Joseph E. Burris

Poster 69: Ipsilesional Motor Cortex N-Acteylaspartate as a Surrogate Marker of Recovery After Stroke – A Pilot Study

Participants: Adults with chronic, troublesome sialorrhea due to Parkinson’s disease, stroke, and other etiologies. Interventions: Subjects received placebo, 75U or 100U incobotulinumtoxinA in the first treatment cycle (MP) and either 75U or 100U incobotulinumtoxinA in each of 3 further treatment cycles in the EP. Main Outcome Measures: Unstimulated Salivary Flow Rate (uSFR); Global Impression of Change Scale (GICS), Drooling Severity and Frequency Scale (DSFS); modified Radboud Oral Motor Inventory in Parkinson’s Disease (mROMP) drooling. Adverse events were monitored throughout. Results: Subjects who received incobotulinumtoxinA throughout the MP and EP demonstrated sustained improvements in uSFR across treatment cycles. In the 75U group, mean uSFR (g/min) was 0.42 at study baseline (n1⁄474) and 0.36 (n1⁄468), 0.28, 0.23, and 0.23 at respective week 4 follow-ups after injections 1 to 4. Response was numerically greater in the 100U group (n1⁄474): 0.40 at study baseline and 0.27 (n1⁄472), 0.22, 0.21, and 0.17 at week 4 follow-ups after consecutive injections. Mean subject GICS scores indicated sustained improvement in both treatment groups. Similar trends of improvement were also observed for the DSFS and mROMP analyses. In the small group of subjects (n1⁄432), who switched from placebo in the MP to incobotulinumtoxinA in the EP, treatment benefit was also shown. Consistent with the MP, safety and tolerability were favorable in the EP, with no new/unexpected findings. Conclusions: Repeated treatment with incobotulinumtoxinA is safe and effective for sustained improvement in sialorrhea. Level of Evidence: Level I

Poster 186: First Successful Bipolar Osteochondral Allograft Transplantation in the Ipsilateral Knee of a Transtibial Amputee: A Case Report

history of lymphoma did provide a hint to the source. It was assumed that the patient was in remission, but recognition of the HOA did lead to the discovery of his lymphoma. Conclusions: Although the intent of the x-ray was to investigate local pathology, the findings were related to his lymphoma. Careful consideration of the locations of the cortical thickening at the tibia and fibula suggested HOA in this setting. HOA is rare, but its finding can be indicative of malignant or pulmonary processes. Further investigation was warranted, revealing the recurrence of lymphoma that produced the secondary hypertrophic complications seen on the knee x-ray. Unusual radiographic findings like this remind us to be cognizant of possible systemic manifestations from remote sources in our imaging. Level of Evidence: Level V

Remote motor system metabolic profile and surgery outcome in cervical spondylotic myelopathy

OBJECTIVE In patients with cervical spondylotic myelopathy (CSM), the motor system may undergo progressive functional/structural changes rostral to the lesion, and these changes may be associated with clinical disability. The extent to which these changes have a prognostic value in the clinical recovery after surgical treatment is not yet known. In this study, magnetic resonance spectroscopy (MRS) was used to test 2 primary hypotheses. 1) Based on evidence of corticospinal and spinocerebellar, rubro-, or reticulospinal tract degeneration/dysfunction during chronic spinal cord compression, the authors hypothesized that the metabolic profile of the primary motor cortices (M1s) and cerebellum, respectively, would be altered in patients with CSM, and these alterations would be associated with the extent of the neurological disabilities. 2) Considering that damage and/or plasticity in the remote motor system may contribute to clinical recovery, they hypothesized that M1 and cerebellar metabolic profiles would predict, at least in part, surgical outcome. METHODS The metabolic profile, consisting of N-acetylaspartate (NAA; marker of neuronal integrity), myoinositol (glial marker), choline (cell membrane synthesis and turnover), and glutamate-glutamine (glutamatergic system), of the M1 hand/arm territory in each hemisphere and the cerebellum vermis was investigated prior to surgery in 21 patients exhibiting weakness of the upper extremities and/or gait abnormalities. Age- and sex-matched controls (n = 16) were also evaluated to estimate the pre-CSM metabolic profile of these areas. Correlation and regression analyses were performed between preoperative metabolite levels and clinical status 6 months after surgery. RESULTS Relative to controls, patients exhibited significantly higher levels of choline but no difference in the levels of other metabolites across M1s. Cerebellar metabolite levels were indistinguishable from control levels. Certain metabolites-myo-inositol and choline across M1s, NAA and glutamate-glutamine in the left M1, and myo-inositol and glutamate-glutamine in the cerebellum-were significantly associated with postoperative clinical status. These associations were greatly improved by including preoperative clinical metrics into the models. Likewise, these models improved the predictive value of preoperative clinical metrics alone. CONCLUSIONS These preliminary findings demonstrate relationships between the preoperative metabolic profiles of two remote motor areas and surgical outcome in CSM patients. Including preoperative clinical metrics in the models significantly strengthened the predictive value. Although further studies are needed, this investigation provides an important starting point to understand how the changes upstream from the injury may influence the effect of spinal cord decompression.

Cortical Neurochemical Profile Depends on the Origin and the Site of the Central Nervous System Injury

Interventions: Not applicable. Main Outcome Measures: Head CT, DRS, and FIM. Results: No statistical differences were found in functional status between the axial and extra-axial groups, except for the FIM follow-up after 1 year, which unexpectedly showed the axial group having greater functional recovery (P1⁄4.046). The combined lesion group showed statistically significant greater negative impact on functional status than the other groups across all three time points. Conclusions: Combined lesions negatively affect functional status more than axial lesions or extra-axial lesions. The effect of combined injuries will increase the awareness of healthcare providers and likely inform the patient care and patient likelihood of recovery. Level of Evidence: Level II

Poster 305 Neural Status of Intact Spinal Cord is a Better Predictor of Surgery Outcome Than Clinical and Imaging Features of Spinal Cord Insult in Cervical Spondylotic Myelopathy: A Case Report

Case/Program Description: A 21-year-old man with no past medical history was admitted for rehabilitation center for C3 AIS A tetraplegia due to a motor vehicle accident with resultant traumatic brain injury and polytrauma 18 months prior. During his hospitalization, he had been on indwelling catheter which was changed monthly. Following a difficult catheter change, he experienced abdominal distention, headache, dizziness and dyspnea. Bladder scan showed 570ml urinary retention. Eventually a new indwelling catheter was replaced successfully after multiple attempts in 10 minutes. Approximately 600ml urine came out. Meanwhile, he continued to have symptoms of headache, dizziness, dyspnea, but was alert and conscious. During the episode, his blood pressure was 50/32 and heart rate was 140s. Setting: Tertiary care hospital. Results: The patient was placed in the supine position. One dose of midodrine 10mg was given and repeated BP was 50/32. Rapid response was initiated. One IV line was obtained and IV fluid bolus started. After these measures, his BP returned to his baseline of 86/52, and his HR was down to 105. The patient was rechecked in two hours, and his vital signs were stable and symptoms resolved. Discussion: Autonomic dysreflexia occurs most often in patients with spinal cord injury with spinal lesions above the T6 spinal cord level. It is characterized by paroxysmal hypertension, sweating, headache and reflex bradycardia. Stimulation from the bladder from high pressures or overdistention is the most common cause of autonomic dysreflexia. However, in this case, bladder distention is adversely associated with hypotention, tachycardia and headache. Mechanism is unknown. Conclusions: This is an unusual case of bladder distension associated with hypotension rather than autonomic dysreflexia in a patient with chronic complete tetraplegia secondary to traumatic spinal cord injury. Physician should aware of atypical presentations of autonomic dysfunction in SCI. Level of Evidence: Level V

Poster 460 The Role of Carbidopa-Levodopa (Sinemet) in Management of Gegenhalten Rigidity in a Patient With Cerebrovascular Accident: A Case Report

Disclosures: L. M. Alday-Magpantay, none. Objective: To determine which of the following factors affect the appearance and time-to-onset of complex regional pain syndrome type I (CRPS I) in stroke: age, gender, stroke type laterality of weakness, degree of paralysis, depression, time of initiation of physical therapy, albumin, and calcium. Design: Prospective cohort. Setting: Tertiary-care hospital. Participants: 155 first-time stroke patients undergoing rehabilitation were evaluated daily until their 120th day after stroke. Main Outcome Measures: Two events were recorded: shoulder-pain onset and hand-pain onset. The following were computed: incidence rate, incidence density, median survival time through Kaplan-Meier Product Limit Estimates, comparison of survival curves within each variable, variables affecting “survival” by using the Cox Proportional Hazards Model. Results: Four months after stroke incidence rate was 43%; incidence density was 13.5 per 100 person-months. Median survival of CRPS I was the following overall, 120 days (95% confidence interval [CI], 81-98 days); age 65.75 days (95% CI, 60-90 days); 3/5 motor, 107 days (95% CI, 72-114 days); hypocalcemia, 50 days (95% CI, 37-91 days); hypoproteinemia: 54 days (95% CI, 33-75 days). Univariate: factors that affect time of appearance of RSD/CRPS I are the following: age, hazard ratio (HR) overall, 1.03 (95% CI, 0.60-4.98); HR 65, 3.45 (95% CI, 1.27-9.38); laterality, HR, 0.53, (95% CI, 0.26-1.07); paralysis, HR, 2.59 (95% CI, 0.1.07-6.31); subluxation, HR, 2.02 (95% CI, 0.70-5.83); albumin, HR, 0.24 (95% CI, 0.10-0.56); and calcium, HR, 0.74 (95% CI, 0.52-1.05). Multivariate: laterality was eliminated after considering sample size, confounding, and interaction. Only age, paralysis, subluxation, albumin, and calcium appeared significant. Conclusions: Risk factors that affect the appearance and time to onset of RSD/CRPS I are, in increasing strength: age, right hemiparesis, paralysis of 3/5, hypoalbuminemia, and hypocalcemia. The incidence rate in this study is higher than in previous studies. This is the first time that incidence density is reported and nutritional indicators such as protein and calcium are implicated as strong predictors of CRPS I in stroke.

Poster 380: Bálint's Syndrome, A Rehabilitation Challenge: A Case Report

revealed a new left cerebellar infarct. Discussion: Anton syndrome is a form of cortical blindness in which the patient denies the visual impairment, experiences visual hallucinations and is able to perceive moving but not static objects. Anton syndrome is caused by damage to the occipital lobe, where a bilateral posterior cerebral artery infarction extends from the primary visual cortex to the visual association cortex. Conclusions: Anton syndrome is a peculiar delusion of reality in which the blind person denies or lacks conscience of his own condition and may experience visual hallucinations. Caregivers should be aware of this rare disorder and patients will need close supervision and close attention.