Mithra B. Maneyapanda

Ultrasound Guidance for Technically Challenging Intrathecal Baclofen Pump Refill: Three Cases and Procedure Description.

ABSTRACTIntrathecal baclofen (ITB) therapy is a common treatment used to reduce spasticity due to neurologic disorders and injuries. A variety of factors can increase the difficulty of ITB pump refill. Excess subcutaneous fat overlying the pump, spasticity, suboptimal positioning, pump rotation or inversion, and scar formation over the reservoir fill port can create challenges during pump refill. As a result, multiple unsuccessful attempts at accessing the reservoir fill port can be painful and increase the risk of infection, particularly when repeat skin puncture is required. Blind attempts to refill a pump in challenging cases may also result in subcutaneous injection or pocket fill, resulting in a potentially fatal baclofen withdrawal syndrome. We describe 3 successful ITB pump refills in technically challenging cases when using ultrasound guidance. This represents an innovative approach to using ultrasound guidance to facilitate ITB refill in adults with intractable spasticity. We present these new clinical data with a literature review of potential complications related to inaccurate pump refill procedures and discuss the utility of ultrasound guidance for preventing such adverse events.

Pharmacologic Management of the Patient With Traumatic Brain Injury

Medication management for individuals who have sustained a traumatic brain injury (TBI) remains one of the most confusing, challenging, and rewarding areas of medicine. This chapter reviews the basic tenets of medication management for individuals with TBI. It outlines the use of the most commonly accepted medications in clinical practice in a problem-based format, including special warnings and comments unique to the brain injury population.

Poster 290: Inpatient Rehabilitation of Delayed Post-Hypoxic Leukoencephalopathy: A Case Report

Results: Copper supplementation arrested the progression of myelopathic symptoms at 1-month follow-up. He was participating in outpatient therapy to enhance functional abilities in gait. Discussion: Nutritional deficiencies are an uncommon cause of myelopathy, however, they should be considered in the appropriate clinical setting when no clear structural etiology is identified. Copper deficiency is being recognized more frequently as an etiology of a progressive ataxic myelopathy. Conclusions: Accurate diagnosis and prompt treatment may result in halting progression of myelopathic symptoms from nutritional deficiencies. Level of Evidence: Level V

Long-Term Dosing of Intrathecal Baclofen in the Treatment of Spasticity After Acquired Brain Injury

Intrathecal baclofen (ITB) often is used to treat severe spasticity of cerebral origin. Although literature exists regarding the efficacy of ITB, there has been minimal investigation related to dosing in the adult‐acquired brain injury population, particularly at long‐term duration.

Poster 85: Prevalence of Endocrinopathy on Admission to Acute Inpatient Rehabilitation after Hypoxic Ischemic Brain Injury

Disclosures: Benjamin Ingraham: I Have No Relevant Financial Relationships To Disclose Objective: To assess the prevalence of neuroendocrine abnormalities in patients with hypoxic-ischemic encephalopathy (HIE) and describe which neuroendocrine abnormalities most commonly occur. Design: Retrospective cohort study. Setting: Brain injury unit in an academic inpatient rehabilitation hospital in the United States. Participants: 46 patients admitted for inpatient rehabilitation after hypoxic ischemic encephalopathy since 2013. Interventions: N/A. Main Outcome Measures: Free T4, TSH, prolactin, testosterone, DHEA sulfate, FSH, LH, estrogen, progesterone, ACTH, cortisol, somatomedin C, serum sodium level. Results: Of the 46 subjects, 26 (56.5%) had a neuroendocrine abnormality. The most common neuroendocrine abnormality was a prolactin abnormality, which was present in 13 (39.4%) subjects. Hypogonadism was the second most common, seen in 5 (25.0%) subjects. Cortisol abnormality was seen in 7 (18.9%) subjects. Conclusions: Neuroendocrine abnormalities are common after traumatic brain injury (TBI), however the prevalence of hypothalamic-pituitary dysfunction in patients with HIE is unknown. On admission to acute inpatient rehabilitation the prevalence of endocrinopathy in our cohort was 56.5% with the most common abnormalities being high prolactin levels followed by hypogonadism. This is a similar pattern to that seen in moderate-to-severe TBI populations. Level of Evidence: Level IV

Poster 372 Long-Term Intrathecal Baclofen Treatment for Spasticity after Acquired Brain Injury: Does Diagnosis Affect Dosing?

Disclosures: J€ org Wissel: Speakers bureau Allergan, Ipsen, Merz, Medtronic Objective: To assess the safety and efficacy of escalating incobotulinumtoxinA (Xeomin, Merz Pharmaceuticals GmbH) doses (400-800U) in patients with spasticity. Design: Prospective dose-escalation study (NCT01603459). Setting: 30 study sites worldwide. Participants: 155 adults (18-80 years) with spasticity due to cerebral causes deemed to require total body doses of incobotulinumtoxinA 800U. Interventions: 3 injection cycles (ICs) with escalating incobotulinumtoxinA doses (400U, 600U and 600-800U, respectively), each followed by 12-16-week observations. Main Outcome Measures: Ashworth Scale (AS) responder rate ( 1point improvement 4 weeks post-injection), Disability Assessment Scale (DAS), Functional Ambulatory Classification (FAC), Investigators Global Efficacy Assessment (IGEA), adverse events (AEs) and antibody testing. Results: Escalation of the total incobotulinumtoxinA dose enabled physicians to treat an increasing number of spasticity patterns in each patient. AS responses were achieved in 364/608 (59.9%) patterns treated in IC1 (155 patients), 431/743 (58.0%) patterns in IC2 (152 patients) and 537/811 (66.2%) patterns in IC3 (140 patients). There was increased reporting of “no”/“slight” disability for the principal target domain (DAS score 0 or 1) after each IC (baseline: 0.7%; study end: 42.9%). The proportion of ambulator-independent patients (FAC level 5) also improved throughout the study (baseline: 24.5%; study end: 40.6%). The proportion of “good”/“very good” IGEA assessments increased with escalating doses (IC1: 55.5%; IC2: 72.4%; IC3: 89.3%). Importantly, dose escalation did not increase the incidence of AEs (IC1: 36.1%; IC2: 37.5%; IC3: 25.7%) or treatment-related AEs (IC1: 4.5%; IC2: 5.3%; IC3: 2.9%). There were no treatment-related serious AEs or cases of clinical non-responsiveness due to antibodies. Conclusions: Increasing incobotulinumtoxinA doses (400-800U) allowed the effective treatment of a rising number of spasticity patterns for each patient while maintaining safety and tolerability. This enhanced efficacy was confirmed by improved muscle tone, favorable investigator global assessments, reduced upper-limb disability and greater ambulator independence. Level of Evidence: Level II

Poster 242 Ultrasound Guided and Doppler Verified Baclofen Pump Refill

Conclusions: SSFS is a potential complication following hemicraniectomy. It is important to quickly recognize in order to prevent potential catastrophic sequelae due to compressive forces on critical neurovascular structures. Additionally, expedited diagnosis and treatment can result in dramatic clinical improvement and increased functional outcome as demonstrated in this case. Level of Evidence: Level V

Psychosis Following an Increase in Intrathecal Baclofen

Baclofen is a commonly used medication to treat spasticity in neurologic disorders. In the traumatic brain injury (TBI) population, the intrathecal administration of baclofen is often preferred over oral administration due to cognitive side effects. Here we report on a case of a psychotic episode following an increase in intrathecal baclofen in a young man with a history of a TBI. Although intrathecal baclofen is commonly used and is generally well tolerated, this case highlights an important potential effect of intrathecal baclofen that has rarely been reported in the literature.

Poster 95 Relationship between Hypogonadism and Agitation on Admission to Acute Inpatient Rehabilitation after Traumatic Brain Injury

increasing oral hydration, salt tablets, and precautions for orthostasis. Therapy included focus on repositioning to a recumbent position at symptom onset. Setting: Acute inpatient rehabilitation. Results or Clinical Course: The patient responded well to interventions. She experienced no further episodes and was discharged after 6 weeks. It was felt her presentation was most likely due to Postural Orthostatic Tachycardia Syndrome (POTS). Discussion: POTS is a type of orthostatic intolerance thought to be due to autonomic dysregulation characterized by a rise in heart rate > 30 beats/min and symptom onset upon upright positioning. To date, POTS is not well understood and there are no definitive treatments. This is the first reported case, to our knowledge, of POTS occurring after meningioma resection in a patient without a previous history of syncope. Conclusion: This case suggests a potential cause for POTS being central dysautonomia due to non-traumatic brain injury. This case specifically provides an alternative diagnosis for patients with seizurelike events and demonstrates a variety of non-pharmacologic interventions and special considerations for physiatrists caring for these patients.