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Clinical Corners in Sleep Medicine Insomnia and sleep-related movement disorder Akram Khan a , Kannan Ramar a, * , R. Robert Auger a , Clete A. Kushida b a Mayo Clinic Sleep Disorders Center, 200 1st Street SW, Rochester, MN 55906, USA b Stanford University Sleep Disorders Clinic and Research Center, Stanford, CA 94305, USA Received 17 May 2007; accepted 22 May 2007 Available online 2 August 2007 1. Introduction A 35-year-old male presented with difficulty sleep- ing for more than 25 years. He described lying in bed tossing and turning for 1–2 h before finally falling asleep, and frequently waking up not feeling refreshed in the morning. He further stated that as long as he could remember he had been shaking his left leg to rock himself to sleep or while sitting for a long per- iod of time. At night, he often had to wrap his left leg in multiple sheets to prevent it from moving. The shaking was relieved by walking and was not associated with any pain, tingling, cramping or creepy crawly sensation. The patient had a history of snoring, worse on his back, but denied being aware of any apneic episodes or arousals due to abnormal breathing events. His Epworth sleepiness scale (ESS) score was 8 out of a pos- sible 24 points, and he had no history suggestive of rapid eye movement (REM) sleep behavior disorder (RBD), cataplexy, narcolepsy, sleep paralysis, bruxism or som- nambulism. He was not taking any medications and did not have any medical problems. The patient had a body mass index (BMI) of 19.61 kg/m 2 . Physical examination was significant for mild retrognathia (normal cephalometric X-rays), and Grade 2 Mallampati airway with no tonsillar enlarge- ment. The rest of the examination was normal, and the basic laboratory work-up and ferritin levels were within normal limits. The patient underwent an overnight polysomnogram (PSG). The hypnogram (Fig. 1) and representative epochs from the PSG are presented (Figs. 2–5), along with a video representative of the movements (available online). The PSG showed a sleep efficiency of 82% with an apnea-hypopnea index of 1 event/hour. The patient’s periodic movement index was 12 events/hour, and the technologists noted repetitive, stereotyped, rhythmic motor activity of the left leg during drowsiness and non-REM and REM sleep. The frequency was 2.1 Hz as noted in Fig. 4. The patient was diagnosed and subsequently started on treatment. He reported subjective improvement in sleep, a decrease in leg movements and improvement in daytime alertness. 2. Discussion question What is the diagnosis and how should the patient be treated? Key Representative Epochs of the Study Presented LOC, ROC: Ocular channels, FZ-CZ, CZ-OZ & C4-A1: EEG channels, Chin & Leg EMG channels, ECG, Nasal P: Nasal Flow, Sono: Snoring, SpO 2 : Oxygen saturation, SUM: Summation of Chest & Abdominal Respira- tory Inductance Plethysmography (RIP) Bands, RC & Abd Chest & Abdomen RIP bands, HR: Heart Rate Black arrows marks the event. Open arrows mark rapid eye movements. 1389-9457/$ - see front matter Ó 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.sleep.2007.05.004 * Corresponding author. E-mail address: [email protected] (K. Ramar). www.elsevier.com/locate/sleep Sleep Medicine 9 (2008) 325–328
