SESSION TYPE: Miscellaneous Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Hypnagogic hallucinations are hallucinatory experiences that accompany the onset of awakening, they can occur in certain states, such as sleep deprivation and conditions such as narcolepsy. Main neural structures responsible for muscle atonia in REM sleep are dorsolateral portions of the pons and brainstem, cholinergic and cholinoceptive REM sleep-on neurons, monoaminergic REM sleep-off neurons. Generalized atonia originates in dorsolateral portions of the pontine reticular formation and descend to the medulla and spinal cord to bring postural atonia. Muscle atonia characteristic of REM sleep produces both cataplexy and sleep paralysis. Disruptions induced experimentally of these neurons can cause REM sleep without atonia. Reports on narcolepsy following traumatic brain injury have been previously described in the literature.
CASE PRESENTATION: We report a case of a 25 year old woman referred to Sleep Clinic with complaints of episodes of drifting off and suffocating while in bed for about 2 years, with visual hallucinations of a figure in the room or the surroundings, feeling paralyzed during these episodes, that occur approximately 3 to four times per week, sometimes occuring more than once per night. Sleep paralysis, nightmares were described. Excessive daytime sleepiness was observed, with propensity to naps that could last 3 to 4 hours and were refreshing. Epworth Sleepiness scale was 6. There was no family history of parasomnias. She denied snoring or sleep attacks. She noticed the symptoms described occurred two years ago after a car accident, when she suffered a concussion. She had reported a recent 15 Lbs weight gain. On Physical exam she had an airway Mallampati class II and was obese (BMI 32) without any neurological findings. Polysomnography results were as follows: Total sleep time: 494 min (efficiency 93%), Sleep latency: 13 min and REM latency: 5 min. Sleep disordered breathing was not observed. Multiple Sleep Latency Test results were: Mean sleep latency of 10 min with mean REM latency of 7.7 min and 3 SOREMPs.
DISCUSSION: We describe a case of Narcolepsy without cataplexy presenting after a concussion following a car accident. Prior associations with multiple sclerosis, encephalitis and had trauma have been reported, but the temporal relationship between these and the onset of symptoms were not clearly established. Hypnagogic hallucinations, sleep paralysis and nightmares are often present in the general population and may not warrant additional testing.
CONCLUSIONS: In our patient, her excessive daytime sleepiness and temporal relationship with the diagnosis of concussion were helpful elucidating her final diagnosis of Narcolepsy.
1) Castriotta R, Murthy J. Sleep disorders in patients with traumatic brain injury: A Reveiw. CNS Drugs; 2011, 25175-85
2) Clavelou P, Tournilhac M, Vidal C, et al. Narcolepsy associated with arteriovenous malformation of the diencephalon. Sleep; 1995, 18:202-5
DISCLOSURE: The following authors have nothing to disclose: Veronica Brito, Chrisoula Politis, Shalinee Chawla
No Product/Research Disclosure InformationWinthrop University Hospital, Mineola, NY