Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
  1. Home
  2. Books
  3. Case Studies in Sleep Neurology
Publisher:
Cambridge University Press
Online publication date:
November 2010
Print publication year:
2010
Online ISBN:
9780511902505
DOI:
https://doi.org/10.1017/CBO9780511902505
Subjects:
Psychiatry and Clinical Psychology, Neurology and Clinical Neuroscience, Medicine, Psychiatry
Series:
Case Studies in Neurology
Information

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.

Refine List

Actions for selected content:

Select all | Deselect all
  • View selected items
  • Export citations
  • Download PDF (zip)
  • Save to Kindle
  • Save to Dropbox
  • Save to Google Drive

Save Search

You can save your searches here and later view and run them again in "My saved searches".

Please provide a title, maximum of 40 characters.
Cancel
×

Contents

Page 2 of 2

Contents
  • Case 17 - Frequent night-time wanderings
    pp 117-122
  • View abstract

    Summary

    This chapter presents the clinical history, examination, and the results of the procedures performed on a 30-year-old male shift worker who was admitted for the evaluation of uncontrolled daytime sleepiness and generalized muscle hypotonic attacks. The patient was also falling to the ground without loss of consciousness. The chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The results of polysomnography (PSG) showed that the patient had a total sleep time of 400 minutes and a total wake time of 40 minutes, with a sleep efficiency of 91%. The diagnosis was narcolepsy with cataplexy. Sodium oxybate was administered in increasing doses, and the progression after a year and a half was satisfactory; no episodes of cataplexy occurred during regular work hours. After 4 months of treatment with sodium oxybate, the patient did not complain of daytime sleepiness.
  • Case 19 - Seeking food in the night
    pp 131-138
  • View abstract

    Summary

    This chapter discusses the case of a 55-year-old woman who reported that for the previous 6 years she had been having episodes at night where she had dreams that often had a fearful content. It presents the clinical history, examination, diagnosis, and the results of the procedures performed on the patient. On examination she was anxious and cried during the interview. The differential diagnosis of paroxysmal nocturnal events includes parasomnia, seizures during sleep or a psychogenic disturbance. Parasomnia classification is usually based on the sleep phase during which the parasomnia occurs. Seizures seen in nocturnal frontal lobe epilepsy (NFLE) are sleep-related seizures that may be difficult to distinguish from other paroxysmal events at night. This is because the motor activity and vocalization may resemble other paroxysmal events with features such as cycling movements of the lower limbs and because patients may be partially responsive during the seizures.
  • Case 21 - Gaining weight while asleep
    pp 146-150
  • View abstract

    Summary

    This chapter presents the clinical history, examination, treatment, management, and the results of the procedures performed on a 27-year-old patient who was admitted for the evaluation of odd sleep-related behaviors. At the time of presentation, the patient had a consistent bedtime of 11.30 pm. Nocturnal polysomnography (PSG) with additional all-night 16-channel EEG running concomitantly with the PSG was obtained. There was no evidence of obstructive sleep apnea (OSA) with normal breathing and normal O2 saturation during sleep averaging 93% with a nadir of 90% and a desaturation index of zero. Given these results, a diagnosis of parasomnia overlap disorder was made. The ICSD-2 defines parasomnia overlap disorder as consisting of both REM-sleep behavior disorder (RBD) and a disorder of arousal. Prognosis is unknown, but careful follow-up is recommended to help with early detection of Parkinsonian disorder or other degenerative neurological disorders that are known to be associated with RBD.
  • Case 22 - Vivid images in the bedroom
    pp 151-155
  • View abstract

    Summary

    This chapter discusses the case of a 56-year-old man who presented to the sleep clinic complaining of frequent episodes of feeling paralyzed as he was going to sleep. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. Examination revealed a pleasant, thin, middle-aged man, in no acute distress, who looked younger than his stated age. Based on the history, the diagnosis of isolated or familial sleep paralysis was made and the patient was started on clomipramine 25 mg at bedtime. Differential diagnosis includes narcolepsy if excessive daytime sleepiness (EDS) is present or a history of hypnic hallucinations and cataplexy can be elicited. Although daytime sleepiness is necessary to make the diagnosis of narcolepsy, sleep paralysis can also occur in other conditions that present with daytime sleepiness such as sleep deprivation, sleep-related breathing disorder and idiopathic hypersomnia.
  • Case 23 - Noisy breathing during sleep
    pp 156-162
  • View abstract

    Summary

    This chapter discusses the case of a 27-year-old male who was admitted to the hospital with right arm numbness. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. His vital signs were normal. There was mild expiratory wheezing at the bases bilaterally related to an upper respiratory infection. There was reduced sensation to light touch, pinprick and vibration in the right upper extremity in C6-C7 distribution. MRI of the brain showed multiple small hyperintense lesions in white matter throughout both cerebral hemispheres and the brainstem. An overnight sleep study followed by a multiple sleep latency test (MSLT) revealed REM sleep without atonia and abundant myoclonic jerks in REM sleep. A diagnosis was made of probable parasomnia overlap disorder in the context of multiple sclerosis. Parasomnia overlap disorder responds favorably to the administration of clonazepam.
  • Case 24 - Sexsomnia and obstructive sleep apnea
    pp 163-168
  • View abstract

    Summary

    This chapter discusses the case of a 46-year-old female with a 5-year history of distressing, unpleasant and bizarre dreams that occurred from a few times a week to once a month, depending on her stress level. It presents the clinical history, examination, diagnosis, follow-up, general remarks and the results of the procedures performed on the patient. Nocturnal polysomnography (PSG) was carried out, and the thyroid-stimulating hormone level in plasma was determined. The diagnosis was nightmare disorder with primary snoring. The relationship between daytime stress, anxiety and nightmares was emphasized. The treatment plan centered on addressing daily stress and anxiety. Recurrent nightmares are frequent in children (20-39%) and less frequent in adults (5-8%). Nightmares also occur in patients with psychiatric illnesses such as anxiety, depression and schizophrenia, as well as in individuals with poor coping mechanisms and creative tendencies.
  • Case 25 - The anxious hitting sleeper
    pp 171-177
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 73-year-old patient who complained of two recent violent dreams that resulted in significant injury. His past medical history included an anterior wall myocardial infarction, sinusitis and a remote history of tuberculosis. The patient was treated with clonazepam 1.0 mg every evening before sleep, with complete resolution of all violent dream-related behaviors over the following year. The MRI scan revealed a right subdural hematoma without mass effect, and a few small 2-3mm foci of deep white matter changes. The polysomnography (PSG) study revealed significant periodic limb movements. A follow-up assessment by a movement disorders specialist led to the diagnosis of Parkinson's disease. The patient's history and PSG analysis are classical for, and diagnostic of, REM-sleep behavior disorder (RBD), which is defined in ICSD-2 as a parasomnia associated with REM sleep.
  • Case 27 - Sleepwalking or seizing?
    pp 185-192
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 38-year-old female patient who was admitted to a university sleep disorders center to address amnestic nocturnal behavior. She was a friendly, non-dysmorphic patient who cooperated throughout the examination. Her vital signs were normal except for a BMI of 26 kg/m2 and borderline systolic hypertension. Her mood and affect were bright and congruent. In particular, there was no evidence on examination of subtle changes suggestive of a dementing illness or a Parkinsonian syndrome. An EEG carried out in 2005 and 2009 demonstrated normal awake and drowsy responses. An MRI carried out in 2009 showed normal brain. Polysomnography (PSG) showed that sleep was initiated without a sedativehypnotic. A diagnosis was made of mixed NREM parasomnia characterized by confusional arousals, sleepwalking (with sleepdriving), sleep-related eating disorder, and sexsomnia exacerbated by zolpidem.
  • Case 28 - Seizure, parasomnia or behavioral disorder?
    pp 193-199
  • View abstract

    Summary

    This chapter discusses the case of a 48-year-old woman who was having episodes of sitting upright in bed, letting out a blood curdling scream and patting the bed with both hands, and often going back to sleep without realizing what had happened. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The specialist ordered an MRI of the brainwith special thin cuts through the frontal and temporal lobes, and nocturnal polysomnography (PSG) with an additional all-night 16-channel EEG running concomitantly with the PSG. Based on the results of the studies, a diagnosis of sleep terrors or disorder of partial arousal was made. She was prescribed clonazepam 0.5mg and was urged to follow up with the behavior therapist. Six months later, her events were all well controlled by the behavioral therapy recommendations.
  • Case 29 - Sounds of choking at night
    pp 200-207
  • View abstract

    Summary

    This chapter discusses the case of a 38-year-oldwoman who had presented to the sleep center's outpatient clinic for evaluation of frequent sleepwalking episodes. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. A comprehensive evaluation including polysomnography (PSG), video-electroencephalography (EEG), psychological testing and necessary medical testing is important as it can have a major impact on the question of the patient's criminal responsibility. The EEG showed no epileptiform abnormalities interictally or during the events. The patient was referred for hypnotherapy and cognitive behavioral therapy (CBT) for her insomnia. Given these results, a diagnosis of sleepwalking, arousal disorder, was made. The daytime sleepiness was thought to be due to the intake of excess clonazepam. Medications (lithium, zolpidem, high doses of neuroleptic drugs and benzodiazepines) and recreational drugs may also induce sleepwalking.
  • Case 30 - Fighting in sleep
    pp 208-216
  • View abstract

    Summary

    This chapter presents the case study of a male adult sleepwalker with recurrence of sleepwalking events previously suffered in childhood. It describes the clinical history, examination, and the results of the procedures performed and the results obtained. He had a history of sleep-walking in childhood but stopped exhibiting events after the age of 14 years. The patient underwent polysomnography (PSG) because the episodes were frequent, violent and potentially dangerous to his wife. He had had 40 hours sleep deprivation previously. A diagnosis of sleepwalking (somnambulism) was made. Sleep deprivation and irregular hours were the main triggers of recurrence of sleepwalking in this patient. The PSG was also important to exclude the presence of concurrent sleep disorders such as sleep apnea and periodic limb movement disorder (PLMD), as both conditions can precipitate sleepwalking events by producing sleep instability secondary to arousals.
  • Case 32 - Violent tongue biting recurring during sleep
    pp 227-233
  • View abstract

    Summary

    This chapter discusses the case of a 43-year-old male having problems with his nocturnal sleep at the age of 23 when he started to present recurrent nocturnal awakenings from sleep associated with involuntary eating. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. Actigraphic recordings for 2 weeks disclosed persistent muscular activity during the nocturnal period and two to five episodes per night of further enhanced muscular activity that corresponded to the eating episodes noted by the patient in his diary. The sleep medicine specialist established a diagnosis of sleep-related eating disorder (SRED) based on the clinical history and on the results of the video-polysomnography (PSG) recording. Low-dosage dopaminergic agents such as levodopa/carbidopa at bedtime, sometimes combined with codeine and/or clonazepam, bromocriptine and pramipexole, have been shown to reduce the eating episodes.
  • Case 33 - A child with behavioral problems and violent sleep behavior leading to trauma
    pp 234-241
  • View abstract

    Summary

    Sleep-related eating disorder (SRED) is a parasomnia that arises primarily from NREM sleep with recurrent episodes of involuntary eating and drinking. This chapter discusses the case of a 32-year-old woman who presented with sleep-related eating episodes, who also had difficulty with sleep initiation insomnia, somnambulism, somniloquy and symptoms of restless legs syndrome (RLS) since she was 6 years old. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. Overnight diagnostic polysomnography (PSG) was performed. Based on the PSG results, a diagnosis of SRED was made. Complications include obesity, injuries, toxic ingestions and psychological distress with excessive weight gain. Treatment of the underlying sleep disorder, if present, is usually effective. Underlying mood disorder or alcohol or substance abuse should be addressed. Pharmacotherapy consists of administration of antidepressants (e.g. SSRIs), dopaminergic agonists or topiramate.
  • Case 34 - Clicking all night
    pp 242-247
  • View abstract

    Summary

    This chapter presents the clinical history, examination, diagnosis, and the results of the procedures performed on a 27-year-old woman patient who was referred for evaluation of eating while asleep. Her tongue was scalloped and her hard palate was high-arched and narrow. The nasal examination was within normal limits. Cardiovascular, pulmonary, extremity and neurological examinations were within normal limits. The patient underwent diagnostic polysomnography (PSG). The patient also underwent a positive airway titration study, which showed that a continuous positive airway pressure (CPAP) setting of 8cmH2O effectively eliminated the obstructive breathing events and snoring. A diagnosis of sleep-related eating disorder (SRED) and obstructive sleep apnea (OSA) was made. This patient suffers from SRED, which is characterized by recurrent episodes of eating after an arousal from night-time sleep with negative consequences. Preliminary data suggest that SRED is a relatively common disorder and occurs more frequently in those with daytime eating disorders.
  • Case 35 - Repetitive arm movements
    pp 248-254
  • View abstract

    Summary

    This chapter presents the case of a 24-year-old woman who presented with 5-year history of hallucinations during night, occurring three to four times a week. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The polysomnography (PSG) study has revealed sleep latency of 11 minutes and REM sleep latency of 99 minutes. Sleep efficiency was 81% with normal distribution of sleep stages. Her apnea-hypopnea index (AHI) was 3 per hour and periodic limb movement (PLM) index was 4 per hour. The patient is awake from stage N2 sleep at 2.05am without any obvious precipitating cause. She describes seeing a woman standing by her bed. The EEG showed an alpha rhythm commencing immediately on waking and persisting for several minutes, and a review of the EEG recorded over the rest of the night showed no potentially epileptogenic activity.
  • Case 36 - Restlessness and jerking upon recumbency when trying to fall asleep
    pp 255-261
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 24-year-old man who was admitted with the chief concern of abnormal breathing sounds during sleep for the past 5 years. Physical examination and vital signs were normal with a BMI of 28 kg/m2. His Epworth Sleepiness Scale score, for subjective assessment of excessive daytime somnolence, was 9. The patient entered sleep through NREM sleep stages, had recognizable NREM/ REM sleep alternations and physiological muscle atonia during REM sleep, with a total sleep time of 222 minutes. The groaning sounds lasted between 5 and 15 seconds and recurred in clusters, 16 minutes in net duration but spanning across 30 minutes. The overall clinical and polygraphic features in this patient were felt to be consistent with the diagnosis of catathrenia, a syndrome whose etiology remains unclear.
  • Case 37 - Jumping and yelling while asleep
    pp 262-265
  • View abstract

    Summary

    This chapter discusses the case of a 32-year-old married man presented with a chief complaint of fondling his wife during sleep. He was an alert, healthy-looking, white male in no distress. The oropharynx was clear, without redundant tissue, and he had a normal neck circumference. A psychiatric interview was unremarkable, apart from some dysphoria over the long-standing, involuntary sleep-sex with his wife. The PSG study documented clinically significant obstructive sleep apnea (OSA), but no other sleep disorder or abnormal polysomnography (PSG) finding. A diagnosis was made of OSA with confusional arousals and sexsomnia, together with sleep-talking. According to the man's history, the sexsomnia began in close association with the onset of snoring, and both progressed in tandem over time. Sexsomnia may be triggered by OSA through confusional arousals with abnormal sexual behaviors during sleep. Nasal continuous positive airway pressure (CPAP) therapy controls both OSA and the associated sexsomnia.
  • Case 39 - Snoring and leg cramps
    pp 275-280
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a man who presented with frequent episodes of sudden and unexplained arousals from nocturnal sleep. The sleep medicine specialist ordered a full-night video-polysomnography (PSG) recording including standard bipolar EEG, right and left electro-oculograms (EOGs), surface EMG of the mylohyoideus muscle, ECG, oro-nasal, thoracic and abdominal respirograms, and circulating oxyhemoglobin saturation. The specialist decided to withdraw clonazepam and advised the patient not to drive due to drowsiness until the results of the investigations became available and appropriate therapy was prescribed. The sleep medicine specialist established a diagnosis of nocturnal frontal lobe epilepsy (NFLE) based on historical features and video-PSG findings. Nocturnal frontal lobe epilepsy is a peculiar partial epilepsy whose clinical features comprise a spectrum of paroxysmal motor manifestations of variable duration and complexity, occurring mainly during sleep.
  • Case 40 - “So tired I take naps in the morning”
    pp 281-286
  • View abstract

    Summary

    This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 54-year-old man who reported that he had been having problems with his sleep for the previous 20 years. He said he had "bad dreams". A detailed neurological examination was completely normal. Cardiac and respiratory examinations were also normal. Overnight video-polysomnography (PSG) was planned. EEG showed occasional 1-second or so runs of moderate amplitude (2-5 Hz) slowing in either temporo-frontal region during early drowsiness. The episodes were thought to be frontal lobe seizures leading to a diagnosis of nocturnal frontal lobe epilepsy (NFLE). The diagnosis was NFLE with central sleep apnea (due to seizures). The differential diagnosis of these nocturnal events includes NREM-sleep-arousal parasomnias, REM-sleep behavior disorder (RBD) and psychogenic disorders. The video-PSG and the home study were very helpful in the diagnosis of this patient.
  • Appendix: - Epworth Sleepiness Scale
    pp 287-287
  • View abstract

    Summary

    This chapter discusses the case of an 8-year-old female who was admitted to a pediatric neurology clinic for evaluation of chronic sleep-related behaviors that were unresponsive to anticonvulsant treatment. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The combination of polysomnography (PSG) and clinical history led to a diagnosis of both somnambulism (sleepwalking) and seizure disorder. The possibility that her sleepwalking episodes were representative of partial complex seizures or prolonged postictal states cannot be ruled out given the relative limitations of the evaluation. The EEG concomitants of an active seizure have classically included generalized depression or slowing, rhythmic slow-wave or spike/polyspike and wave activity that can occur immediately prior to or during an event, and postictal slowing or depression frequently following a spell. Video recording and response to treatment aid in making a diagnosis of probability.

Page 2 of 2

References

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Book summary page views

Total views: 0 *
Loading metrics...

* Views captured on Cambridge Core between #date#. This data will be updated every 24 hours.

Usage data cannot currently be displayed.