Accepted Manuscript
Title: Cataplexy causing subdural hematomas
Author: Nuria Matos, Carles Gaig, Joan Santamaria, Alex Iranzo
PII:
DOI:
Reference:

S1389-9457(16)00064-2
http://dx.doi.org/doi: 10.1016/j.sleep.2016.01.018
SLEEP 3021

To appear in:

Sleep Medicine

Received date:
Revised date:
Accepted date:

12-11-2015
17-12-2015
15-1-2016

Please cite this article as: Nuria Matos, Carles Gaig, Joan Santamaria, Alex Iranzo, Cataplexy
causing subdural hematomas, Sleep Medicine (2016), http://dx.doi.org/doi:
10.1016/j.sleep.2016.01.018.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service
to our customers we are providing this early version of the manuscript. The manuscript will
undergo copyediting, typesetting, and review of the resulting proof before it is published in its
final form. Please note that during the production process errors may be discovered which could
affect the content, and all legal disclaimers that apply to the journal pertain.

Cataplexy causing subdural hematomas
Nuria Matos a, Carles Gaig a,*, Joan Santamaria a, Alex Iranzo a

a

Neurology Service and Multidisciplinary Sleep Unit, Hospital Clinic de Barcelona, IDIBAPS,

CIBERNED, Barcelona, Spain

Authors: is this part of
the affiliation? This journal requires
department, institution, city and country for
affiliations (which i added for you)

* Corresponding author: Neurology Service and Multidisciplinary Sleep Unit, Hospital Clinic de
Barcelona, C/Villarroel 170, Barcelona, 08036 Spain. Tel.: +34932275413; fax: + 34932275783.
E-mail address: cgaig@clinic.ub.es (C. Gaig)

Keywords:
Narcolepsy type 1
Cataplexy
Injury
Subdural hematoma

Page 1 of 3

Introduction
A 76-year-old man with narcolepsy type 1, with a 50-year history of excessive daytime sleepiness and
cataplexy, HLA DQB1*0602 positive, and undetectable CSF hypocretin-1 levels, complained of
progressive clumsiness of the left limbs, which was associated with a dull headache of 1-week duration.
The patient was treated with modafinil (100 mg per day) and clomipramine (25 mg per day) for 5 years.
His hypersomnia improved and the cataplectic attacks decreased with this medication, but they still
persisted with a frequency of one episode per week. He took neither anticoagulants nor antiaggregants.

An examination demonstrated hemiparesis with Babinski sign and hypoesthesia in his left limbs. A brain
MRI was performed, which showed bilateral subdural hematomas (Figure) – one recent and another more

Editor: no figure
provided to check the number and legend

chronic. The hemogram and coagulation tests were normal. The patient explained that 4 weeks earlier, he
had hit his head against a tree during a cataplectic attack while laughing, which left him with a moderate
headache and no other symptoms. Two weeks later, he had another attack, during which, after the
excitement of discovering and killing a spider that he had found in his living room, he suddenly fell down
and hit his head against the floor without losing consciousness. After surgical removal of both subdural
hematomas, the patient fully recovered.

Image analysis
A coronal T2-weighted MRI image showed two subdural hematomas, one in each cerebral convexity.
These subdural hematomas had a significant mass effect. They had different MRI intensities: the right
hematoma was hypointense on T2 (asterisk) and isointense on T1, suggesting a subacute evolution, and
was probably related to the first cataplectic attack in which the patient hit his head against a tree. The left
hematoma was hyperintense on T2 (arrow) and hypointense on T1, indicating a more recent onset, and
was likely caused by the latter episode of cataplexy triggered by the spider.

Page 2 of 3

Discussion
Loss of muscle tone in cataplexy can be abrupt and maximal from the beginning, leading to extremely
sudden and violent falls that can cause traumatic lesions. In one study, up to 14% of patients with
narcolepsy reported repeated injuries secondary to cataplexy [1]. Most of these injuries were mild, like
bruises and excoriations of the limbs. Twenty percent of the patients, however, experienced at least once
in a lifetime a more severe injury due to cataplexy, such as superficial wounds or head concussion [1].
The present case underscores the need to effectively treat cataplexy in order to prevent injuries.

Conflict of interest: None.

References
1.

Overeem S, van Nues SJ, van der Zande WL, et al. The clinical features of cataplexy: a questionnaire
study in narcolepsy patients with and without hypocretin-1 deficiency. Sleep Med 2011;12:12-8.

Authors: please list the
first six authors before using et al. Please
amend this.

Figure 1

Page 3 of 3