200 Section - Rehabilitation Management of Recurrent Ischemic Stroke in a Young Patient With SLE and Prior Transverse Myelitis

Recurrent multifocal cortical ischemic strokes in a young woman with systemic lupus erythematosus and pre-existing paraplegia from transverse myelitis.

Case Description:

A 31-year-old woman with systemic lupus erythematosus, prior ischemic stroke, and transverse myelitis resulting in paraplegia was transferred to an acute inpatient rehabilitation after hospitalization for progressive slurred speech. Brain MRI demonstrated multiple punctate foci of acute ischemia scattered in the bilateral frontal and temporal cortices, concerning for vasculitis or embolic disease. Further evaluation identified a mitral valve echodensity consistent with Libman-Sacks endocarditis, as well as concurrent deep vein thrombosis and pulmonary emboli. She was initiated on anticoagulation and immunosuppressive therapy, including rituximab.

At baseline, she was a high-functioning manual wheelchair user and employed full-time as a data analyst. Rehabilitation focused on cognitive-communication therapy, adaptive goal setting, and interdisciplinary medical coordination. Her inpatient rehabilitation course was complicated by stroke recrudescence.

Discussions:

This case highlights the rehabilitation complexity that arises when new ischemic injury occurs in a patient with longstanding neurologic disability. In individuals with pre-existing paraplegia, functional decline following stroke may manifest primarily through cognitive, communicative, and executive impairments rather than mobility loss. Accurate differentiation between baseline deficits from transverse myelitis and new stroke-related impairments was essential to guide therapy intensity, goal setting, and outcome measurement. Additionally, fluctuating neurologic symptoms, including transient expressive aphasia consistent with stroke recrudescence, required ongoing reassessment and close interdisciplinary collaboration.

Conclusions:

Patients with chronic neurologic disability who sustain new cerebrovascular injury present unique rehabilitation challenges that extend beyond traditional stroke recovery models. In this case, new multifocal cortical strokes in a young woman with paraplegia required acute inpatient rehabilitation which provided a critical setting for reassessing functional baselines, addressing evolving neurologic deficits, and coordinating care amid complex medical comorbidities. Recognition of how new brain injury alters function in patients with established disability is essential for optimizing care.