The Role of Rehab in Recovery from Stroke Recrudescence: A Case Report

Case Diagnosis: Stroke recrudescence with aphasia

Case Description or Program Description: 72-year-old male with history of recent left M2 infarct with residual aphasia re-presented with right arm and face movements, right facial droop, and worsened expressive aphasia. Abnormal movements resolved with anti-seizure medication but right-hand weakness and aphasia were persistent.

Setting: Urban academic inpatient rehabilitation facility

Assessment/Results: Extensive work-up was done and overall unremarkable for any new pathology. In the setting of this workup and worsening of prior stroke deficits, neurology made the diagnosis of post-stroke recrudescence (PSR). Given severity of deficits, patient was admitted to acute inpatient rehabilitation. After three weeks in rehab, the patient made functional improvements in mobility and speech. Duloxetine was started for depressed mood and neuropathic pain with improvements in each, and donepezil was added for aphasia with improvements in expressive language. He was discharged home at a supervision level.

Discussion (relevance): PSR is not well-defined or understood and is infrequently seen in the acute rehab setting, with no readily available case reports. While most patients experience resolution of symptoms within 24 hours, some may have lasting deficits. Studies have identified that most common triggers for recrudescence are infection, hypotension, hyponatremia, insomnia or stress, and opioid and benzodiazepine use. It is not well described in the literature how rehabilitation can affect recovery from lasting PRS symptoms. This case demonstrates the benefits of an acute rehab program to improve language and strength deficits.

Conclusions: Inpatient rehabilitation may have a role in the treatment of post-stroke recrudescence. Patients with lasting deficits from PSR would benefit from an acute rehab setting where sleep, stress, vitals, medication use, and labs can all be closely monitored and appropriately treated. Understanding the etiology of PSR and the potential toxic-metabolic triggers is key for PM&R physicians to avoid future recurrence.