Persistent pre-sleep behaviour and paroxysmal sweating with a stab lodged in the head

Abstract

Behavioural, autonomic and sleep disorders may follow traumatic brain injury [1–4]. We report a patient in whom a stab lodged into the brain was associated to chronic headache, excessive daytime sleepiness and recurrent episodes of asymmetric excessive sweating and piloerection. A 26-year-old man received a stab in the forehead during an assault about which he was amnesic. Admitted to an emergency wait, he was however discharged with the stab still lodged in his head. One year later he come to our attention complaining of daily headache, tiredness and constant desire to sleep. According to his wife, his initiative was decreased and he often yawned, stretched and assumed a sleeping posture. However, when given active tasks, he was able to perform them correctly. In addition he had become quiet, ‘‘easy-going’’, kind and overtly religious. Finally, he complained of paroxysmal excessive sweating triggered by exposure to hot temperatures, and rarely by apprehension, when he broke out in profuse sweating and piloerection limited to the left side of the body. Hot-induced excessive sweating was preceded by a feeling of ‘‘inner heat’’, and was a source of considerable fatigue and embarrassment. General examination revealed a linear scar in the left forehead. Body temperature was 36.6 C, heart rate 65 beats/ min and regular, respiratory rate 14 breaths/min, and blood pressure 125/75 mm Hg. Epworth Sleepiness Scale score, for measuring subjective daytime sleepiness, was 12 (n.v. B 10) [5]. Skull X-ray showed a metal stab which from the left frontal region projected just right of the midline into the suprasellar region (Fig. 1a). Marked beam hardening artefacts due to the metal blade hindered brain evaluation with cranial CT. Digital subtraction arteriography revealed that the tip of the stab was located just in front of the distal portion of the A1 segment of the anterior right cerebral artery beside the anterior communicating artery (Fig. 1b). This suggested that the distal portion of the blade had crossed the left diencephalon and reached the right hypothalamus. Neuropsychological evaluation [Wechsler Adult Intelligence Scale III score: 89 (lower limits); Wisconsin Card Sorting Test score: 94 mistakes on 128 (no category was completed); Rey’s 15 Words Immediate Recall Test score: 49/75 (corrected: 44.55/75); Rey’s Words Delayed Recall Test score: 4/15 (corrected: 2.25/15); Rey’s Complex Figure Copy Test score: 36/36 (corrected: 37.03); Rey’s Complex Figure Reproduction Test score: 14/36 (corrected: 11.97/36)] revealed impairment of long-memory and executive functions. Nocturnal sleep was unremarkable, but upon multiple sleep latency test (MSLT) he fell asleep during each session, with a mean sleep latency of 8min 30sec and without sleep onset REM periods. However, between every MSLT session, the patient constantly held a pre-sleep behaviour, all the time lying in bed or sitting on a chair, repetitively yawning and often with closed eyes. However, he could promptly resume full-wake behaviour upon stimulations. Assessment of body core temperature M. Fabbri R. Vetrugno (&) P. Montagna Department of Neurological Sciences, University of Bologna, Via Ugo Foscolo 7, 40123 Bologna, Italy e-mail: roberto.vetrugno@unibo.it