S252 S290
Poster 377:
Unusual Presentation of Acute Inflammatory Demyelinating
Polyneuropathy with Predominant Upper Extremity
Symptomatology
Brandon Trivax, DO, MPH (Wm Beaumont Hosp, Commerce Twp, MI,
United States)
Disclosures:
Brandon Trivax: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 57-year-old Caucasian man presented
with tetraplegia and paresthesias. His symptoms started 5 days prior
to admission with intense pain and progressive weakness of his
bilateral arms. The patient stated that an inability to write prompted
him to seek medical attention. Upon admission, the patient was
noted to have autonomic dysfunction in the form of tachycardia and a
neurological exam revealing a upper extremity dominant tetraplegia
with diffuse diminished vibratory and light touch sensation. Lumbar
puncture was performed and was consistent with an albuminocyto-
logic dissociation. Patient had a magnetic resonance image (MRI) of
his brain, thoracic, cervical, and lumbar spine that was negative for
acute pathology. Laboratory studies including human immunodefi-
ciency virus (HIV), thyroid stimulating hormone (TSH), Vitamin B12,
antigangioside antibodies (GM1, asialo-gm1, GD1a, GD1b, GQ1b),
myelin-associated glycoprotein (MAG) antibodies, sulphated glucur-
onyl paragloboside (SGPG) antibodies IgM, and neuronal nuclear an-
tibodies were unremarkable. Electromyography (EMG) was
performed and showed findings demonstrating a demyelinating motor
greater than sensory peripheral neuropathy consistent with an acute
inflammatory demyelinating polyneuropathy (AIDP). No evidence of
motor neuron disease or fasciculations were seen on EMG. The pa-
tient was placed on IVIG for a full 5 day course and was admitted
inpatient rehabilitation for intensive physical therapy, occupational
therapy, and speech therapy.
Setting:
Acute Hospital Setting.
Results:
Patient’s symptoms improved and he was discharged home at
a modified independent level for his basic and advanced activities of
daily living.
Discussion:
This is the first reported case, to our knowledge, of a
tetraplegic patient with predominantly upper extremity symptom-
atology and EMG findings consistent with acute inflammatory demye-
linating polyneuropathy.
Conclusions:
Acute inflammatory demyelinating polyneuropathy pre-
sents as a spectrum of disorders that can result in tetraplegia that
affects the upper extremities greater than the lower extremities.
Level of Evidence:
Level V
Poster 378:
Impressive Functional Recovery Following an Intracerebral Arterial
Bypass Procedure: A Case Report
Kathleen Vonderhaar, MD (University of Minnesota, St. Paul, MN,
United States), Diane Mortimer, MD, Molly E. Hubbard, MD
Disclosures:
Kathleen Vonderhaar: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 66-year-old man presented with severe
headache, speech changes and vertigo. Imaging showed a left tem-
poral subarachnoid hemorrhage and a ruptured left middle cerebral
artery (MCA) aneurysm. He underwent craniotomy for aneurysm clip-
ping on the following day. During surgery, a hole in the aneurysm was
found at the temporal branch of the MCA. The vessel’s anterior tem-
poral branch was truncated at the neck of the aneurysm and then re-
anastomosed to the distal M2 branch. Post-operatively, he had aphasia
and right sided weakness. Imaging showed a left frontal and temporal
infarct.
Setting:
Acute Inpatient Rehabilitation Unit.
Results:
.
Discussion:
On admission to acute rehabilitation on hospital day 17,
impairments included right hemiplegia, expressive and receptive
aphasia, impaired balance, and impulsivity. Given his functional status
and underlying pathology, the interdisciplinary team predicted that his
rehabilitation course would be prolonged with significant cognitive and
physical assistance required on discharge.
He worked intensively with the speech, occupational, physical and
recreational therapy teams. Rehabilitation and neurosurgery providers
closely collaborated regarding his activity level, medications, and
blood pressure management. Surprisingly, at the end of his first week
in rehabilitation, he was communicating appropriately in full senten-
ces and ambulating without an assistive device. He continued to make
dramatic functional gains in an unexpectedly rapid fashion. At
discharge, he was independent in all activities of daily living and was
preparing to return to driving.
Conclusions:
Bypassing injured portions of intracerebral arteries has
long been considered a possible treatment for patients with ischemic
strokes. However, the implementation of such procedures has been
hindered by their inherent difficulty and high potential for complica-
tions. In this patient, bypassing the damaged section of the left MCA
led to effective subsequent cerebral perfusion. This aggressive surgical
approach, combined with an intensive course of acute inpatient
rehabilitation, led to a remarkable functional recovery.
Level of Evidence:
Level V
Poster 379:
Concurrent Symptoms of Benign Paroxysmal
Positional Vertigo and Cerebellar Infarct: A Case
Report
Conan So (University of Maryland, Baltimore, MD, USA),
Robynne Braun, MD, PhD
Disclosures:
Conan So: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
The patient is a 79-year-old woman who
presented after 1 week of intermittent dizziness brought on by posi-
tional changes. She denied tinnitus, nausea, or hearing impairment.
Past medical history included hypertension, hypothyroidism, hyper-
lipidemia, benign paroxysmal positional vertigo, and a right parietal
stroke. MRI revealed an acute punctate infarct of the left inferior
cerebellum. On the date of her rehabilitation admission, she had an
ataxic gait and gaze-evoked nystagmus, more notable when looking
towards the left. Her neurological exam was otherwise unremarkable.
The next morning, she reported worsening dizziness and endorsed a
sensation that the room was spinning. Dix-Hallpike to the left
demonstrated immediate rotational nystagmus with severe vertigo.
The Epley maneuver was performed with subsequent resolution of the
rotational nystagmus. Four days later, she continued to have constant
mild dizziness that was not associated with positional changes. A
repeat Dix-Hallpike was negative. The rest of her hospital course was
unremarkable and she was discharged home on hospital day 20.
Setting:
Inpatient Rehabilitation Unit.
Results:
This patient demonstrated symptoms consistent with benign
paroxysmal positional vertigo, superimposed upon concurrent symp-
toms of cerebellar infarct. Both issues were therefore treated during
her rehabilitation stay with good effect. 9 days after discharge, the
patient had a stable Berg Balance Scale of 49/56, and was ambulating
independently without an assistive device. She denied further epi-
sodes of vertigo.
Discussion:
Symptoms of dizziness secondary to peripheral and cen-
tral etiologies overlap considerably. Here we discuss the importance of
distinguishing between these etiologies and maintaining a low
threshold to evaluate for posterior circulation stroke even when the
history may suggest other more benign causes.
Conclusions:
Patients can present with simultaneous peripheral and
central causes of vertigo and nystagmus.
Level of Evidence:
Level V
S252
Abstracts / PM R 9 (2017) S131-S290