320 - Uncovering a Rare Diagnosis of Gerstmann's Syndrome in an Inpatient Rehabilitation Facility after Left Frontoparietal Hemorrhage and Superior Sagittal Sinus Thrombosis

Case Diagnosis: A 79-year-old man was admitted to the intensive care unit (ICU) after presenting with a first-time seizure. Neuroimaging revealed an occlusive superior sagittal sinus thrombosis with multifocal left frontoparietal hemorrhages. His ICU course was complicated by recurrent seizures and progressive hemorrhages causing worsening aphasia, ataxia, right hemiparesis, and right hemineglect. On admission to inpatient rehabilitation (IRF), he required total assistance for ambulation, maximum for ADLs, and moderate for transfers. Multidisciplinary evaluation at IRF revealed additional deficits of acalculia, agraphia, finger agnosia, and right-left disorientation, consistent with a diagnosis of Gerstmann's syndrome.

Case Description:
Standard rehabilitation targeting aphasia and right-sided deficits resulted in limited improvement. Upon recognition of Gerstmann syndrome's characteristic impairments in spatial reasoning, sequencing, writing, and calculating, the rehabilitation plan was revised to incorporate focused cognitive-linguistic therapy and compensatory strategy training with with sports-based activities, assistive technology, modified constraint-induced movement therapy, and immersive virtual reality. By discharge, the patient demonstrated substantial gains, requiring only supervision for ambulation, transfers, and ADLs. At four months post-discharge, he achieved full independence and resumed golfing, his primary passion in life, underscoring the efficacy of proper diagnosis and individualized, goal-oriented rehabilitation in optimizing functional outcomes. 



Discussions: Gerstmann's syndrome is a rare neurobehavioral syndrome classically linked to dominant parietal lobe lesions and subcortical white matter disconnection. It is a diagnostically challenging entity, often masked by overlapping deficits from left frontoparietal lesions or left MCA strokes. Its core features may be obscured by hemiparesis, hemineglect, and aphasia, complicating rehabilitation planning. Early recognition and syndrome-specific rehabilitation are critical for optimizing functional recovery.

Conclusions: This case highlights the importance of maintaining Gerstmann syndrome in the differential diagnosis for dominant parietal lobe injury. Syndrome-specific rehabilitation, tailored to the unique cognitive and motor deficits, can drive substantial functional gains and community reintegration, underscoring the need for targeted assessment and individualized therapy in this population.