis (right greater than left),
positive left Babinski’s sign, and bilaterally decreased sensation to
light touch below the L1 dermatome. MRI demonstrated spinal
cord edema and enhancement suggestive of transverse myelitis
from T6-T7 through the Conus Medullaris. CSF analysis showed
pleocytosis with high IgG. Infectious workup was negative. She
received IV steroids and plasmapheresis for suspected NMO trans-
verse myelitis. Patient was discharged from inpatient rehabilita-
tion without significant improvement in pain symptoms. She
returned to the hospital 5 weeks after discharge with complaints
of worsening abdominal pain, neuropathy, spasms, and BLE
weakness. Exam was remarkable for worsening paraparesis with
increased left lower extremity weakness and a T5 sensory level.
Repeat MRI showed increased cord enhancement from T3 through
the Conus Medullaris. Spinal angiogram demonstrated a dural
AV fistula (DAVF) supplied by a medullary branch at the level of
right L1.
Setting:
Acute Rehabilitation Setting.
Results:
Presumed venous hypertension was the cause of the patient’s
myelopathy. She underwent resection of the DAVF by Neurosurgery.
Post operatively; she had slight improvement in the degree of her BLE
weakness, spasticity, and neuropathy.
Discussion:
Delayed diagnosis of DAVF is common given the rarity of
the disease. Patients may present with intermittent weakness, bowel
and bladder dysfunction, paresthesias, and erectile dysfunction,
which are also common symptoms of myelopathy. MRI demonstrates
spinal cord edema and can mimic transverse myelitis but flow voids
may also be seen. A spinal angiogram is often needed for definitive
diagnosis.
Conclusions:
Although DAVF are rare, they must be considered in a
patient with progressive myelopathy because rapid diagnosis and
surgical treatment is indicated for the best prognosis.
Level of Evidence:
Level V
Poster 344:
Diverticular Associated Colitis After Gastric Tube Placement
in a Hemorrhagic Stroke Patient with Severe Dysphagia:
A Case Report
Andrew Y. Chang, MD (WA Univ/BJH/SLCH Consortium), Sindhu Jacob,
MD
Disclosures:
Andrew Chang: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
Patient with recent IPH and subsequent
aphasia, right sided hemiparesis, and severe dysphagia was unable
to tolerate a pureed diet. Decision was made to place a gastric tube
due to poor oral intake and concern for possible aspiration.
Following placement of gastric tube patient spent a week at the
acute care facility for treatment of pneumonia. Patient was re-
admitted to rehab following completion of antibiotic regimen.
Following re-admission to rehab patient reported having abdominal
pain that became more persistent and severe. Physical exam
revealed some tenderness to palpation around the gastric tube site
however rest of the exam was benign. Patient was tolerating tube
feeds with no residuals and complete blood count (CBC) and basic
metabolic panel (BMP) were within normal limits. Vitals obtained
during this period were within normal limits as well. Abdominal x-
ray obtained revealed no acute pathology. Patient then developed
diarrhea and persistent emesis at which point patient was trans-
ferred to the Emergency Department. Work-up revealed diverticu-
losis with transverse and descending colitis on CT. Stool samples
were negative for
Clostridium difficile
.
Setting:
Inpatient Rehabilitation of a community-based, academic,
tertiary care facility.
Results:
Patient’s gastric tube was revised to gastric jejunal tube and
following revision repeat CT imaging revealed resolution of the colitis.
Patient’s pain also improved.
Discussion:
This is the first reported case, to our knowledge, of
diverticular-associated colitis following gastric tube placement.
Conclusions:
Many stroke patients come to inpatient rehabilitation
centers with gastric tubes and those with diverticulosis however rare,
can develop colitis.
Level of Evidence:
Level V
Poster 346:
Lance Adams Syndrome Mistaken for Status
Epilepticus in an Anoxic Encephalopathy Patient: A
Case Report
Annamaria L. Dunn, MD (JFK Med Cntr), Alessandra Dunn, N/A
Disclosures:
Annamaria Dunn: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The case of a 56-year-old woman with a
history of asthma suffered respiratory and cardiac arrest and devel-
oped constant myoclonic activity which was wrongly diagnosed as
status epilepticus and denied rehabilitation.
Setting:
Acute care 7000 bed Level one Trauma/Comprehensive
Stroke Center.
Results:
A consult was called on a patient by the palliative care team
to discuss functional goals of care. The patient was a 55-year-old
woman with severe asthma who suffered respiratory and cardiac ar-
rest after being exposed to cleaning products in a highway rest-stop.
There was prolonged CPR. At the time of the consult the patient had
generalized myoclonus which was determined to be status epilepticus
as a result of the severe hypoxic-ischemic incident. This diagnosis
carried a poor prognosis. The patient was evaluated by the consulting
PM&R team and determined to be following commands. A neurologist
was called in and the diagnosis of Lance-Adams was made. This diag-
nosis had a good prognosis with treatment. The patient was accepted
to an inpatient rehabilitation facility and was subsequently discharged
home after an intensive program.
Discussion:
Patients who suffer a severe hypoxic-ischemic event with
subsequent myoclonic movements are sometimes misdiagnosed as
having status epilepticus and are not referred for rehabilitation. A
thorough physiatric examination can determine if the patient is
tracking and command following and hence allow the patient to
receive the benefits of an intensive inpatient rehabilitation program.
Lance Adams syndrome has a good prognosis for recovery.
Conclusions:
More attention needs to be paid to the patients with
severe hypoxic/ischemic events with subsequent myoclonic activity.
Level of Evidence:
Level V
Poster 347:
Moyamoya Disease, Intracranial Hemorrhage vs Ischemic
Infarction: A Case Series
Stephanie Li (Moss Rehabilitation/Temple University, Philadelphia,
PA, USA), Ning Cao, MD, Tariq Rajnarine, MD, Jennifer Yu, MD
Disclosures:
Stephanie Li: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Case 1: A 38-year-old Hispanic man with
Moyamoya disease (MMD) diagnosed in 2015 and who underwent right
superior temporal artery (STA) to middle cerebral artery (MCA) bypass
in January 2016 was found down at home on July 2016. His CT head
showed large intraventricular hemorrhages in the 3rd and 4th ventri-
cles along with hydrocephalus. He received evacuation of a frontal
hematoma, but continued to present neurological deficits including
impaired executive functioning and apraxia. Case 2: A 43-year-old
African-American woman with a history of stroke with right-hemi-
paresis presented with worsening right-sided weakness and dysarthria.
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Abstracts / PM R 9 (2017) S131-S290