Recovery of Hypersomnia Concurrent With Recovery of an Injured Ascending Reticular Activating System in a Stroke Patient

Abstract

We report on a stroke patient who showed recovery of hypersomnia concurrent with the recovery of an injured ascending reticular activating system (ARAS), which was demonstrated by diffusion tensor tractography (DTT).A 70-year-old female patient underwent coiling of the left ruptured posterior communicating artery after subarachnoid hemorrhage and both extraventricular drainage for management of an intraventricular hemorrhage. At 2 months after onset, when she started rehabilitation, she exhibited intact consciousness, with the full score on the Glasgow Coma Scale: 15. However, she showed severe hypersomnia: she always fell asleep without external stimulation and the Epworth Sleepiness Scale (EPS) score was 24 (full score: 24, cut off for hypersomnia: 10). She underwent comprehensive rehabilitative therapy, including neurotropic drugs, physical therapy, and occupational therapy. Her hypersomnia has shown improvement as 14 (3 months after onset), 11 (4 months after onset), 7 (12 months after onset), and 6 (24 months after onset), respectively.On 2-month DTT, narrowing of both lower dorsal and ventral ARASs was observed on both sides: in particular, among 4 neural tracts of the lower ARAS, the right lower ventral ARAS was the narrowest. By contrast, on 24-month DTT, the 4 narrowed neural tracts of both lower dorsal and ventral ARASs were thickened compared with those of 2-month DTT.Recovery of hypersomnia with recovery of an injured lower ARAS on DTT was observed in a stroke patient. Our results suggest that evaluation of the lower ARAS using DTT might be useful for stroke patients with hypersomnia.

Aggravation of excessive daytime sleepiness concurrent with aggravation of an injured ascending reticular activating system in a patient with mild traumatic brain injury

“…Subsequently, a study demonstrated recovery from hypersomnia with recovery of injured dorsal and ventral (more recovery than the dorsal lower ARAS) lower ARAS in a patient with subarachnoid hemorrhage. [ 4 ] Recently, Jang et al reported on patients with hypersomnia and injury of the dorsal and ventral (more injury than the lower dorsal ARAS) lower ARAS in patients with pontine hemorrhage (1 patient) and mild TBI (2 patients), respectively. [ 5 , 6 ] These studies suggest that injury of the ARAS could be a probable cause for the hypersomnia in patients with brain injury particularly TBI.…”

Excessive Daytime Sleepiness and Injury of the Ascending Reticular Activating System Following Whiplash Injury

“…Many studies report an association between injury of the hypothalamus with sleep disorders, such as narcolepsy and hypersomnia, following TBI (Baumann et al, 2005 , 2009 ; Valko et al, 2015 ; Jang and Kwon, 2016 ; Jang et al, 2016b , c ; Jang and Lee, 2017 ). In addition, since the reconstruction of the ARAS using DTT is possible, many studies have demonstrated that the lower ventral ARAS, which is connected to the hypothalamus, is closely related with hypersomnia following brain injury (Jang and Kwon, 2016 , 2017 ; Jang et al, 2016a , b , 2017 , in press ). Therefore, the results of our study appear to be consistent with previous studies (Jang and Kwon, 2016 , 2017 ; Jang et al, 2016a , b , 2017 , in press ).…”

“…In addition, since the reconstruction of the ARAS using DTT is possible, many studies have demonstrated that the lower ventral ARAS, which is connected to the hypothalamus, is closely related with hypersomnia following brain injury (Jang and Kwon, 2016 , 2017 ; Jang et al, 2016a , b , 2017 , in press ). Therefore, the results of our study appear to be consistent with previous studies (Jang and Kwon, 2016 , 2017 ; Jang et al, 2016a , b , 2017 , in press ).…”

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

“…Subsequently, Jang et al [11] demonstrated injury of the lower ventral ARAS in a patient who showed hypersomnia and narcolepsy following mild traumatic brain injury. During the same year, Jang et al [12] reported on a patient who showed recovery of hypersomnia concurrent with the recovery of an injured lower dorsal and ventral ARAS following spontaneous subarachnoid hemorrhage. This patient also showed more severe injury and more recovery of the lower ventral ARAS than the lower dorsal ARAS.…”