ACOUSTIC SLEEP STARTS WITH SLEEP-ONSET INSOMNIA RELATED TO A BRAINSTEM LESION

Abstract

Sensory sleep starts are variants of the more common motor sleep starts (hypnic jerks).1 Though sensory sleep starts may lead to repeated awakenings resulting in sleep-onset insomnia, their course is usually benign and no cerebral lesion has yet been described as being pathogenetically involved. Here we report a case of acoustic sleep starts (“exploding head syndrome”) which contests this latter assertion because their onset coincided with the occurrence of a brainstem lesion. ### Case report. A 64-year-old woman reported on problems initiating sleep related to the impression of a cracking sound of average loudness. Up to 15 times during the first hours after going to bed this sound occurred shortly after losing full consciousness, followed by an experience of jerking in all four limbs and a brief sensation of fear leading to full wakefulness. The patient, who had been healthy until then, noticed her sleep problem for the first time 12 years ago, coinciding with the diagnosis of pulmonary and extrapulmonary sarcoidosis. Corticosteroids were instituted under which no further progression of sarcoidosis occurred, even when steroids were tapered. Over this period the patient’s sleep problem was waxing and waning in intensity. Treatment with doxepin, citalopram, trimipramine, and amitriptyline led to no improvement. Only bromazepam (6 mg/day, 8 weeks) instantly led to unhampered sleep. Successive MRI scans of the brain (figure, A and B) revealed an unchanging, nonenhancing, singular, symmetric T2-hyperintense pontomesencephalic lesion around the periaquaductal gray reaching into the tegmentum. Figure MRI …