recurrent miller fisher variant of guillain-barré syndrome: a case report

PM&R Vol. 5, Iss. 9S, 2013 S281

Complicating matters was her history of a bilateral transradialamputation due to a work injury in 1988. Prior to admission shelived alone and was independent with basic and advanced activitiesof daily living (ADLs) using bilateral body powered prostheses withvoluntary opening hand hooks. She was proficient enough withtheir use that she continued to be a one half pack per day smoker.Setting: Tertiary Care Hospital.Results or Clinical Course: The main goal of therapy was tohelp the patient return to her baseline status with ADLs. The majorbarrier was her left visual field deficit causing double vision. Thiswas addressed with taping her glasses, which helped with thedouble vision, but resulted in a loss of depth perception anddifficulty donning her prostheses. Over time, her vision graduallyimproved and she was able to accommodate for her residual visualdeficits. She was discharged home with her daughter at a standbyassist level given increased time to complete tasks.Discussion: To our knowledge there are no documented cases ofvisual deficit from cardioembolic stroke in a bilateral handamputee. As stroke survival rates increase we are faced with uniqueco-morbidities that affect function.Conclusions: As survival rates for both stroke and amputationincrease we need to be prepared to address the challenges of both tokeep our patients as functional and independent as we can.

Poster 410Rehabilitation of an Eighteen-Year-Old Male witha Severe Traumatic Brain Injury Complicated bySinking Skin Flap Syndrome: A Case Report.Mary E. Russell, DO, MS (Baylor College of Medicine,Houston, TX, United States); Monica E. Crump, MD.

Disclosures: M. E. Russell, No Disclosures: I Have Nothing ToDisclose.Case Description: The patient is an 18-year-old male whopresented to an outside hospital after a self-inflicted gunshotwound to the head for which the patient underwent emergenthemicraniectomy and decompression. Patient had ventriculoper-itoneal shunt placement for hydrocephalus on hospital day 22. Hepresented to our inpatient rehabilitation hospital 28 days afterinjury. Patient was making great strides during his rehabilitationcourse and progressed from total assistance to minimal assistancewith ADLs and transfers. However, six weeks into his rehabilitationstay, patient became extremely limited by pain from positionalheadaches. Multiple medications for pain, including norco, gaba-pentin and topiramate were started for headaches presumed to besecondary to an overdraining shunt. The shunt was adjusted andheadaches improved slightly. Patient began to digress with thera-pies and was noted to have increasing lethargy, decreased respon-siveness, increased spasticity and irretractable nausea and vomiting.Head CT done during week seven of inpatient rehabilitationshowed an increase in the sunken in appearance of the brain withincreased left to right subfalcine herniation. Patient was transferredto an acute care hospital to expedite cranioplasty given neurologicdeterioration from sinking skin flap syndrome.Program Description: 18-year-old male with severe neurolog-ical deficits secondary to a gunshot wound to the head.Setting: Rehabilitation hospital.Results or Clinical Course: Three months after injury, patienthad shown significant improvement before neurologic deteriorationsecondary to sinking skin flap syndrome. It is uncertain what

deficits may remain after cranioplasty. Patient was discharged toa post-acute brain injury rehabilitation program. Further develop-ments will be discussed.Discussion: Sinking skin flap syndrome is a serious and unusualcomplication of hemicraniectomy after traumatic brain injury andshould be considered given neurologic deterioration in the settingof subfalcine herniation in a patient with hydrocephalus managedwith a ventriculoperitoneal shunt.Conclusions: Sinking skin flap syndrome is an unusual neuro-logical complication of hemicraniectomy in the traumatic braininjury population.

Poster 411Recurrent Miller Fisher Variant of Guillain-BarréSyndrome: A Case Report.Hannah A. Shoval (New York Presbyterian Hospital ofColumbia and Cornell, New York, NY, United States);Allyson A. Shrikhande, MD.

Disclosures: H. A. Shoval, No Disclosures: I Have Nothing ToDisclose.Case Description: AF, a 33-year-old woman, presented witha second episode of Guillain-Barre syndrome Miller Fisher variant(MFS) 12 years after her first episode. She reported numbness of thehands and feet, "lazy" left eye and ataxic gait starting 10 days after anupper respiratory illness. Brain magnetic resonance imaging showedenhancement of bilateral cranial nerve seven. Patient’s GQ1b anti-body was positive. Electromyography showed sensorimotor demy-elinating peripheral neuropathy. AF required mechanical ventilationand a percutaneous endoscopic gastrostomy (PEG). Exam showedabsent reflexes and near complete paralysis retaining only the abilityto raise her left eyebrow and move her right toes. AF had unreactivepupils, no blink to threat, complete opthalmoplegia and absent gag.AF was treated with intravenous immunoglobulin. Methadone andclonazepam started for anxiety and pain. Metoprolol started fortachycardia to the 150’s secondary to dysautonomia. Gabapentinstarted for neuropathic pain. AF improved and after one month wasadmitted to inpatient rehabilitation unit (IRU).Setting: Tertiary care hospital.Results or Clinical Course: In the IRU, AF was decannulatedand underwent a trial of void successfully. Metoprolol wasdecreased; methadone discontinued. Re-empowering AF wascrucial given her prior inability to communicate. Therapistsencouraged, physicians explained medication choices carefully, andpsychiatry supported with psychotherapy. After 21/2 weeks, AFambulated 800 feet independently and was modified independentwith activities of daily living. AF passed a modified barium swallowand advanced to a regular diet.Discussion: MFS is characterized by ataxia, areflexia and oph-thalmoplegia. Recurrence does not exclude the diagnosis. It ismostly an acute self-limiting condition but can progress rapidly andclose monitoring is critical. Early mobilization including rangingextremities is important. Admission to IRU enables a multi-disci-plinary team approach with physical and occupational therapists,speech and language pathologists, supportive counseling and closemedical surveillance. This can re-empower the patient for an effi-cient transition to home.Conclusions: The effects of MFS can be devastating for patientsand correct diagnosis is critical. IRU is a valuable resource fortransitioning to a home setting.