1008 - Botulinum Toxin Injection Guidance Modality Selection after Acquired Brain Injury

Thursday, February 19, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

KS

Katherine Schenkel, MD

Resident
The University of New Mexico Hospital - 2211 Lomas Blvd NEAlbuquerque, NM 87106-2719UNITED STATES - Albuquerque, NM
Albuquerque, New Mexico, United States

Co-Author(s)

EL

Ellese A. Lupori, BA

OMS-IV
Western University of Health Sciences - COMPNW
Bend, Oregon, United States

Corresponding Author(s)

AD

Austin Davis, MD

Attending Physician
University of New Mexico
Albuquerque, New Mexico, United States

Submitter(s)

KS

Katherine Schenkel, MD

The University of New Mexico
Albuquerque, New Mexico, United States

Case Diagnosis: Botulinum Toxin Injection Guidance Modality Selection after Acquired Brain Injury

Case Description: This is a 29-year-old man with remote gunshot wound to the head, initial GCS of 3T requiring right-side craniectomy and skull base repair along with subsequent cranioplasty. He presented to clinic with dysphagia and concern for oromandibular dystonia that was limiting progress with speech language pathology and preventing him from adequately opening his mouth. Baclofen was trialed without benefit, and the decision was made to evaluate with electromyography and trial botulinum toxin injection prior to surgical referral. On the day of injection, ultrasound (US) revealed fluid accumulation continuous with his cranioplasty site and highly suspicious for pseudomeningocele that extended inferiorly to above the zygomatic arch, superficial to the remaining temporalis muscle. Botulinum toxin injection was deferred at that site due to ultrasound findings.

Discussions: Post-cranioplasty subcutaneous cerebral spinal fluid (CSF) collection, or pseudomeningocele, has a documented incidence of 3.6% to 23.7%. There is level 1 evidence that EMG, electrical-stimulation, and US guidance with botulinum toxin injection is superior to landmark-based injections. However, despite variability in guidance methods and patient needs, existing evidence suggests that these methods are equivalent. This case report suggests that patient safety may be improved with guidance techniques tailored to injection target(s) and situation.

Conclusions: Specifically with head and neck injections in individuals with prior significant surgical intervention, US guidance may be an important tool to ensure patient safety as it allows for real-time visualization of post-surgical anatomic variances and thus decreases the risk of injections into unintended sites with pathology that otherwise may not be visualized. This case demonstrates a situation in which more specific clinical practice guidelines regarding recommended injection guidance modalities may be relevant and useful for the safety of complex post-acquired brain injury patients.