Disclosures: Mark Linsenmeyer, MD: No financial relationships or conflicts of interest

Case Description: A 62-year-old woman presented to inpatient rehabilitation six days after being struck by a motor vehicle as a pedestrian. Initial CT head revealed 1.5cm hemorrhagic contusions at the inferior right frontal lobe as well as small left parietal and right frontal subdural hematomas, subarachnoid hemorrhage, and left temporal bone fracture. Injuries were managed nonoperatively. Upon presentation to inpatient rehabilitation, she was abulic with markedly flattened affect. She demonstrated impaired attention, memory, and orientation and she required moderate assistance for ADLs and functional mobility. She complained of headache which was unresponsive to valproic acid, acetaminophen, codeine, and amantadine. She slowly but consistently progressed functionally during her first week. However, on rehabilitation day nine, basic physical examination by physiatrists was unchanged, physical therapists actually noted improved walking distances, but her occupational therapists reported new-onset upper extremity apraxia with marked worsening in her ability to perform ADLs.

Setting: Inpatient rehabilitation unit at a level I trauma center.

Patient: 62-year-old previously-independent and employed woman with a history of hypertension and former smoking. Assessment/

Results: For the new apraxia, CT head was obtained and was concerning for a new left parietotemporal infarct. MRI brain re-demonstrated this infarct and also suggested a left dural sinus thrombosis which was confirmed with CT venogram. Headaches improved with the addition of anticoagulation. Apraxia slowly improved. Attention and processing also improved with the addition of methylphenidate.

Discussion: Deliberate multidisciplinary collaboration and conversation between therapists and physicians on an inpatient rehabilitation unit prompted workup of new-onset apraxia which did not localize to the patient’s existing injury burden. An infarct likely secondary to dural sinus thrombosis was identified and the patient was able to continue to make functional improvement after initiation of appropriate medications.

Conclusion: Physiatrists must be able to synthesize and incorporate new information presented by all team members in order to ensure patient safety and recovery.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/multidisciplinary-identification-of-cerebral-ischemia-due-to-dural-sinus-thrombosis-a-case-report/