Medical Director Delaware Neurorehab Dover, Delaware, United States
Case Diagnosis: Upper extremity deep vein thrombosis (DVT) post ultrasound guided incobotulinum toxin A (Xeomin) injection.
Case Description: 61 year old male with residual spastic left-sided hemiplegia after right-sided MCA infarct. Prior to starting treatment for spasticity, he had a modified Ashworth scale (MAS) of 3 to 4 in the left upper extremity and lower extremity, significantly affecting his functionality. He started treatment with tizanidine, baclofen, physical and occupational therapy however these modalities did not provide improvement. Initially started botulinum toxin injection treatment with 500 units total, 275 units to the upper extremity, and 225 units to the lower extremity. He had adjunctive medial and lateral pectoral nerve chemical denervation with 10 mL of 6% aqueous phenol. The patient had increase in functionality, and subsequently underwent an additional 3 rounds of incobotulinum toxin at 3 month intervals. However, 6 days after his latest injection with incobotulinum toxin, he presented with left upper extremity swelling. Ultrasound of the upper extremities revealed a DVT in the left internal jugular vein.
Discussions: Deep vein thrombosis are a common complication of strokes in the acute phase, usually within the first 10 days. In addition, most DVTs normally occur in the lower extremities. However in this patient, his DVT occurred a year later in the upper extremity after undergoing 4 rounds of botulinum toxin injections. The mechanism behind the DVT is unclear, as increasing mobility in the affected extremities would decrease the risk of a DVT by decreasing blood stasis. There may be a component of endothelial injury in patients with chronic spasticity gaining increase of function.
Conclusions: This case demonstrates a rare occurrence of upper extremity DVT post incobotulinum toxin injection under ultrasound guidance. There is minimal literature behind DVT post botulinum toxin injection.
