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Brown-Sequard-Plus Syndrome with Features of Autonomic Dysreflexia

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Brown-Sequard-Plus Syndrome with Features of Autonomic Dysreflexia Brown-Sequard-Plus syndrome with features of Autonomic Dysreflexia and Horner’s syndrome caused by blunt trauma 'DQLHOD$QGHUVRQ7KRPDV$QGHUVRQ $OH[/LQQ'DYLG5HQQHU 'HSDUWPHQWRI1HXURORJ\6FKRRORI0HGLFLQH 7KH8QLYHUVLW\RI8WDK6DOW/DNH&LW\87 Abstract 7KLVFDVHGHVFULEHVWKHFOLQLFDOPDQLIHVWDWLRQRI%URZQ6HTXDUG3OXVV\QGURPH %636 LQDPDOHSDWLHQWZKR Imaging VXVWDLQHG EOXQW FHUYLFDO VSLQH WUDXPD IURP D PRWRU YHKLFOH DFFLGHQW %636 LQYROYHV LQFRPSOHWH VSLQDO FRUG KHPLVHFWLRQ ZLWK LSVLODWHUDO KHPLSOHJLD DQG ORVV RI SURSULRFHSWLRQ FRQWUDODWHUDO SDLQ DQG WHPSHUDWXUH VHQVDWLRQ +RUQHU¶V V\QGURPH $ % ERZHOEODGGHU G\VIXQFWLRQ DQG DXWRQRPLF G\VUHIOH[LD PDQ\ RI ZKLFK ZHUH GHPRQVWUDWHG LQ WKLV FDVH 05, RI WKH FHUYLFDO VSLQH UHYHDOHG 7 K\SHULQWHQVLW\ DQG GLIIXVLRQ UHVWULFWLRQ FRQVLVWHQW ZLWK OHIW KHPLFRUG FRQWXVLRQ 7KH SDWLHQW PHHWV FOLQLFDO DQG UDGLRORJLFDO GLDJQRVWLF FULWHULD IRU %636 FDXVHG E\ LQFRPSOHWH VSLQDO FRUG KHPLVHFWLRQ Patient History $ && /HIWVLGHG ZHDNQHVV Ɣ \HDUROG PDQ SUHVHQWHG ZLWK WUDQVLHQW ORVV RI FRQVFLRXVQHVV DQG OHIWVLGHG ZHDNQHVV DIWHU D KLJK VSHHG PRWRU YHKLFOH DFFLGHQW % Ɣ ,QLWLDO H[DP ZHDNQHVV LQ OHIW XSSHU H[WUHPLW\ DQG OHIW ORZHU Figure 4: MRI C Spine. $$[LDO705,VKRZLQJKHPLFRUGFRQWXVLRQ%6DJLWWDO 67,505,RIFHUYLFDOVSLQHVKRZLQJDFPVHJPHQWRIWKHOHIWKHPLFRUG H[WUHPLW\ DQLVRFRULD DQG XSJRLQJ OHIW JUHDW WRH K\SHULQWHQVHVLJQDOH[WHQGLQJIURPWKHLQIHULRUHQGSODWHRI&WKURXJKWKHVXSHULRU Ɣ )XUWKHUPRUH QRWHG WR KDYH DXWRQRPLF LQVWDELOLW\ ZLWK IOXFWXDWLQJ HQGSODWHRI&7KHUHZDVDQDVVRFLDWHGGLIIXVLRQUHVWULFWLRQDQGVPDOOVHJPHQWRI EORRG SUHVVXUHV DQG KHDUW UDWH VXVFHSWLELOLW\ PP RQ6:,VHTXHQFH Ɣ ,QFRQWLQHQW RI ERZHO DQG EODGGHU Discussion Ɣ ,QLWLDO LPDJLQJ LQFOXGLQJ &7 VSLQH &7 EUDLQ &7$ DQG 05, '7, VKRZHG QR HYLGHQFH RI DFXWH LVFKHPLF VWURNH & Ɣ Epidemiology: %636 LV PRUH FRPPRQ WKDQ SXUH %66 Ɣ Etiology: SHQHWUDWLYH VSLQDO FRUG WUDXPD PRUH FRPPRQ WKDQ EOXQW WUDXPD LQ %636 Physical Exam Ɣ Diagnosis : FOLQLFDO DQG LPDJLQJ ILJXUH Figure 1: Neurologic Exam. Ɣ Autonomic dysreflexia: EUDG\FDUGLD EORRG SUHVVXUH ODELOLW\ 5HG PRWRU ILQGLQJV IOXVKLQJ RFFXU LQ VHWWLQJ RI QR[LRXV VWLPXOXV VXFK DV XULQDU\ %OXH VHQVRU\ ILQGLQJV Left miosis and ptosis Figure 2: Physical exam. $ /HIWVLGHG PLRVLV DQG SWRVLV UHWHQWLRQ ILJXUH % /HIWVLGHG IOXVKLQJ & /HIWVLGHG ZHDNQHVV 3DWLHQW SHUPLVVLRQ JLYHQ WR SXEOLVK LPDJHV Ɣ Treatment: PHGLFDO VWDELOL]DWLRQ VXUJLFDOQRQVXUJLFDO VSLQDO LPPRELOL]DWLRQ FRUWLFRVWHURLGV H[WHQGHG UHKDELOLWDWLRQ Clinical Course Ɣ Prognosis: WUDQVLHQW HGHPD LQIODPPDWLRQ DQG FRQGXFWLRQ EORFN 5/5 elbow flexion SRVH FKDOOHQJH LQ SUHGLFWLQJ SURJQRVLV 6RPH UHSRUWV VKRZ 3/5 elbow extension Ɣ 8QGHUZHQW ODPLQHFWRP\ DQG SRVWHULRU DUWKURGHVLV RI &7 ZLWKRXW FRPSOLFDWLRQV RI SDWLHQWV DEOH WR DPEXODWH DW GLVFKDUJH Ɣ 6SHQW GD\V RQ WKH DFXWH LQSDWLHQW Ɣ Conclusion: 7KLV FDVH LOOXVWUDWHV WKH FOLQLFDO PDQLIHVWDWLRQV DQG ȼ pain/cold 2/5 wrist extension UHKDELOLWDWLRQ VHUYLFH ZLWK PXOWLSOH FRPSOLFDWLRQV UDGLRORJLF ILQGLQJV RI %636 $V %636 LV D UHODWLYHO\ UDUH ILQGLQJ below T1 1/5 finger abduction WKLV FDVH PDNHV DQ LPSRUWDQW FRQWULEXWLRQ WR WKH PHGLFDO OLWHUDWXUH ȼ pain/cold at C7-C8 References: &KHVKLUH:LOOLDP3$XWRQRPLF'LVRUGHUVDQG7KHLU0DQDJHPHQW *ROGPDQ&HFLO0HGLFLQHWKHGLWLRQ 5/5 hip flexion, extension 0/5 hip flexion, *DUFLD0DQ]DQDUHV0'%HOGD6DQFKLV-,*LQHU3DVFXDO00LJXHO/HRQ,'HOJDGR&DOYR0 $OLR \6DQ]-/ %URZQ6HTXDUG V\QGURPHDVVRFLDWHGZLWK+RUQHU VV\QGURPHDIWHUDSHQHWUDWLQJWUDXPDDWWKHFHUYLFRPHGXOODU\ MXQFWLRQ extension 6SLQDO&RUG 0F/HDQ09HUW &'XWFKHU 0.ROODU 57LOQH\ 3$<HDU2OG0DQ:LWKDQ,QFRPSOHWH6SLQDO&RUG,QMXU\ $LU0HG- 3DVFDXO 06HEDVWLD 93RPDUHV 0DQG$OEHUROD 0%URZQ6HTXDUGSOXVV\QGURPHDIWHUDVWDELQMXU\1HXUR5HKDE Intact pain/cold ± 3UXLWW '0F0DKRQ06SLQDO&RUG,QMXU\DQG$XWRQRPLF&ULVLV0DQDJHPHQW 1HOVRQ7H[WERRNRI3HGLDWULFV&KDSWHU below T1 5RWK5RWK(-3DUN73DQJ7<DUNRQ\ *0/HH0< 7UDXPDWLFFHUYLFDO%URZQ6HTXDUG DQG%URZQ6HTXDUGSOXV Figure 3ECG.6KRZLQJ MXQFWLRQDO EUDG\FDUGLD OHIW V\QGURPHVWKHVSHFWUXPRISUHVHQWDWLRQVDQGRXWFRPHV3DUDSOHJLD YHQWULFXODU K\SHUWURSK\ ZLWK UHSRODUL]DWLRQ DEQRUPDOLW\ DQG 7 5XVVHOO-+-RVHSK6-6QHOO%- -LWKRR5%URZQ6HTXDUG V\QGURPHDVVRFLDWHGZLWK+RUQHU¶VV\QGURPH ZDYH LQYHUVLRQ PRUH HYLGHQW LQ LQIHULRU OHDGV. IROORZLQJDSHQHWUDWLQJGULOOELWLQMXU\WRWKHFHUYLFDOVSLQH-RXUQDORI&OLQLFDO1HXURVFLHQFH ;LDR<RQJ=KDQJ<LQJ0LQJ<DQJ6FLVVRUVVWDEZRXQGWRWKHFHUYLFDOVSLQDOFRUGDWWKHFUDQLRFHUYLFDO MXQFWLRQ7KH 6SLQH-RXUQDO Acute Arterial thrombosis in a cancer patient Devon Baker, MD, Kenneth Grossman, MD, Benjamin Solomen, MD University of Utah Hospital/Huntsman Cancer Insitute Abstract Case Description Initially neurologyResults was consulted (Research for concern over acute Only) paralysis and vascular surgery was consulted concurrently. Neurology workup was deferred after vascular surgery did doppler exam showing no obvious This case describes a young patient diagnosed previously with a rare This case is a 56 year old female with a PMH significant for plamacytoid pulses. The pt was taken for emergent vascular surgery and thrombectomy metastatic plasmacytoid urothelial cancer who presented with acute paralysis carcinoma who presented to the Huntsman Cancer center with 24 hours of bilaterally and was also found to have compartment syndrome requiring over the preceding 24 hours. The pt was found to have bilateral femoral progressive bilateral lower extremity weakness. This had been evaluated bilateral fasciotomies. The pt regained pulses and was starting to regain thrombosis and taken to emergent vascular surgery for thrombectomy. The pt the day prior in the ER at South Jordan were a MRI of the L spine was done some strength in her lower extremities. She continued to have some also was found to have compartment syndrome requiring fasciotomy. She did and did not show any spinal cord compression or other etiologies of her sxs. numbness and tingling in her legs but this did improve over the next several not have any trauma or other symptoms that would have caused compartment The pt had some improvement at that time and was sent home. The next syndrome. A CTA done in the ER also showed splenic and renal infarcts and a days. The pt developed abdominal bloating and pain which required NG day she noted worsening of her sxs to the point that she could no loner get CT head revealed infarcts in the brain as well. Testing for anticardiolipin tube for a SBO. The pt had increasing leukocytosis up to 30 but this was up and walk. She was taken to the ACC by her husband for further antibody was positive. The pt did have a complication of SBO after her surgery thought to be due to the administration of neulasta in the week prior to requiring bowel resection as well and a long hospitalization. This case evaluation. The pt also noted paresthesia that progressed and started in her presentation. The pts sxs did not improve and repeat CT abdomen was highlights a rare complication of hypercoagulability as a result of underlying toes and was now at her knees. By the time she had arrived at the done showing bowel perforation. She was taken to the OR a second time malignancy. There is very little data available about this patients particular Hunstman she had total numbness in both of her legs up to her knees. She and required bowel resection. The pt improved and was eventually cancer and according to some reviews there are only 75 case reports also noted some constipation, but did not have any problems voiding urine. discharged after a long hospital stay. She will be on indefinite available.1 It may be that these types of cancer are particularly thrombogenic anticoagulation. There is some thought the pt had catastrophic but it is likely that the pts underlying malignancy led to acute arterial occlusion. antiphospholipid syndrome, however follow up labs are needed to diagnose She did recover some ability Objectivesto remove her lower extremities although was still Physical Exam: significant for numbness bilaterally from the knees down to as it is difficult to determine this during acute illness. experiencing some paresthesia at discharge and will be on life long the toes, decreased hip flexor strength bilaterally 2-3/5, unable to dorsiflex anticoagulation going forward. or plantarflex the ankles, absent lower extremity reflexes, Babinski with down going toes, Rectal exam with decreased tone, Ext were cool to the touch and it was difficult to palpate distal pulses Discussion The pt is a rare presentation of hypercoagulability due to malignancy. Very Laboratory studies were positive for thrombocytopenia with platelets in the high mortality rates of pts with malignancy presenting with acute limb 80s. Alkaline phosphatase was elevated in the 500s. The pt was also ischemia up to 83% have been reported in previous studies.3 Fortunately for hyponatremia with sodium of 132. LFTs were otherwise normal. Other this patient, she was able to have limb salvage as a result of this laboratory evaluation was unrevealing. Further laboratory eval showed complication. The initial decision was made to consult vascular surgery Introduction elevated cardiolipin IgM antibodies elevated at over 150. instead of starting immediate anticoagulation as has been recommended in CTA Abd/Pelvis showing splenic infarcts: treatment of acute limb ischemia. This decision was made because of the pts confusing presentation including rectal tone absence which made a Plasmacytoid urothelial cancer is a rare type of urothelial carcinoma. neurological disorder high on the differential. The migration of sxs from the The prognosis for these patients is almost universally poor as they are toes upwards also led us to believe that the possibility of
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