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Central Hypersomnolence: History is the Key

Reviewed By Sleep and Respiratory Neurobiology Assembly

Submitted by

Tirsa M. Ferrer Marrero, MD

Fellow

Section of Pulmonary, Critical Care, Sleep, and Allergy

University of Illinois at Chicago

Chicago, Illinois

Bharati Prasad, MD, MS

Assistant Professor

Section of Pulmonary, Critical Care, Sleep, and Allergy

University of Illinois at Chicago

Chicago, Illinois

Submit your comments to the author(s).

History

A 39 year old man presented with insidious onset of excessive daytime sleepiness; EDS over 10 years (Epworth Sleepiness Scale score 16) and sudden onset of “passing out spells” occurring several times daily for 5 years. One spell was witnessed by consulting neurologist, resulting in referral of the patient to our sleep center. The passing out was described as symmetrical weakness of his arms and legs, without loss of consciousness. He stated he had learnt to support himself against a wall or sit down to prevent falls. These episodes lasted a few minutes and no specific triggers were identified. These symptoms resulted in loss of employment 2 years prior to presentation. Other symptoms included habitual snoring, difficulty maintaining sleep at night, frequent hypnogogic and hypnopompic visual hallucinations, and sleep paralysis. Self-reported nightly sleep duration was approximately 7 hours with a regular sleep wake schedule (11 PM to 6 AM). No past medical history, medication use, drug use, shift work, or family history of sleep disorders were reported.  Alcohol use was described as social (3-6 drinks over the weekend).

Physical Exam

Body mass index (BMI) was 29, Mallampati was 3, and neck circumference was 15.5 inches. Neurological exam and previous neurological evaluation with EEG and MRI brain were normal. A baseline polysomnography followed by a 4-nap Multiple Sleep Latency Test (MSLT) the following day was performed (patient refused the fifth nap).

Image: Hypnogram of baseline polysomnography (PSG) 

PSG summary:

  • Sleep Efficiency: 36% (Total Sleep Time; TST of 182 minutes)
  • Sleep Latency: 27 minutes
  • REM Latency: 127 minutes
  • Apnea hypopnea index (AHI) of 10/hour, nadir oxygen saturation of 89%, and PLMS-index of 0/hour.
table

Question 1

Which of the following is not an appropriate next step? 

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