1327 - Rehabilitation Challenges in a Patient with Four-Limb Amputations and Concomitant Hypoxic Brain Injury with Visual Impairment

Hypoxic brain injury complicated by limb ischemia requiring four-limb amputations

Case Description:

A 51-year-old male with past medical history abdominal aortic aneurysm (AAA) presented to acute care hospital for planned cardiac Bentall procedure with AAA repair. Postoperative course was complicated by cardiac arrest requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and mechanical ventilation, continuous renal replacement therapy, and transvenous pacemaker placement. As a result, the patient developed limb ischemia requiring bilateral transtibial amputations, right digits 2-3 metacarpophalangeal joint and thumb interphalangeal joint amputations, and a left transradial amputation. Moreover, CT and MRI brain showed evidence of diffuse hypoxic brain injury with hypodensities seen in the bilateral frontal lobes, occipitoparietal lobes, and cerebellar hemispheres.

He was admitted to acute inpatient rehabilitation (AIR) with mobility and activities of daily living (ADL) impairments due to his four-limb amputations. However, with his concomitant brain injury and subsequent visuospatial, proprioceptive, and motor planning deficits, his rehabilitation course proved to be challenging.

Discussions:

Neuro-optometry and vision therapists were consulted to implement strategies such as high-contrast therapy, visual scanning exercises, and verbalization to facilitate functional tasks in the setting of low vision. Furthermore, hemi-neglect and motor planning issues needed to be addressed during therapy sessions. Upper extremity residual limb compression was deferred to preserve his tactile sensation. As his vision improved, a power wheelchair with modified joystick was trialed. He progressed from requiring total assistance for all mobility and ADLs on admission to requiring partial/moderate assistance on discharge from AIR. He continues to improve with intensive outpatient therapy, now ambulating 1000 feet with supervision in his bilateral transtibial prostheses.

Conclusions:

The addition of visual-perceptual and vision impairments to a patient with multiple limb amputations can complicate rehabilitation and prosthetic fitting and utilization. These patients benefit from low vision and visual-perceptual as well as cognitive remediation in conjunction with prosthetic and orthotic intervention.