Sporadic Insulinoma Presenting as Early Morning Night Terrors.

A 16-year-old boy with a recent diagnosis of night terrors was evaluated for recurrent early morning hypoglycemia after an early morning seizure. Evaluation in clinic with critical laboratories identified hyperinsulinemic hypoglycemia. Additional investigation revealed a sporadic insulinoma as the etiology of his hypoglycemia and all symptoms were resolved after pancreaticoduodenectomy. The importance of obtaining critical laboratory samples is highlighted and appropriate radiologic, medical, and pathologic testing is discussed. We additionally review the medical and surgical management of hyperinsulinemic hypoglycemia. A discussion of multiple endocrine neoplasia type 1 associated insulinomas is included as well. This case highlights the importance of considering hypoglycemia in the evaluation of night terrors and new-onset seizures.

Fahr's Syndrome and Secondary Hypoparathyroidism.

A typical case of Fahr's syndrome is described in a 76-year-old Brazilian female who underwent a total thyroidectomy three decades ago. Six years before the current admission, she started with generalized tonic-clonic seizures. Associated disorders involved extra-pyramidal, cognitive, nocturnal terror and mood changes. With suspicion of hypocalcemia due to secondary hypoparathyroidism, laboratory determinations confirmed the diagnoses. Furthermore, imaging studies of the central nervous system detected multiple calcifications, with characteristic distribution of Fahr's syndrome. Clinical management was successful.

Relevância clínica de pesadelos em pacientes com transtorno depressivo / Clinical significance of nightmares in patients with depressive disorder

INTRODUÇÃO: Diversos estudos sugerem uma estreita relação entre pesadelos e o transtorno depressivo. O objetivo deste estudo foi detectar a prevalência de pesadelos em pacientes com transtorno depressivo e observar sua relação com idade, sexo, tempo de doença, gravidade do quadro depressivo e ideação suicida. MÉTODOS: Sessenta pacientes foram entrevistados e avaliados por meio da escala de depressão de Beck (EDB) e da escala de ideação suicida de Beck (EIS). Os pesadelos foram avaliados segundo os critérios da DSM-IV para transtorno de pesadelos. A análise dos dados foi realizada mediante a análise descritiva e o teste-t de Student, com nível de significância de 5 por cento. RESULTADOS: Nesta amostra, houve prevalência de 60 por cento de pesadelos nos pacientes, com predominância entre mulheres. Os pacientes deprimidos com pesadelos apresentaram significativamente (p < 0,05) maior tempo de doença depressiva, média de pontuações mais elevadas nas duas escalas e nos itens sobre sensação de fracasso, alterações de sono e ideação suicida da EDB. DISCUSSÃO: Na amostra de pacientes deprimidos estudada, a presença de pesadelos foi relacionada com a gravidade do quadro depressivo e a presença de ideação suicida clinicamente marcante. Assim, os pesadelos devem ser considerados na avaliação de pacientes com transtorno depressivo.

INTRODUCTION: Several studies have suggested a strong association between nightmares and depressive disorder. The aim of this study was to detect the prevalence of nightmares among patients with depressive disorders and to observe its relationship with age, sex, duration of disease, severity of depression and suicidal ideation. METHODS: Sixty patients were interviewed and assessed by means of the Beck Depression Inventory (BDI) and the Beck Scale for Suicidal Ideation (SSI). Nightmares were assessed according to the DSM-IV criteria for Nightmare Disorder. Data analyses were performed by Descriptive analyses and Students t-test with statistical significance at p<0.05. RESULTS: Prevalence of 60 percent of nightmares was encountered among patients, with predominance among women. Depressed patients with nightmares had significantly (p < 0.05) longer duration of depressive disease, higher mean scores in both scales and in the items related to failure, sleep disturbances and suicidal ideation of the BDI. DISCUSSION: In the study sample, nightmares were associated with the severity of depression and clinically significant suicidal ideation. Thus, nightmares should be considered in the evaluation of patients with depressive disorder.

Night terrors associated with thalamic lesion.

OBJECTIVE: To describe a case with night terrors (NT) symptomatic of a thalamic lesion. METHODS: Videopolysomnography and brain MRI were used to study a 48 year old woman with a recent onset of brief episodes, occurring exclusively during nocturnal sleep, where she suddenly sat up in bed, screamed and appeared to be very frightened. RESULTS: Videopolysomnography recorded an episode suggestive of NT. Sleep fragmentation with frequent brief arousals or microarousals was also evident mainly during slow wave sleep. The brain MRI showed increased T2 signal from the right thalamus suggestive of a low-grade tumor. CONCLUSIONS: Our case suggests that NT starting in adulthood can, rarely, be symptomatic of neurological disease, and warrant further investigation with MRI. SIGNIFICANCE: A thalamic dysfunction, disrupting at this level the arousal system, may play a role in provoking NT.

Sleepwalking and sleep terrors in prepubertal children: what triggers them?

OBJECTIVES: To evaluate the clinical presentation and polysomnography of prepubertal children with repetitive sleep terrors and sleepwalking, to compare them with a control group, and to evaluate the treatment of associated sleep disorders. METHODS: Patients with complaint of sleep terrors with or without sleepwalking were studied retrospectively. A control group was also recruited. Each subject received a standardized evaluation, which included the following: 1) Pediatric Sleep Questionnaire; 2) interview regarding child's medical and sociofamilial history, orthodontic history, schooling, psychological difficulties, medication intake, and family history of medical and sleep disorders; 3) general pediatric physical examination and neurologic, otolaryngological, and craniofacial examination by a specialist; 4) obtaining medical history on variables relevant to early life sleep disorders; 5) polysomnography, which included electroencephalogram (EEG; C3/A2, Fp1/T1, T1/O1, O1/C3, C4/A1, Fp2/T2, T2/O2, O2/C4), chin and leg electromyelogram, right and left electro-oculogram, and electrocardiogram (modified V2 lead); respiration was monitored with a nasal cannula/pressure transducer system, mouth thermistor, chest and abdominal bands, pulse oximeter, and neck microphone; respiratory effort was monitored with calibrated esophageal manometry; variables were collected on a computerized sleep system; and 6) available family members with a positive history of sleep terrors and sleepwalking received clinical evaluations similar to those used for index cases; they also underwent ambulatory monitoring with an Edentrace system, which monitors heart rate, body position, oro-nasal flow, chest impedance, breathing noises (neck microphone), and pulse oximetry. Movements are deduced from artifact, and leg movements may be recorded on one channel if the equipment is preset for such recording. Subjects used logs to record "lights out" time, "lights on" time, nocturnal awakenings, and other events that occurred during the night. All original and follow-up recordings were rescored by 2 of 4 randomly selected specialists who were blind to subject identity. Mann-Whitney U test was used for group comparison. Nonparametric chi2 test was used to compare percentages of symptoms in symptomatic children versus control children. RESULTS: Eighty-four children (5 with sleep terrors and 79 with both sleep terrors and sleepwalking) and 36 normal control children formed the studied population. All subjects were Tanner stage 1 (prepubertal). None of the control children had any parasomnias. Fifty-one (61%) of 84 children with parasomnia had a diagnosis of an additional sleep disorder: 49 with sleep-disordered breathing (SDB) and 2 with restless leg syndrome (RLS). Twenty-nine of the children with both parasomnia and SDB had a positive family history of parasomnias, and 24 of the 29 also had a positive family history of SDB. Of the 51 children with associated sleep disorders, 45 were treated. Forty-three of 49 children with SDB were treated with tonsillectomy, adenoidectomy, and/or turbinate revision, and 2 of 2 children with RLS were treated with Pramipexole, a dopamine agonist, at bedtime. Treatment of the precipitating sleep disorder eliminated parasomnias in all 45 children. In all 43 children who received surgery, polysomnography performed 3 to 4 months later indicated the disappearance of SDB. The recordings also showed an absence of confusional arousals. The number of EEG arousals significantly decreased from a mean of 9 +/- 2.6 EEG arousals > or =3 seconds/hour during total sleep time to 3 +/- 1.5. The number of EEG arousals > or =3 seconds during the first sleep cycle of slow wave sleep (stage 3-4 non-rapid eye movement sleep) decreased from 4 +/- 1.4 to 1 +/- 0.2. In all surgically treated cases, parents also reported subsequent absence of the parasomnia. The 2 symptomatic children who were treated with Pramipexole had a complete absence of confusional arousals on the follow-up recording and reported no parasomnia since treatment. The periodic limb movemia since treatment. The periodic limb movement syndrome arousal index (number of EEG arousals associated with periodic limb movement/hour) decreased from 11 and 16 to 0 and 0.2, respectively. Parasomnia persisted in the 6 children who were untreated for SDB. Surgeons had refused to perform surgery on these children because of lack of data on the relationship between parasomnia and SDB-related tonsil and adenoid enlargement. CONCLUSION: Children with chronic parasomnias may often also present SDB or, to a lesser extent, RLS. Furthermore, the disappearance of the parasomnias after the treatment of the SDB or RLS periodic limb movement syndrome suggests that the latter may trigger the former. The high frequency of SDB in family members of children with parasomnia provided additional evidence that SDB may manifest as parasomnias in children. Children with parasomnias are not systematically monitored during sleep, although past studies have suggested that patients with sleep terrors or sleepwalking have an elevated level of brief EEG arousals. When children receive polysomnographies, discrete patterns (eg, nasal flow limitation, abnormal respiratory effort, bursts of high theta or slow alpha EEG frequencies) should be sought; apneas are rarely found in children. Children's respiration during sleep should be monitored with nasal cannula/pressure transducer system and/or esophageal manometry, which are more sensitive than the thermistors or thermocouples currently used in many laboratories. The clear, prompt improvement of severe parasomnia in children who are treated for SDB, as defined here, provides important evidence that subtle SDB can have substantial health-related significance. Also noteworthy is the report of familial presence of parasomnia. Studies of twin cohorts and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias. RLS and SDB have been shown to have familial recurrence. RLS has been shown to have genetic involvement. It remains to be investigated whether a genetic factor directly influences sleep terror and sleepwalking or instead influences other disorders that fragment sleep and lead to confusional arousals. Additional studies are needed to investigate the association between SDB and non-;rapid eye movement parasomnias in the general population.

Pavor nocturnus of proven epileptic origin.

PURPOSE: To evaluate the suspected epileptic origin in children with episodes masquerading as sleep terrors. METHOD: One such child was investigated with scalp-derived long-term monitoring (LTM), inter and ictal single photon emission computed tomography (SPECT) scans, and an invasive LTM, followed by surgical subpial slicing of the focally discharging motor cortex. RESULTS: The scalp-derived LTM and the SPECT scans did not localize the suspected epileptogenic focus. The invasive LTM revealed the focal onset of the ictal discharge. After the surgery, the seizures have been 90% controlled. No deficits resulted from the surgery. CONCLUSIONS: Although most nocturnal terrors (NTs) are parasomnias, in a few children their frequent episodes that masquerade as NTs have an epileptic origin. There are several features to distinguish these from common NTs or from other frontal lobe epilepsies.