1412 - Fueling Functional Recovery: Recurrent Aspiration and Nutritional Challenges in Locked-In Syndrome: A Case Report

Case Diagnosis: Feeding intolerance and inadequate nutrition in locked-in syndrome patient resulting in impaired functional recovery.

Case Description: A 56-year-old male with a history of epilepsy was diagnosed with a basilar artery occlusion. He underwent thrombectomy and had a long hospital course complicated by multifocal strokes, respiratory failure with ventilator dependence ultimately requiring tracheostomy, recurrent aspiration pneumonia, and dysphagia requiring percutaneous endoscopic gastrotomy (PEG) tube. He was ultimately able to be weaned from the ventilator to a tracheostomy collar and progress to be able to tolerate intensive therapies.
He was admitted to acute inpatient rehabilitation on total enteral nutrition (TEN). He continued to experience aspiration events. Despite lowering his feeding rate, optimizing his bowel regimen, and trialing metoclopramide, he continued to aspirate resulting in prolonged periods without nutrition and a plateau of functional recovery. After discussion with gastroenterology and nutrition, the patient was transitioned to total parenteral nutrition (TPN) which he tolerated well. Within a week of adequate caloric intake, he showed significant functional improvements in therapies.

Discussions: Nutrition is key to the successful rehabilitation of patients with stroke. Appropriate and adequate nutrition is not just supportive care but should be considered a central therapeutic target in rehabilitation. This case highlights the importance of early recognition of feeding intolerance and illustrates the benefits of close collaboration between physiatry, gastroenterology, and nutrition. Transitioning to TPN minimized aspiration risk, ensured consistent caloric intake, and allowed uninterrupted participation in rehabilitation, which ultimately supported significant functional gains for this patient. Proactive identification and intervention for feeding intolerance can prevent setbacks, accelerate functional recovery, and enhance outcomes in complex neurologic patient populations.

Conclusions: For patients with recurrent aspiration and inadequate intake on TEN, TPN should be considered to optimize medical stability, facilitate therapy participation, and improve functional outcomes.