S260 S290
Case/Program Description:
One patient, a 74-year-old woman with
history of hypothyroidism, presented to the emergency department
with headache, right sided weakness, and difficulty ambulating for one
day. Another patient, a 68-year-old man with no known medical his-
tory presented with headache, slurred speech, left sided weakness,
and difficulty with ambulation.
Setting:
Acute Inpatient Rehabilitation Facility.
Results:
One patient’s head CT was significant for hematoma in the
left centrum semi-ovale with mild edema around it. The other pa-
tient’s head CT demonstrated posterior right parietal intra-
parenchymal hematoma.
Discussion:
Given evidence of micro-hemorrhages on the imaging of
both patients, it was determined that the underlying cause of intra-
parenchymal hemorrhage in each of these patients was most probably
cerebral amyloid angiopathy (CAA).
Conclusions:
The diagnosis of CAA can only be definitively made upon
most-mortem examination, but a diagnosis of “probable CAA” is clin-
ically made according to the Boston Criteria in patients greater than 60
years old with multiple lobar hemorrhages without another cause. In
patients with suspected CAA it is prudent to avoid anti-platelets, anti-
coagulants, and NSAIDs given the increased risk of cerebral hemor-
rhage resulting from the effects of amyloid on the cerebral vascula-
ture. This case series is innovative because it brings attention to the
importance of considering CAA when managing a patient with hem-
orrhagic stroke. Missing this diagnosis and treating these patients as
one treats patients who have cerebral hemorrhage secondary to hy-
pertension may engender catastrophic results, as the typical man-
agement of patients with cerebral vascular accidents is
contraindicated in patients with CAA.
Level of Evidence:
Level V
Poster 403:
A Remarkable Emergence from Persistent Vegetative
State: A Case Report
Naomi Kaplan, MBBS (Hofstra Northwell School of Medicine, Great
Neck, NY, United States), Komal G. Patel, DO, Susan Maltser, DO
Disclosures:
Naomi Kaplan: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
The patient is a 31-year-old woman, who
suffered a cardiac arrest at 7 weeks gestation with anoxic brain injury
and bilateral cortical infarcts leading to a persistent vegetative state
(PVS). Nine weeks later, she made a rapid and unexpected recovery to
full consciousness. The patient, who had a history of coagulopathy and
fertility treatment, was found unconscious in her home. She was
resuscitated, intubated, and diagnosed with septic shock and
abdominal compartment syndrome. Following emergent surgery, the
patient had a complicated hospital course. Despite 5 days off sedation,
the patient demonstrated no response to stimuli. Examination was
significant for eyes open with inattention, lack of tracking, inability to
follow commands, and quadriplegia. The patient was assessed as being
in PVS. CT, MR and PET imaging demonstrated findings consistent with
anoxia. The patient was commenced on amantadine in week 6 to
enhance neuro-recovery.
Setting:
Tertiary referral hospital.
Results:
Nine weeks post-event, the patient suddenly regained con-
sciousness and rapidly became alert and oriented. She was verbal,
responsive to single step commands, and subsequently discharged to
acute inpatient rehabilitation. She continues to make functional gains
in therapy.
Discussion:
PVS is a clinical syndrome on the “disorders of con-
sciousness” spectrum. It is characterized by unawareness of self or
environment, without sustained, reproducible voluntary responses,
but with an intact sleep-wake cycle. Prognosis is variable and
guarded. Non-traumatic PVS carries a poorer prognosis than PVS
resulting from trauma. After 3 months, atraumatic PVS is considered
permanent. The longer the time spent in PVS, the lower the likeli-
hood of recovery. There is a high mortality rate for the first year
in PVS.
Conclusions:
This young patient in atraumatic PVS for nine weeks,
with a poor prognosis, made a rapid and remarkable recovery from a
profound state of disordered consciousness and was discharged to an
acute brain injury unit.
Level of Evidence:
Level V
Poster 404:
Doxazosin for Treatment of Refractory Autonomic Dysreflexia:
A Case Report
Sara N. Raiser, MD (Univ of VA, Charlottesville, Virginia, United
States), Heather Asthagiri, MD
Disclosures:
Sara Raiser: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 53-year-old man with C4 ASIA C tet-
raplegia was admitted to the acute care hospital setting for
nonresponsive episodes, thought to be related to significant fluc-
tuations in blood pressure. During his hospitalization, the patient
had difficulty with recurrent autonomic dysreflexia (AD) in the
setting of multiple active medical co-morbidities. Systolic blood
pressures rose as high as 220/124 mmHg, but also dropped as low as
66/49 mmHg with treatment of these AD episodes. Prior to hospi-
talization, lisinopril and carvedilol had been started for elevated
blood pressures. These medications were continued as an inpatient,
and underlying bowel, bladder, and pain stimuli for AD were
addressed; however, episodes of AD persisted. Doxazosin was the
only available alpha-1 blocker on hospital formulary and was started
for refractory AD.
Setting:
Tertiary care hospital.
Results:
Patient had decreasing frequency and severity of episodes
of AD after initiation of doxazosin, in addition to closely managing
other potential stimuli of AD. At discharge, lisinopril was dis-
continued, but carvedilol was continued for rate control in the
setting of atrial fibrillation. Patient was discharged on doxazosin 6 mg
daily and referred for follow up with a physiatric spinal cord injury
specialist.
Discussion:
AD is a dangerous condition, which puts spinal cord
injury patients at risk for serious cardiovascular sequelae. Currently,
there is evidence for use of two alpha-1 blockers, terazosin and
prazosin, for treatment of refractory autonomic dysreflexia; howev-
er, there is currently no literature addressing use of other alpha-1
blockers. This is the first case report suggesting that doxazosin may
be another potential pharmaceutical option for treatment of re-
fractory AD.
Conclusions:
The best method for treatment of AD is prevention.
Doxazosin may be a potential pharmaceutical option for preventative
treatment of refractory AD.
Level of Evidence:
Level V
Poster 405:
Acute Motor Axonal Neuropathy Presenting as Muscle
Cramps in an Avid Runner: A Case Report
Udai Nanda, DO (VA Greater LA Hlth Care Sys/UCLA, Los Angeles, CA,
United States), Jana Baumgarten, MD
Disclosures:
Udai Nanda: I Have No Relevant Financial Relationships
To Disclose
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Abstracts / PM R 9 (2017) S131-S290