Recent Advances in trunk door and it hit her head Immediately after - - PowerPoint PPT Presentation

2/15/2019 1

Recent Advances in Neurology: Challenging Cases

Liza Ashbrook, MD Assistant Clinical Professor UCSF Department of Neurology February 15, 2019

History of Present Illness

• 54 year-old female executive presented with head injury: pulled close SUV

trunk door and it hit her head

• Immediately after developed headache, nausea, dizziness, memory changes,

blurred vision, no loss of consciousness

• For the first 2-3 months after head injury had trouble falling asleep and

staying asleep which then evolved into fatigue

• Four months after head injury she had three concerning episodes

HPI: Concerning episodes

• When stopped in a car dropping her daughter off at camp, driver behind

her started to honk and she awoke and realized she had lost time. She was able to keep her foot on the brake. Denies feeling of sleepiness prior to the event but notes sleepiness afterwards

• Sitting in her home, daughter spoke to her from behind, she reportedly did

not reply, she “awoke” and felt sleepy

• Driving around a corner alone and felt a car drive by the other direction but

reports she was not fully aware of this, denies feeling sleepy prior but felt sleepy afterwards

Part Medical History

• Gastric ulcer
• Seasonal allergies
• Irritable bowel syndrome
• MVA age 9 with LOC and concussion
• No history of previous seizures
• No history of CNS infection

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Additional history

Medications at time of concussion

• Ibuprofen prn

Medications started during treatment of concussion

• Melatonin 1mg prn
• Nortriptyline 10mg
• Rizatriptan prn

FH: No FH of seizure or sleep disorders. Father snores SH: Mother of 3, twin 14 yo and 12 yo. Works full time as an executive in banking. No smoking, heavy alcohol use

Physical Exam

• General: not manifestly sleepy.
• Normal HEENT exam with Mallampati 2, no turbinate hypertrophy,

micrognathia, retrognathia, or high arched palate

• Neuro
• MS: Alert, oriented, memory intact to details of the history aside from the moment of the events

above

• CN: intact, no nystagmus
• Motor: intact rapid tapping, no pronator drift
• Sensory: intact to light touch, negative Romberg
• Coordination: No dysmetria
• Gait: normal casual gait, can tandem

Evaluation

• Patient was referred to epilepsy clinic and an outpatient EEG was performed and

normal

• Then referred for sleep evaluation in which she reported
• Bedtime: 11
• Wake time: 6:30-8am
• Sleep latency: 20-60 minutes
• Awakenings after sleep onset: 0-1
• Naps: 1-3 times per week (recommended by psychologist), they are refreshing
• Epworth sleepiness scale: 7 (>10 ‘pathologic’)
• She does snore, no witnessed breathing pauses and no report of leg kicking
• No hypnogogic or hypnopompic hallucinations, sleep paralysis, cataplexy

Question 1: Which sleep disorder is NOT noted to occur more commonly after TBI than in the general population?

• A. Insomnia
• B. Hypersomnia
• C. Advanced sleep-wake phase disorder
• D. Narcolepsy
• E. Central sleep apnea

I n s

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n i a A d v a n c e d s l e e p

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a k e p h a s e . . . N a r c

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e p s y C e n t r a l s l e e p a p n e a

3% 3% 15% 63% 17% :01

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PSG with MSLT was performed

• MSLT: mean sleep latency test
• Following an all night polysomnogram, patient undergoes a series of 5

naps at two hour intervals

• There is a 20 minute opportunity to sleep
• Once asleep, the patient’s sleep is observed for 15 minutes to assess for

the presence of REM

Question 2: What are the MSLT criteria for narcolepsy?

KEY: MSL=Mean sleep latency; SOREMP=sleep onset REM period

• A. MSL<15 minutes, 5/5 SOREMP
• B. MSL <8 minutes, 2+/5 SOREMP
• C. MSL <5 minutes, 5/5 SOREMP
• D. MSL <8 minutes, 0/5 SOREMP
• E. MSL <15 minutes, 2+/5 SOREMP

M S L < 1 5 m i n u t e s , 5 / 5 S O R E M P M S L < 8 m i n u t e s , 2 + / 5 S O R E M P M S L < 5 m i n u t e s , 5 / 5 S O R E M P M S L < 8 m i n u t e s , / 5 S O R E M P M S L < 1 5 m i n u t e s , 2 + / 5 S O . . .

6% 44% 15% 6% 29% :01

PSG results MSLT

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MSLT Results Epidemiology of sleep disorders in traumatic brain injury

Prevalence varies by definition of TBI, sleep disorder: 30% to 70%

• Insomnia 29%
• Hypersomnia 28%
• Periodic limb movements 19%
• Obstructive sleep apnea 25%
• Narcolepsy 4%

From a meta-analysis with all TBI, Mild 214, mod 38, severe 1147

Mathias et al, Sleep Medicine, 2012

Natural history

• Mild TBI
• 65% report some sleep disruption initially (N=346, Theadom et al Sleep Medicine, 2015)
• Excessive daytime sleepiness increased from the two weeks to one month post-injury
• Less than 10% reported pre-injury sleep trouble
• Improvement up to six months
• After six months many sleep issues remain stable or worsen
• At 18 months those with TBI of any severity require more sleep on average than controls (7.1

vs 8.1 hours)

• Patients are often not aware of their daytime sleepiness or higher sleep need
• Severe TBI
• 84% had sleep-wake disturbances upon admission to rehab, 66% at one month post-injury

Natural history

• By one year post injury

‒41% still have some sleep difficulties ‒20% have insomnia symptoms at a clinically significant level (PSQI>8) ‒20% have excessive daytime sleepiness (ESS>10) ‒Within mild TBI, severity of injury did not predict sleep disturbance

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Risk factors for sleep trouble at one year

• Pre-injury sleep difficulty
• Sleep difficulty within first two weeks after injury
• Cognitive difficult within first two weeks after injury
• Increased age (in some studies)
• Female gender (in some studies)

Question 3: Sleep trouble immediately after concussion predicts trouble with what at one year?

• A. Prolonged concussion recovery
• B. Anxiety
• C. Depression
• D. Worsened post-concussive symptoms
• E. All of the above

P r

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c u s s i v e . . . A l l

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1% 0% 93% 5% 1% :01

Sleep disruption predicts worse recovery

• Sleep trouble within first two weeks predicts at twelve months
• Post concussive symptoms
• Anxiety
• Depression
• Decreased social integration
• Productivity

 These factors do not predict sleep quality at one year

• Among patients with mTBI who presented to the ED, those with sleep complaints were
• nearly five times more likely to have depression at six weeks
• three times more likely to have headache
• Premorbid sleep disruption contributes to prolonged recovery

Bramley et al, Clinical pediatrics 2017; Chaput et al, Sleep Medicine, 2009

Mechanisms of sleep change in TBI

Hypocretin (orexin):

• Hypocretin is low in >90% of TBI patients admitted to the hospital but returns to normal in all but 19%

at six months

• Mouse models show low hypocretin in mild TBI as well

Melatonin

• Total melatonin levels are decreased in TBI
• Most studies show normal timing of dim light melatonin onset (DLMO), arguing against TBI causing a

phase delay Other

• Diffuse axonal injury interferes with sleep and circadian circuits
• Countercoup injuries can impact the basal forebrain, a major wake promoting center, due to collision with

sphenoid ridge at the skull base

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Treatment: Insomnia

• Treatment is similar to insomnia in the general population including:
• Cognitive behavioral therapy for insomnia
• Melatonin and melatonin agonists
• Antidepressants including trazodone, doxepin
• Hypnotics: zolpidem, eszopiclone, zaleplon, suvorexant

Treatment: Circadian disruption

• One of three with insomnia have a circadian rhythm disorder
• Delayed sleep-wake phase disorder or irregular sleep-wake phase disorder are the

most common circadian disorders in the post concussive period

• Likely blunting of circadian rhythm from injury and/or from change in

external circadian cues and unmasking of underlying chronotype rather than a shift in the rhythm

• Treated with morning light, evening melatonin 0.5 mg 4-5 hour before

bedtime, daytime activity, minimizing evening light exposure

Treatment: Excessive daytime sleepiness

Look for underlying causes:

• Insufficient sleep
• Sedating medications
• Obstructive sleep apnea
• Restless leg syndrome/periodic leg movement disorder
• Depression
• Adequate sleep opportunity at night
• Timed naps
• Morning bright light: sunlight, lightbox 10,000 Lux full spectrum, blue light
• 45 min/morning, short wavelength blue light therapy (λmax = 465 nm, 39.5 lux) superior to yellow light therapy
• Wake promoting medication
• Modafinil 100-200mg BID improves excessive daytime sleepiness but not fatigue
• Armodafinil 150-250mg
• Stimulants: methylphenidate, dextroamphetamine/amphetamine

Our patient

• Narcolepsy criteria
• Daily periods of irrepressible need to sleep or daytime lapses into sleep for at least

three months

• MSLT with MSL<8 min and 2+ SOREMPs
• The patient does not meet the daily sleepiness criteria
• Differential diagnosis for positive MSLT:
• Sleep deprivation: this reported tinnitus and husband’s snoring were disturbing her

sleep in the two weeks prior to the study, 44% stage 3 sleep suggests rebound from sleep deprivation

• Antidepressant withdrawal: she was actually on nortriptyline 20mg at the time of

the study, reports sometimes missing doses

• Treatment: modafinil 100-200mg

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Take home points

• Sleep disturbance during the post concussive period is very common
• Sleep complaints predict longer recovery and increased post-concussive

symptoms

• Sleep complaints in mild TBI are nearly as common as in severe TBI
• Interventions for sleep complaints in TBI mirror those in the general

population

• All patients with TBI should be screened for sleep complaints
• Commonly used sleep questionnaires include Pittsburgh Sleep Quality

Index (PSQI) and the Epworth Sleepiness Scale (ESS)

Thank you!

Do you have patients with neurologic or psychiatric related sleep concerns? Consider referral to UCSF’s Neuro/Psych Sleep Clinic, located within UCSF Neurology

• Phone: 415-353-2273
• Fax: 415-353-2898