Accepted Manuscript Rem Sleep Behavior Disorder Causing Subdural Hematoma Oscar Ramos-Campoy, Carles Gaig, Monica Villas, Alex Iranzo, Joan Santamaria PII: S1389-9457(16)30267-2 DOI: 10.1016/j.sleep.2016.09.025 Reference: SLEEP 3226 To appear in: Sleep Medicine Received Date: 7 June 2016 Revised Date: 2 September 2016 Accepted Date: 15 September 2016 Please cite this article as: Ramos-Campoy O, Gaig C, Villas M, Iranzo A, Santamaria J, Rem Sleep Behavior Disorder Causing Subdural Hematoma, Sleep Medicine (2016), doi: 10.1016/ j.sleep.2016.09.025. 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. ACCEPTED MANUSCRIPT REM SLEEP BEHAVIOR DISORDER CAUSING SUBDURAL HEMATOMA Oscar Ramos-Campoy a, Carles Gaig a, *, Monica Villas a, Alex Iranzo a, Joan Santamaria a RI PT Neurology Service and Multidisciplinary Sleep Unit, Hospital Clinic de Barcelona, IDIBAPS, CIBERNED. * Corresponding author: Carles Gaig Neurology Service and Multidisciplinary Sleep Unit. C/Villarroel 170, Barcelona, 08036 Spain. Phone: +34932275413 Fax: + 34932275783 TE D E-mail address: cgaig@clinic.ub.es M AN U Hospital Clinic de Barcelona. SC a AC C EP Keywords: REM sleep behavior disorder, nightmares, injury, subdural hematoma ACCEPTED MANUSCRIPT 1. Introduction An 80-year-old man with a two-year history of idiopathic REM sleep behavior disorder (RBD) presented to the emergency department because of progressive unsteady gait and mental slowness and right limb weakness during in the previous two weeks. Neurological examination showed right hemiparesis with Babinski sign, and Hhead CT scan demonstrated a left chronic subdural hematoma. RI PT One month before the patient had fallen out of the bed when he was sleeping, hitting his head against the nightstand while he dreamt he had to jump out of his car because it was going to fall off a cliff. As a consequence, the patient suffered a laceration to the left forehead that required several suture stitches. Due to mild daytime somnolence, the patient had abruptly stopped clonazepam (0.5 mg at bedtime) a week before he jumped out of the bed. Past medical history included arterial hypertension and SC depression treated with paroxetine. The patient did not take any anticoagulant or antiplatelet therapy. Idiopathic RBD had been diagnosed eight months before because of a two-year history of violent nightmares associated with sleep talking, punching and kicking. Video-polysomnography (three weeks M AN U after suppressing paroxetine) demonstrated excessive tonic and phasic muscle activity during REM sleep associated with body jerks, punching and vocalizations. Clonazepam 0.5 mg at bedtime reduced the intensity and frequency of nightmares and dream-enactment behaviors. The patientstopped abruptly clonazepam a few months later because of mild daytime somnolence, and few days later he jumped out of bed resulting in the subdural hematoma. After surgical removal of the subdural hematoma, mental slowness and gait instability and resolved but mild right hemiparesis improvedpersisted. Clonazepam was reinitiated and protective measures were placed in the bedroom. Additional sleep-related falls or 2. Image analysis TE D injuries did not occur after nine months of follow-up. EP Head CT scan on an axial sequence shows a large subdural hematoma on the left convexity causing a midline deviation of eight millimeters with compression of the lateral left ventricle (Figure A, arrows). The hematoma is hypodense, which reflects its chronic nature, with some hyperdense areas indicative AC C of acute bleeding. After subdural hematoma, pPillows and a bed rail were added in the patient’s bedroom to cover the nightstands and prevent further falls and injuries (Figure B and C). Eight months before the subdural hematoma and three weeks after suppressing paroxetine a diagnostic videopolysomnography was performed. A 30-second epoch during REM sleep (Figure D) showed abnormally increased tonic and superimposed phasic EMG activity in the mentalis as well as excessive phasic EMG activity in the upper and lower limbs, associated with body jerks, punching and vocalizatio ns; these elements are all characteristic of RBD. 3. Discussion ACCEPTED MANUSCRIPT The present case illustrates the potential danger of abrupt discontinuation of clonazepam, which may cause a rebound of RBD symptomatology and increase risk of injury. Patients with RBD are at risk for sleep-related injuries because of the vigorous and action-filled dream-enacting behaviors. Selfinflicted injuries Injuries occur in 38 to 59% of patients(particularly prior to treatment), and are usually consequences of hitting a wall or nightstand, or jumping out of bed [1, 2]. Mild bruises, lacerations, and RI PT sprains are the most frequent injuries seen in RBD, but extreme cases include dislocations, fractures, and rarely subdural hematomas [1-5]. Clonazepam and melatonin (which can be less sedating and worth to consider as a first option in elderly patients) are both effective to reduce the intensity and frequency of abnormal sleep behaviors and injuries. Abrupt discontinuation of clonazepam, as seen in our case, may allow reappearance of RBD symptomatology [1]. Safety measures in the bedroom, such SC as removing or protecting nightstands or other pieces of furniture with hard surfaces and sharp corners, installing bed rails, or placing a mattress, cushions or blankets on the floor or adjacent wall to the bed, M AN U are also effective measures for reducing the risk of injuries. Acknowledgements: We would like to thank both the patient and his family for providing the photos of the patient’s bedroom. Conflict of interest: None. References Fernández-Arcos A, Iranzo A, Serradell M, Gaig C, Santamaria J. The Clinical Phenotype of Idiopathic TE D 1. Rapid Eye Movement Sleep Behavior Disorder at Presentation: A Study in 203 Consecutive Patients. Sleep 2016;39:121-132. 2. McCarter SJ, St Louis EK, Boswell CL, et al. Factors associated with injury in REM sleep behavior disorder. Sleep Med 2014;5:1332-1338. Gross PT. REM sleep behavior disorder causing bilateral subdural hematomas. Sleep Res 1992; 21:204. 4. EP 3. Dyken ME, Lin-Dyken DC, Seaba P, Yamada T. Violent sleep-related behavior leading to subdural AC C hemorrhage. Arch Neurol 1995;52:318-321. 5. Olson EJ, Boeve BF, Silber MH. Rapid eye movement sleep behaviour disorder: demographic, clinical and laboratory findings in 93 cases. Brain 2000;123:331-339. Figure Legend: ACCEPTED MANUSCRIPT A Air THO ABD FDS L FDS R AT L AT R EP EOG L EOG R F3-A2 F4-A1 C3-A2 C4-A1 O1-A2 O2-A1 Chin EKG AC C D TE D M AN U SC C RI PT B 50 µV 1s