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

2/15/2019 History of Present Illness  54 year-old female executive presented with head injury: pulled close SUV Recent Advances in trunk door and it hit her head  Immediately after developed headache, nausea, dizziness, memory changes, Neurology: Challenging Cases blurred vision, no loss of consciousness  For the first 2-3 months after head injury had trouble falling asleep and Liza Ashbrook, MD staying asleep which then evolved into fatigue Assistant Clinical Professor  Four months after head injury she had three concerning episodes UCSF Department of Neurology February 15, 2019 HPI: Concerning episodes Part Medical History  When stopped in a car dropping her daughter off at camp, driver behind  Gastric ulcer her started to honk and she awoke and realized she had lost time. She was  Seasonal allergies able to keep her foot on the brake. Denies feeling of sleepiness prior to the  Irritable bowel syndrome 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  MVA age 9 with LOC and concussion  Driving around a corner alone and felt a car drive by the other direction but  No history of previous seizures reports she was not fully aware of this, denies feeling sleepy prior but felt  No history of CNS infection sleepy afterwards 1

2/15/2019 Additional history Physical Exam  General: not manifestly sleepy. Medications at time of concussion  Normal HEENT exam with Mallampati 2, no turbinate hypertrophy,  Ibuprofen prn micrognathia, retrognathia, or high arched palate Medications started during treatment of concussion  Neuro  Melatonin 1mg prn • MS: Alert, oriented, memory intact to details of the history aside from the moment of the events  Nortriptyline 10mg above • CN: intact, no nystagmus  Rizatriptan prn • Motor: intact rapid tapping, no pronator drift FH: No FH of seizure or sleep disorders. Father snores • Sensory: intact to light touch, negative Romberg SH: Mother of 3, twin 14 yo and 12 yo. Works full time as an executive in banking. No • Coordination: No dysmetria smoking, heavy alcohol use • Gait: normal casual gait, can tandem Evaluation Question 1: Which sleep disorder is NOT noted to occur more commonly after TBI than in the general population?  Patient was referred to epilepsy clinic and an outpatient EEG was performed and normal A. Insomnia 63%  Then referred for sleep evaluation in which she reported B. Hypersomnia • Bedtime: 11 C. Advanced sleep-wake phase disorder • Wake time: 6:30-8am D. Narcolepsy • Sleep latency: 20-60 minutes E. Central sleep apnea 17% 15% • Awakenings after sleep onset: 0-1 3% 3% • Naps: 1-3 times per week (recommended by psychologist), they are refreshing • Epworth sleepiness scale: 7 (>10 ‘pathologic’) a a y a i n i . s e n . . p m m e n • She does snore, no witnessed breathing pauses and no report of leg kicking e p o s l o a o a s s h c n r p e p r e I p a e N e y k l H s a w a l • No hypnogogic or hypnopompic hallucinations, sleep paralysis, cataplexy - r p t n e e e l C s d e c n a :01 v d A 2

2/15/2019 PSG with MSLT was performed Question 2: What are the MSLT criteria for narcolepsy? KEY: MSL=Mean sleep latency; SOREMP=sleep onset REM period 44%  MSLT: mean sleep latency test A. MSL<15 minutes, 5/5 SOREMP 29% • Following an all night polysomnogram, patient undergoes a series of 5 B. MSL <8 minutes, 2+/5 SOREMP naps at two hour intervals 15% C. MSL <5 minutes, 5/5 SOREMP • There is a 20 minute opportunity to sleep D. MSL <8 minutes, 0/5 SOREMP 6% 6% • Once asleep, the patient’s sleep is observed for 15 minutes to assess for E. MSL <15 minutes, 2+/5 SOREMP the presence of REM P P P P M M M M . E E E E . R R R R O . O O O O S S S S S 5 5 5 5 5 / / / / / + + 2 5 5 0 2 , s , , , s e , s s e s e e t e t t t u t u u u n u n n n i n i i m i m i m m m 5 5 8 5 1 8 < < 1 < < < L L :01 L L L S S S S M M S M M M PSG results MSLT 3

2/15/2019 Epidemiology of sleep disorders in traumatic brain injury MSLT Results 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 Natural history • By one year post injury  Mild TBI • 65% report some sleep disruption initially ( N=346, Theadom et al Sleep Medicine, 2015) ‒ 41% still have some sleep difficulties • Excessive daytime sleepiness increased from the two weeks to one month post-injury ‒ 20% have insomnia symptoms at a clinically significant level (PSQI>8) • Less than 10% reported pre-injury sleep trouble ‒ 20% have excessive daytime sleepiness (ESS>10) • Improvement up to six months • After six months many sleep issues remain stable or worsen ‒ Within mild TBI, severity of injury did not predict sleep disturbance • 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 4

2/15/2019 Question 3: Sleep trouble immediately after concussion Risk factors for sleep trouble at one year predicts trouble with what at one year? • Pre-injury sleep difficulty A. Prolonged concussion recovery 93% • Sleep difficulty within first two weeks after injury B. Anxiety • Cognitive difficult within first two weeks after injury C. Depression • Increased age (in some studies) D. Worsened post-concussive symptoms • Female gender (in some studies) E. All of the above 5% 1% 0% 1% n y e y t o . r e . . v e i s i e o x s b v n v o e i a c A r s p s e e u h r e D c t n n o o f o s i c - l l s t A u s c o n p o c d e d n e e g s n r o o :01 W l o r P Sleep disruption predicts worse recovery Mechanisms of sleep change in TBI  Sleep trouble within first two weeks predicts at twelve months Hypocretin (orexin): • Post concussive symptoms • Anxiety  Hypocretin is low in >90% of TBI patients admitted to the hospital but returns to normal in all but 19% • Depression at six months • Decreased social integration  Mouse models show low hypocretin in mild TBI as well • Productivity Melatonin  These factors do not predict sleep quality at one year  Total melatonin levels are decreased in TBI  Among patients with mTBI who presented to the ED, those with sleep complaints were  Most studies show normal timing of dim light melatonin onset (DLMO), arguing against TBI causing a • nearly five times more likely to have depression at six weeks phase delay • three times more likely to have headache Other  Premorbid sleep disruption contributes to prolonged recovery  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 Bramley et al, Clinical pediatrics 2017; Chaput et al, Sleep Medicine, 2009 5

2/15/2019 Treatment: Insomnia Treatment: Circadian disruption  Treatment is similar to insomnia in the general population including:  One of three with insomnia have a circadian rhythm disorder • Cognitive behavioral therapy for insomnia • Delayed sleep-wake phase disorder or irregular sleep-wake phase disorder are the most common circadian disorders in the post concussive period • Melatonin and melatonin agonists  Likely blunting of circadian rhythm from injury and/or from change in • Antidepressants including trazodone, doxepin external circadian cues and unmasking of underlying chronotype rather • Hypnotics: zolpidem, eszopiclone, zaleplon, suvorexant 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 Our patient Look for underlying causes: • Insufficient sleep • Sedating medications  Narcolepsy criteria • Obstructive sleep apnea • Daily periods of irrepressible need to sleep or daytime lapses into sleep for at least • Restless leg syndrome/periodic leg movement disorder three months • Depression  Adequate sleep opportunity at night • MSLT with MSL<8 min and 2+ SOREMPs  Timed naps  The patient does not meet the daily sleepiness criteria  Morning bright light : sunlight, lightbox 10,000 Lux full spectrum, blue light  Differential diagnosis for positive MSLT: • 45 min/morning, short wavelength blue light therapy (λmax = 465 nm, 39.5 lux) superior to yellow light therapy • 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  Wake promoting medication sleep deprivation • Modafinil 100-200mg BID improves excessive daytime sleepiness but not fatigue • Antidepressant withdrawal : she was actually on nortriptyline 20mg at the time of the study, reports sometimes missing doses • Armodafinil 150-250mg  Treatment: modafinil 100-200mg  Stimulants : methylphenidate, dextroamphetamine/amphetamine 6