Hypersomnia due to injury of the ventral ascending reticular activating system following cerebellar herniation

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Abstract

Rationale:

We report on a patient with hypersomnia who showed injury of the lower ascending reticular activating system (ARAS) following cerebellar herniation due to a cerebellar infarct, detected on diffusion tensor tractography (DTT).

Patient concerns:

A 53-year-old male patient was diagnosed as a left cerebellar infarct, and underwent decompressive suboccipital craniectomy due to brain edema at 2 days after the onset of a cerebellar infarct. Three weeks after onset when the patient started rehabilitation, he showed hypersomnia without impairment of consciousness; he fell asleep most of daytime without external stimulation and showed an abnormal score on the Epworth Sleepiness Scale: 15 (full score: 24, cut off for hypersomnia: 10).

Diagnoses and Outcomes:

On 3-week DTT, narrowing of the upper portion of the lower ventral ARAS between the pontine reticular formation and the hypothalamus was observed on both sides. In addition, partial tearing was observed in the middle portion of the right lower ventral ARAS.

Lessons:

In conclusion, we found injury of the lower ventral ARAS in a patient with hypersomnia following cerebellar herniation due to a cerebellar infarct.

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Most cited references 13

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German version of the Epworth Sleepiness Scale.

O Schoch, K Bloch, Jinghui Zhang … (1998)

The Epworth Sleepiness Scale (ESS) is a questionnaire widely used in English speaking countries for assessment of subjective daytime sleepiness. Our purpose was to translate and validate the ESS for use in German-speaking countries. A German translation of the ESS was administered to 159 healthy German-speaking Swiss and to 174 patients with various sleep disorders. The mean +/- SD of ESS scores in normals was 5.7+/-3.0, in patients it was 13.0+/-5.1 (p<0.001). Scores were not correlated with age or gender but with the percentage of time spent at an oxygen saturation <90% (R = 0.35, p<0.001), and the respiratory disturbance index (R = 0.26, p<0.001) in primary snorers and sleep apnea patients. Item analysis confirmed internal consistency of the scale (Cronbach alpha = 0.60 in normals, and 0.83 in patients). Follow-up scores in 25 sleep apnea patients on treatment showed a reduction by 7+/-5 points (p<0.05). Our data validate the ESS for application in German-speaking populations. The simplicity, reliability and the apparent lack of relevant influences of language and cultural background on performance of the ESS makes it a valuable tool for clinical management and research.

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The ascending reticular activating system from pontine reticular formation to the hypothalamus in the human brain: a diffusion tensor imaging study.

Sung-Ho Jang, Hyeok Gyu Kwon (2015)

The ascending reticular activating system (ARAS) is responsible for regulation of consciousness. Precise evaluation of the ARAS is important for diagnosis and management of patients with impaired consciousness. In the current study, we attempted to reconstruct the portion of the ARAS from the pontine reticular formation (RF) to the hypothalamus in normal subjects, using diffusion tensor imaging (DTI). A total of 31 healthy subjects were recruited for this study. DTI scanning was performed using 1.5-T, and the ARAS from the pontine RF to the hypothalamus was reconstructed. Values of fractional anisotropy, mean diffusivity, and tract volume of the ARAS from the pontine RF to the hypothalamus were measured. In all subjects, the ARAS from the pontine RF to the hypothalamus originated from the RF at the level of the mid-pons, where the trigeminal nerve could be seen, ascended through the periaqueductal gray matter of the midbrain anterolaterally to the anterior commissure level, and then terminated into the hypothalamus. No significant differences in DTI parameters were observed between the left and right hemispheres and between males and females (p<0.05). We identified the ARAS between the pontine RF and the hypothalamus in normal subjects using DTI. We believe that the reconstruction methodology and the results of this study would be useful to clinicians involved in the care of patients with impaired consciousness and researchers in studies of the ARAS.

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Post-stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation.

Ari Harris, Jessica Elder, Nicholas D Schiff … (2014)

Apathy and hypersomnia occur after stroke and, by definition, reduce participation in rehabilitation, but their effect on outcome from acute rehabilitation is not known. We performed a retrospective review of 213 patients admitted to a stroke-specialized acute rehabilitation unit in the United States. All patients had ischemic or hemorrhagic stroke, and no dementia or dependence on others pre-stroke. We diagnosed apathy and hypersomnia using standardized documentation by treating therapists. We used multiple regression analysis to control for overall impairment (combination of strength, cognitive and sensory measures), age, time since stroke, and stroke type (ischemic or hemorrhagic). Forty-four (21%) of the patients had persistent apathy, and 12 (5.6%) had persistent hypersomnia. Both groups were more impaired in cognition, sustained attention, and more likely to be treated for depression. Patients with apathy were 2.4 times more likely to go to a nursing home, and had discharge FIM scores 12 points below the mean. Patients with hypersomnia were ten times more likely to go to a nursing home, and had discharge FIM scores 16 points below the mean. These findings indicate that studies to prospectively define these clinical factors and potential confounds using standardized tools are indicated, and if confirmed, justify studies to identify these patients early and develop targeted interventions.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date Collection: January 2017

Publication date (Electronic): 10 January 2017

Volume: 96

Issue: 1

Electronic Location Identifier: e5678

Affiliations

[a ]Department of Physical Medicine and Rehabilitation

[b ]Department of Neurosurgery, College of Medicine, Yeungnam University, Daegu, Republic of Korea.

Author notes

[∗ ]Correspondence: Hyeok Gyu Kwon, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, 317-1, Daemyungdong, Namku, Daegu 705-717, Republic of Korea (e-mail: khg0715@ 123456hanmail.net ).

Article

Publisher ID: MD-D-16-01988 Accession ID: 05678

DOI: 10.1097/MD.0000000000005678

PMC ID: 5228662

PubMed ID: 28072702

SO-VID: 3668733b-5ee3-488e-87dd-8483d6837087

License:

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

History

Date received : 23 March 2016

Date revision received : 31 October 2016

Date accepted : 25 November 2016

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Keywords: ascending reticular activating system,cerebellar herniation,diffusion tensor imaging,hypersomnia,stroke

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Keywords: ascending reticular activating system, cerebellar herniation, diffusion tensor imaging, hypersomnia, stroke

Hypersomnia due to injury of the ventral ascending reticular activating system following cerebellar herniation : A case report

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Abstract

Rationale:

Patient concerns:

Diagnoses and Outcomes:

Lessons:

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Network Medicine

Most cited references 13

German version of the Epworth Sleepiness Scale.

The ascending reticular activating system from pontine reticular formation to the hypothalamus in the human brain: a diffusion tensor imaging study.

Post-stroke apathy and hypersomnia lead to worse outcomes from acute rehabilitation.

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