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Case Studies in Sleep Neurology
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Book description

Sleep disorders are increasingly recognized as a major clinical problem, with significant morbidity and considerable economic importance. This compendium of case studies presents a diverse range of situations which challenge the problem-solving abilities of all those interested in sleep disorders, covering both common and unusual cases. Each case begins with a clinical history, followed by examination findings and special investigations and culminating in diagnosis, treatment and management, with discussion of differential diagnosis where appropriate. Focusing attention on the major categories of sleep medicine, including insomnia, hypersomnias, sleep-breathing disorders, parasomnias, movement disorders, circadian dysrhythmias and the neurology of sleep, this clinical guide promotes integrative thinking and diagnostic skill. Historical and review citations, illustrations and concise real-life stories stimulate memory and facilitate learning. Written and edited by an international cadre of sleep professionals, this book will inform and challenge established specialists and provide a stimulating teaching tool for those in training.

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Contents


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  • Case 8 - A shift worker falls repeatedly
    pp 51-56
  • View abstract

    Summary

    This chapter discusses the case of a 42-year-old patient who was admitted for the evaluation of opioid-induced central sleep apnea. It presents the clinical history, examination, follow-up, treatment, and the results of the procedures performed on the patient. The patient was presented for evaluation of frequent breathing pauses during sleep, which had been witnessed by his wife for 5 years along with intermittent mild snoring. His social history was negative for alcohol or other substance abuse, but he was an ex-smoker and he drank 12 cups of coffee per day. The patient had been maintained on narcotics for treatment of his chronic pain following the laminectomy, for a period of 8 years. In view of his sleep respiratory symptoms, polysomnography (PSG) was performed. Opioid-induced central sleep apnea (CSA) has attracted attention in recent years because of the surge in opioid administration to patients with pain.
  • Case 9 - Extreme dreams
    pp 59-66
  • View abstract

    Summary

    This chapter presents the clinical history, examination, and the results of the procedures performed on a patient who was a 14-year-old young woman who, according to her parents, has had problems sleeping for several years. The results of the studies showed that the patient had a total of 144 sleep-related respiratory events, with an apnea-hypopnea index (AHI) of 22.47 per hour. There were 140 central apneas and four hypopneas, with 126 events occurring in NREM sleep. The diagnosis was Chiari 1 malformation with associated central sleep apnea. The patient also had a syrinx from C3 through the thoracic cord. Treatment of Chiari 1 malformation involves suboccipital decompression (posterior fossa craniectomy), with or without upper cervical laminectomy. In this case too, the patient underwent suboccipital decompression, and remained in the hospital for 4 days, with some immediate post-operative sleep-related apneas but subsequent significant improvement of sleep.
  • Case 10 - Odd sleep-related behaviors
    pp 67-73
  • View abstract

    Summary

    This chapter discusses the case of a 54-year-oldwoman with disturbing respiratory noise during nocturnal sleep. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. EMG investigation of laryngeal muscle activity was subsequently performed during wakefulness and sleep, placing fine-wire electrodes in the posterior cricoarytenoid, cricothyroid and thyroarytenoid muscles. The specialist made a diagnosis of nocturnal inspiratory stridor based on the characteristics of the noise present only during sleep, particularly during NREM sleep. A diagnosis of REM-sleep behavior disorder (RBD) was also made due to the characteristic clinical history of violent motor behaviors during sleep associated with polysomnography (PSG) evidence of REM sleep without atonia. Tracheostomy and continuous positive airway pressure (CPAP) are effective treatments of stridor; however, they do not always prevent death in multiple-system atrophy.
  • Case 11 - Paralyzed and unable to breathe
    pp 74-80
  • View abstract

    Summary

    This chapter describes the case of a 7.5-month-old Caucasian infant with a birthweight of 3.9 kg, born full term to a 35-year-old mother. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The patient's pediatrician suspected an upper respiratory tract infection and treated her with "Infants' Cold Formula" with no relief. A soft-tissue X-ray of her neck revealed hypertrophy of her adenoids, which were obstructing the nasal airway. There was paradoxical inward rib-cage motion during inspiration throughout much of the study. Tachypnea was present, particularly during REM sleep. The diagnosis based on the polysomnography (PSG) results was severe obstructive sleep apnea (OSA), pediatric. The patient's symptoms and O2 saturation improved immediately thereafter. A follow-up sleep study 2 months later revealed that the patient no longer demonstrated an obstructive breathing pattern or impairment in gas exchange.
  • Case 13 - Screaming at night
    pp 86-91
  • View abstract

    Summary

    This chapter discusses the case of an 11-year-old Asian-American girl who was admitted for treating sleep disturbances, excessive daytime sleepiness (EDS) and paroxysmal weakness in the sleep center. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. Nocturnal video-polysomnography (PSG) followed by a multiple sleep latency test (MSLT) were ordered. She went into REM sleep, without going into any other sleep stages at the beginning of the MSLT in three of the five naps. The diagnosis was narcolepsy with cataplexy. Sodium oxybate was administered and titrated twice nightly, which helped further decrease her cataplexy to once or twice daily. Cataplexy may take the form of prolonged waxing and waning, with partial or complete muscle atonia, called status cataplecticus. Schizophreniamay be co-morbid or an intrinsicmanifestation of narcolepsy. Obesity is frequently observed in association with narcolepsy, contributing to sleepiness.
  • Case 14 - Violent sleep behavior resulting in subdural hemorrhage
    pp 92-100
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 25-year old patient who was admitted for the evaluation of insomnia. The specialist made a diagnosis of narcolepsy with possible cataplexy and decided not to pursue a CSF hypocretin analysis in light of the diagnostic certainty of the polysomnography (PSG) results. The multiple sleep latency test (MSLT) showed the presence of REM sleep in all four naps with a latency of 5 minutes. He prescribed modafinil 200 mg to be taken in the morning, a dose that could be increased to 400 mg if necessary. Narcolepsy is a life-long disorder presenting with excessive daytime sleepiness (EDS) and, ironically, with fragmented sleep that may lead to an erroneous diagnosis of insomnia. In addition to modafinil, patients may respond favorably to the administration of methylphenidate and dexedrine.
  • Case 15 - Amnestic nocturnal behavior
    pp 103-109
  • View abstract

    Summary

    This chapter discusses the case of a 17-year-old girl who was admitted for the evaluation of excessive daytime sleepiness (EDS). It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. She suffered developmental delay, and was later diagnosed with mild mental retardation. Nocturnal polysomnography (PSG) and a multiple sleep latency test (MSLT) were carried out. The diagnosis was childhood-onset narcolepsy with cataplexy. The parents declined CSF testing for hypocretin. The onset of narcolepsy may occur with any of the four cardinal symptoms (excessive sleepiness, sleep paralysis, hypnagogic hallucinations and cataplexy), the most frequent being EDS. Childhood onset of narcolepsy is uncommon, but has been reported. The usual age of onset is mid- to late teens up to mid-20s. Occasionally patients may become ill after the age of 40.

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