Supraspinal baclofen for the treatment of secondary generalized dystonia: A case series.

PURPOSE: The aim of the study was to evaluate the use of a novel technique for baclofen delivery using an intrathecal catheter inserted through a lumbar laminotomy with the tip placed at the cisterna magna (supraspinal baclofen (SSB)) for the treatment of severe generalized secondary dystonia. METHODS: A cohort study of six individuals (4M/2F, mean±SD = 15±4.86 years) with generalized dystonia unresponsive to oral medications were treated with SSB and followed clinically for 9 years. Intrathecal catheter tips were positioned under fluoroscopic guidance just above the level of the foramen magnum, at the cisterna magna. RESULTS: Five of the 6 patients experienced sustained benefit with SSB; the group mean modified Fahn-Marsden scale scores decreased from 95 to 55 (t = 3.29, p = 0.02). One patient suffered complex pump pocket infection, and therefore underwent pump explantation. CONCLUSION: Supraspinal baclofen may be an effective method for infusing baclofen into the ventricular system of the brain for treatment of secondary dystonia which is unresponsive to oral therapy.

High Rates of Vitamin D Deficiency in Acute Rehabilitation Patients.

OBJECTIVE: To determine the prevalence of low vitamin D (<30 ng/mL), including vitamin D insufficiency (20-29.9 ng/mL) and deficiency (<20 ng/mL), in an acute rehabilitation setting. DESIGN: Cross-sectional, retrospective cohort study. SETTING: University-affiliated inpatient rehabilitation facility (IRF) at a metropolitan county hospital. PARTICIPANTS: Patients (N=100; 64 men/36 women), aged 19-92 years (mean, 62±18.9y), who were admitted to and discharged from an IRF over a 6-month study period. The most frequent admitting diagnoses included stroke (n=11), brain injury (n=36), spinal cord injury (n=14), and polytrauma (n=10). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Serum vitamin-25 (OH)D level at admission to the IRF. RESULTS: Of 100 patients, 76% had low vitamin D (<30 ng/mL), with 29% demonstrating vitamin D insufficiency (20-29.9 ng/mL) and 47% demonstrating vitamin D deficiency (<20 ng/mL). Younger patients demonstrated higher rates of vitamin D deficiency compared with older patients (P<.0001). CONCLUSIONS: Low vitamin D is common in patients admitted to the IRF, with rates more than double those reported in the general population among individuals younger than 45 years. The current results suggest that the IRF setting may be a favorable checkpoint to screen for and initiate treatment of low vitamin D and optimize rehabilitation outcomes.

Thalamic Dementia in Acute Inpatient Rehabilitation-Role for Amantadine?

ABSTRACT: Thalamic dementia is an uncommon type of stroke that presents with disorientation, behavioral changes, and impairment of executive functions, with relative preservation of motor functions. It is typically caused by paramedian territory infarctions of the thalamus, most often due to ischemic insult at the tip of the basilar artery. In this report, we present a case of bilateral thalamic infarcts resulting in thalamic dementia with severe behavioral manifestations in a 64-yr-old man with no preexisting neuropsychiatric comorbidities. A trial of amantadine, a dopamine-promoting agent, in the acute rehabilitation unit in an attempt to manage his agitation led to multiple weeks of dramatic behavioral improvement and increased participation in therapies. Dopamine receptors are believed to be present at increased densities in thalamic nuclei with mesolimbic projections, suggesting that they are able to modulate limbic functions such as arousal, emotion, and memory. This case report, aimed both to increase the awareness of this uncommon stroke syndrome and describe the observed effect of amantadine, will ultimately help clinicians properly recognize thalamic dementia, minimize unnecessary investigations, and develop effective neurorehabilitation strategies in these patients.