Poster 195: Focal dystonia after stroke leading to trismus: a case report.

Abstract

Setting: Midwest acute inpatient rehabilitation hospital. Patient: A 58-year-old woman. Case Description: The patient was diagnosed with a middle cerebral artery and lacunar stroke on January 9, 2002. She was admitted to acute inpatient rehabilitation on February 14, 2002, and was found to have trismus on the second day of admission. Differential diagnoses included: tetanus, abscess, dislocation, slipped disk, fracture, volitional noncooperation, and dystonia. Plain films followed by facial computed tomography with thin cuts did not reveal pathologic findings. Manipulation at bedside with sedation and bilateral masseter muscle block did not result in resolution of trismus. Treatment for tetanus was initiated while titer results were pending. The patient subsequently underwent exam under anesthesia, where her jaw was opened fully and no evidence of fractures, abscess, or dislocation was noted. Facial electromyography revealed increased activity in the left temporalis muscle, consistent with spastic dystonia. The tetanus titers were negative and the most likely diagnosis was focal spastic dystonia. Aggressive treatment was pursued because the patient was unable to accept oral intake and had been at severe nutrition risk since the onset of trismus. Tizanidine was started, and she received adjunctive treatment with 10U of botulinum toxin type A (BTX) by electromyographic guidance to the left temporalis muscle. 6 days later, she had partial resolution of her trismus and was able to tolerate oral intake. Assessment/Results: Focal dystonia of the left temporalis muscle. Discussion: Alterations in muscle tone are a common finding after acute stroke. However, this case demonstrates an unreported complication of stroke, and the importance of dystonia in the differential diagnosis of trismus. We demonstrate the use of BTX for focal spastic dystonia in the acute rehabilitation setting. Conclusions: Focal dystonia of the temporalis muscle is a rare complication of stroke, and must be considered in the differential diagnosis of trismus.