David Rosenblum

Recurrent Episodes of Brief Global Amnesia Related to Intrathecal Baclofen Pump: Originally Mistaken for Psychogenic Nonepileptic Seizures

Background: Baclofen is a GABA-B receptor agonist widely used for treatment of spasticity by intrathecal route when oral baclofen was ineffective or intolerable. Here we report a case of recurrent episodes of brief global amnesia in a patient with multiple sclerosis treated with an intrathecal baclofen pump. Case report: A 64-year old widowed white woman with multiple sclerosis was admitted for ambulatory EEG monitoring unit for a 3-year history of recurrent periods of 10-40 minutes of confused behavior, with anterograde and retrograde amnesia, but without loss of consciousness or abnormal movements. Episodes were more likely when under stress or around family events. An intrathecal baclofen pump had been placed 12 years before admission to control lower extremity spasticity. EEG monitoring demonstrated no epileptic activity during the events. Over the next 6 months intrathecal baclofen was gradually decreased, with reduced frequency of episodes. At the lowest dose episodes stopped but there was some return of spasticity. With careful titration upwards a dose was reached with adequate treatment of spasticity but no episodes. Conclusions: Intrathecal baclofen can induce brief episodes of global amnesia. This is the second reported such case, and the first to be successfully managed by dose titration. The episodes resembled those of transient global amnesia and of transient epileptic amnesia, and we review mechanisms by which baclofen can affect memory function. These episodes were initially thought to represent conversion disorder, emphasizing the caution required before postulating psychogenic etiologies of medical symptoms. Rosenblum et al 2016 3

Poster 14 Treatment of Neurogenic Bladder in Spinal Cord Injury Using Mirabegron with, and without, Anticholinergic Medication

Results or Clinical Course: The comfortable 10-m gait speed was significantly faster at 4 weeks than at baseline (baseline: 0.83 0.28 m/s, 4 weeks: 0.91 0.25 m/s; P < .05). However, there was no significant difference between baseline and 4 weeks in 6MWT (baseline: 274.3 84.1 m, 4 weeks: 293.7 90.2 m; P 1⁄4 .076) and TUG (baseline: 15.0 4.0 s, 4 weeks: 14.3 3.1 s; P 1⁄4 .13). Conclusion: In this study, gait training and gait-related training with FES yielded statistically significant improvement in comfortable walking speed for chronic stroke patients. Our study provided encouraging evidence that rehabilitation intervention with FES can have a positive impact for chronic stroke patients. In the future, it will be necessary to do a randomized controlled trial to compare the effects of gait training and gait-related training without FES.

Poster 272 Intrathecal Baclofen Therapy for Spasticity in Amyotrophic Lateral Sclerosis 4

Disclosures: D. Rivera, No Disclosures. Case Description: A 26-year-old woman whose spasticity had been managed with intrathecal baclofen (ITB) presents to the Spasticity Clinic for routine pump refill. Of note, her dose had been increased consistently over the past due to poor spasticity control. The leftover baclofen volume was noted to be almost the same as what was placed on the previous visit. The patient was taken to the procedure room for pump dye and roller studies. During the dye study, after an unusual amount of initial resistance, the contrast solution was visualized exiting the catheter tip into the intrathecal space. The roller study was found to be normal. The pump was then re-programmed at the most recent rate. Setting: Tertiary academic hospital. Results or Clinical Course: The evening after the procedure the patient began experiencing lightheadedness and somnolence. Upon evaluation at the ER she was found to be hypotensive and flaccid. She was thought to be suffering from baclofen overdose so the pump’s reservoir was immediately evacuated. After resolution of her symptoms the pump was refilled and programmed at a lower dose. She was seen at the clinic 1 week afterward with better-controlled spasticity and no signs of baclofen overdose or withdrawal. Discussion: Given the unusual initial resistance noted during the dye study, we suspect that the catheter was being mechanically obstructed but got unclogged during contrast injection. This would explain the high residual baclofen and the patient’s progressive dose requirement, as well as the overdose symptoms while on the same dose following the dye study. There have been numerous cases reported in the literature regarding intrathecal catheter obstruction, most notably due to catheter-tip granulomas. To our knowledge, the occurrence of baclofen overdose related to failure of recognition of this problem has not been reported yet in the literature. Conclusions: The idea of a catheter-tip associated mass was not entertained until after the resolution of the apparent mechanical problem. However, this problem should be considered in all patients receiving intrathecal baclofen presenting with a relatively rapid increase in dose requirement and persistent high residuals. These patients might deserve more specific investigation, such as MRI or CT myelogram to confirm the associated abnormality.

Poster 441 Effective Treatment of Hyperhidrosis Secondary to Bowel Program in Spinal Cord Injury: A Case Report

Disclosures: D. Rosenblum, none. Patients or Programs: Hyperhidrosis, or significant sweating, in spinal cord injury can be precipitated by noxious stimuli. The culprit is often ambiguous. It can be associated with autonomic dysreflexia and other conditions such as syrinx. This case is of a 57-year-old woman who sustained C5 ASIA A tetraplegia secondary to trauma. She was stabilized and admitted for further medical and rehabilitative care. She has a neurogenic bladder, neurogenic bowel, and has rarely had dysreflexia episodes. However, shortly after each effective bowel program, she reported chills and excessive hyperhidrosis, with no headache and no hypertension. Her medications included baclofen and Neurontin. Physical examination did not reveal any source of noxious stimuli, such as wounds. A workup revealed normal laboratory tests, and a KUB showed no excessive stool. Magnetic resonance imaging of the spine did not show a syrinx. Different bowel medications, oral and suppositories, including lidocaine gel instillation as well as enemas with anesthetic agents, were unsuccessful in alleviating her symptoms. Scopolamine patch trials were unsuccessful. Tricyclic antidepressant medications, added at night to also help with neuropathic pain, did not impact the hyperhidrosis. Probantheline was provided, with complete resolution of her bowel program–induced hyperhidrosis. Program Description: Use of medication to control hyperhidrosis. Setting: Inpatient rehabilitation unit. Results: Probantheline successfully controlled the patient’s hyperhidrosis. Other medications, as noted, did not. Discussion: Hyperhidrosis is excessive sweating and is seen in people with both tetraplegia and paraplegia. The pathophysiology includes overactivity of the sympathetic nervous system and may be triggered by noxious stimulation. Hyperhidrosis will be reviewed, including the applicable neuroanatomy and sweat gland innervations, as well as workup and treatment approaches. The pharmacology of probantheline is reviewed. Conclusions: Probantheline effectively treated bowel program– induced hyperhidrosis. The mechanism of action of prophantheline, its pharmacology, uses, and adverse effects are reviewed. The prevalence, pathophysiology, differential diagnosis, and treatment options of hyperhidrosis in spinal cord injury are presented.

Poster 2 Rehabilitation of Glioneurocytoma. A Case Report

DMCP used in TBI subjects ( 2-year polytrauma history) from outpatient rehabilitation clinic records; average retail charges (Internet-based) were calculated for a 12-month period. Main outcome measures used were %NSD, PROMIS Physical Function (PF), and 6-Minute Walk Test (6MWT). The subjects were stratified by %NSD, a neurologic impairment assessment system from the AMA Guides to Evaluation of Permanent Impairment, 6th Edition, based on the following: state of consciousness/level of awareness; mental status evaluation/integrative functioning; language use/understanding; and behavior and mood influence. Global physical health (GPH) was measured by using the PROMIS Physical Function (PF) subscale, and the physical performance status (PPS) was calculated by using the 6MWT. Results: Yearly DMCP was

Poster 277 Nasal Visual Occlusion Treatment for Diplopia

1416.48-

Poster 12: Lance-Adams Syndrome: Effective Treatment and Functional Improvement with Phenytoin. A Case Report

13,764.48 (average,

Poster 374: Zoledronic Acid in the Treatment of Immobilization Hypercalcemia in Spinal Cord Injury: A Case Report

5329.86) and accounted for 8%-46% of total medications costs (TMC), which averaged 23% TMC. Clinical scores were 10%55%NSD (average, 36%); PROMIS-PF, 23.745.7 (average, 31.8 T score); 6MWT distance and metabolic equivalents (METS), 3391330 ft (average, 982 ft), and 1.58-2.93 METS (average, 2.45 METS). DMCP only slightly accounted for TMC. %NSD were mostly in the mild severity, but GPH and PPS level low. There was no trend relationship of the DMCP to the %NSD, GPH, or PPS. Conclusions: The studied cost type only included a portion of TMC in managing TBI, that is, not included opioids, rehabilitation, and cognitive-behavioral therapy. Nevertheless, it found the health and economic burden from medical care related to TBI to be substantial. The study recommends that TBI pharmacologic management needs to be continued to be individualized. Further study on the correlation of DMCP in TBI and %NSD, GPH, and PPS should be done.

Poster 352 Transient Global Amnesia from Intrathecal Baclofen- A Case Report

10% (6 months) increase for the TMT group. Treadmill PFET increased by 173% (3 months) and 139% (6 months) for the CET cohort, and by 58% (3 months) and 107% (6 months) for the TMT cohort. Treadmill MXT increased by 96% (3 months) and 320% (6 months) for the CET cohort, and by 53% (3 months) and 59% (6 months) for the TMT cohort. Mean calf exercise PFET increased by 56% (3 months) and 46% (6 months) for the CET cohort, and by 6.5% (3 months) and 4.5% (6 months) for the TMT cohort. Mean calf exercise MXT increased by 189% (3 months) and 255% (6 months) for the CET cohort, and by 4.5% (3 months) and 23% (6 months) for the TMT cohort. Both groups demonstrated an increase in mean StO2 resaturation slope over time. The mean PAQ Summary Score decreased by 9% (3 months) and increased by 13% (6 months) for the CET group, and increased by 19% and 2%, respectively, for the TMT group. Conclusions: CET may be beneficial as an alternative to TM walking for patients with PAD.

Poster 104 Improved Gait Speed after Use of Ekso ™ in a Person with Paraparesis from Transverse Myelitis- a Case Report

was on 10 mg bid for approximately 6 months before the medication was weaned. Upon tapering (5 mg twice daily 7 days, 5 mg daily 7 days) the patient’s emotional lability worsened dramatically with outbursts of rage, and physical displays of aggression and violence. Memantine was therefore reinitiated. (Prior to initiating memantine, the patient had occasional emotional lability with rare anger outbursts, which were well controlled.) Setting: Outpatient traumatic brain injury clinic. Results: Within 24 hours of restarting memantine, the patient’s aggression resolved completely. He continues to have occasional difficulty with emotional lability which is once again well controlled and has been for 12 months. He remains on memantine 10 mg bid. The patient continues to have short term memory deficits. Discussion: Memantine was not initiated for behavioral purposes in this patient, however, the dramatic worsening behavioral symptoms described upon weaning memantine— and resolution upon resuming—suggest a potential therapeutic benefit associated with this NMDA receptor antagonist. Conclusions: Memantine is being used more frequently in chronic TBI patients for cognitive deficits but may have a broader use in the TBI population. Memantine’s moderateaffinity NMDA receptor antagonist properties, similar to amantadine, may help explain a beneficial effect on emotional lability, agitation, and aggressive behavior frequently encountered in TBI patients. Further research is warranted.