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MRI demonstrated multiple small acute lacunar infarcts in the left
frontal cortex. MRA showed bilateral MCA and proximal anterior ce-
rebral artery occlusions suggestive of MMD. She received STA to MCA
bypass. She also presented with significant cognitive impairment and
aphasia.
Setting:
Acute inpatient rehabilitation unit.
Results:
The first patient required max to total assist for most activ-
ities of daily living (ADLs) on admission. On discharge he was super-
vision to minimal assist for most ADLs. The second patient
demonstrated expressive and receptive aphasia, dysarthria, as well as
reduced impaired executive functioning. On discharge she was at
distant supervision level for all mobility, ADLs, and communication
skills. In summary, both patients exhibited vast improvements in their
functional status after comprehensive physical, occupational and
speech therapy and were successfully discharged home.
Discussion:
The incidence of MMD is exceedingly rare and documen-
tation of its rehabilitation potential has been sparse, especially among
non-Asian populations. Here we describe the clinical presentation as
well as rehabilitation course of two adult non-Asian patients who
suffered from MMD. There are 2 main types of symptoms: ischemia and
hemorrhage. Surgical revascularization has been the traditional
treatment for prevention of recurrence.
Conclusions:
Adult patients with MMD who experience either hemor-
rhagic or ischemic complications can have good rehabilitation
potential.
Level of Evidence:
Level V
Poster 348:
An Unusual Cause of Visual Hallucinations: Embolic
Occipital Infarct Causing Charles Bonnet Syndrome: A
Case Report
Araj Sidki, DO (SUNY At Stony Brook, St. Charles Hospital), Jun Zhang,
MD, Nicole Fiorentino, OTR/L
Disclosures:
Araj Sidki: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
An 87-year-old man with a history of
atrial fibrillation, hyperlipidemia and cataracts reported 3 visual
hallucination incidents. CT head was negative, but MRI demonstrated
punctate embolic cerebral infarcts in the occipital lobe. Patient was
medically stabilized and transferred to acute inpatient rehabilitation.
On admission, three daily visual hallucinations of brown rice covering
his table, and chicken wire covering the wall still persisted. These
hallucinations would occur with meals and fatigue. Patient was
cognizant that these hallucinations were unreal, as they disappeared
with changes in vision angle. Physical exam revealed generalized
weakness, decreased vision and visual field defects, with corrective
lenses. Extraocular muscles and cranial nerves were intact. Charles
Bonnet Syndrome (CBS) was suspected based on clinical findings and
interval history. Routine occupational therapy (OT) was used to
improve visual perceptual skills to baseline.
Setting:
Community Rehabilitation Hospital.
Results:
OT sessions decreased visual hallucinations by time of
discharge. OT helped identify hallucination triggers and improve visual
perceptual skills, leading to increased daily activity participation. Vi-
sual exercises such as scanning, figure ground skill training and
compensatory strategies were used. Providing education of CBS to
patient and family was essential.
Discussion:
CBS is a condition characterized by vivid and recurring
visual hallucinations with insight, in older adults with later-life vision
loss in the absence of neuropsychiatric disease. CBS can be triggered
by stress, inactivity, and low lighting. One theory explaining CBS is
deafferentation, where steady input to the visual cortex is needed to
suppress random image expression. When input is interrupted,
inhibited images emerge as visual hallucinations. This case warrants
review as it describes a unique cause of visual hallucinations in the
elderly.
Conclusions:
CBS cases are underreported as patients may be un-
willing to report hallucinations due to psychiatric stigma. This case
demonstrates the importance of identifying CBS and proper treatment
with OT modalities.
Level of Evidence:
Level V
Poster 349:
Bilateral Distal Thigh Sciatic Nerve Injury Caused by
Improper Application of a Cooling Blanket, A
Challenging Electromyography Case Confirmed by
Diagnostic Nerve Ultrasound: A Case Report
Ilya Igolnikov, MD MS BA (Moss Rehabilitation, Philadelphia, PA,
United States), Mary S. Keszler, MD, Shawn M. Peterson, DO,
Katie Hatt, DO, Miriam Segal, MD, Theera Vachranukunkiet, MD BS
Disclosures:
Ilya Igolnikov: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 41-year-old man presented with acute
right middle cerebral artery embolic infarct and underwent embo-
lectomy complicated by post-operative intracranial hemorrhage of
the right basal ganglia requiring acute decompressive hemi-
craniectomy. His hospital course was complicated by cardiac arrest
for which he was placed on therapeutic hypothermia protocol. Upon
removal of the cooling blanket circumferential frostbite injury of
the distal thighs was noted. The patient was transferred to a
regional burn center where he underwent excision of wounds and
skin grafts from the proximal thighs. He later complained of
weakness in both legs and paresthesia in the left lower limb.
Physical examination revealed residual left flaccid hemiparesis
secondary to right CVA, but also substantial right lower leg weak-
ness prompting electrodiagnostic studies.
Setting:
Acute inpatient rehabilitation.
Results:
Physical examination and electrodiagnostic studies pointed
to acute bilateral sciatic nerve injury with predominant axon loss
affecting motor and sensory fibers in both the tibial and peroneal di-
visions with no signs of critical illness neuropathy or myopathy. Ul-
trasound evaluation showed intraneural fascicular swelling and
circumferential perineural swelling at the level of the frostbite injury.
Discussion:
The mid-distal thigh is a highly unusual location for
bilateral sciatic nerve injury. EMG-determined location of injury in our
patient corresponded with the location of frostbite to his bilateral
thighs. The exact mechanism of injury is unknown and to our knowl-
edge this has not been previously reported in the literature. As the
patient was transferred from another facility, it is unknown which
model of cooling blanket was used, and whether the device was
applied circumferentially, was compressive, or duration of
application.
Conclusions:
Iatrogenic sciatic nerve injury due to frostbite is a novel
mechanism to our knowledge with a unique electrodiagnostic pre-
sentation. Diagnostic nerve ultrasound can be a useful adjunct
confirmatory test in unusual presentations of nerve injury.
Level of Evidence:
Level V
Poster 350:
Acute Stroke Rehabilitation Complicated by New
Onset Unilateral Cerebellar Kinetic Tremor: A Case
Report
Anna Rozman, DO, MBA (Montefiore Medical Center, New York, NY,
United States), Yuriy O. Ivanov, DO, Maria A. Jouvin-Castro, MD
Disclosures:
Anna Rozman: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 42-year-old diabetic and hypertensive
man admitted to rehab with ataxia, difficulty ambulating and dizziness
due to left posterior medullary acute infarct. Two weeks after his
stroke, he developed a coarse sustained high amplitude action tremor,
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Abstracts / PM R 9 (2017) S131-S290