Aimee Wilson, MD
Resident Physician
Texas Rehabilitation Hospital Fort Worth
Fort Worth, Texas, United States
Kristen E. Taylor, DO
Pediatric Rehabiliation Physician
Cook Children's Medical Center
Aledo, Texas, United States
A 16 year-old healthy female presented to the ER unresponsive status post seizure like activity. MRI revealed thrombus in the basilar artery causing ischemia in the pons. She underwent thrombectomy, during which a cervical rib was discovered. Doppler ultrasound studies revealed arterial thrombi in the right axillary, brachial, and radial arteries, leading to a diagnosis of aTOS. Once successfully extubated, the patient was found to be nonverbal, but could communicate via vertical eye movements, and had flaccid tetraplegia. These findings, in combination with imaging results, resulted in the diagnosis of locked-in syndrome. She was transferred to inpatient rehabilitation and over the course of 3 months, she advanced to a state of oromotor apraxia and began ambulating household distances with a walker. Remarkably, following her discharge from inpatient rehabilitation, she has continued to improve and has been able to return to school full-time without need for assistive devices.
Discussions: This is the first documented case of locked-in syndrome secondary to aTOS. This case demonstrates that with comprehensive diagnostic evaluation and targeted interventions, including thrombectomy and rehabilitation, the patient was able to make significant functional recovery within the first 5 months after her stroke.
Conclusions: This case report illustrates a rare and complex presentation of locked-in syndrome secondary to arterial thoracic outlet syndrome. The combination of early medication intervention and multidisciplinary rehabilitation has led to substantial recovery. While locked-in syndrome can be a devastating diagnosis, we present a case in which a teenager made remarkable functional recovery in her communication and mobility.
