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Hypersomnia after head–neck trauma

A medicolegal dilemma

From the Stanford University Sleep Disorders Center, CA.

Address correspondence and reprint requests to Dr. Christian Guilleminault, Stanford Sleep Disorders Center, 401 Quarry Road, Suite 330, Stanford, CA 94305.

OBJECTIVES: To evaluate the severity of daytime sleepiness in patients with a history of head trauma who complain of daytime somnolence, to investigate polygraphic abnormalities during nocturnal sleep, and to determine whether daytime sleepiness was the cause or consequence of the head trauma.

METHODS: The authors performed a systematic evaluation of 184 patients comprised of clinical interviews, sleep disorders questionnaires, sleepiness and depression scales, medical and neurologic evaluations, sleep logs with actigraphy, nocturnal polysomnography, and the Multiple Sleep Latency Test (MSLT). Assessments of sleepiness before the accident were based on bed partner interviews, coworker and employer reports, health reports, driving records, and employment history that included absenteeism.

RESULTS: Post-traumatic complaint of somnolence was associated with variable degrees of impaired daytime functioning in more than 98% of patients. Patients who were in a coma for 24 hours, who had a head fracture, or who had immediate neurosurgical interventions were likely to have scores > 16 points on the Epworth Sleepiness Scale (ESS) and 5 minutes on the MSLT. Pain at night was an important factor in nocturnal sleep disruption and daytime sleepiness. Sleep-disordered breathing was a common finding and was the only finding in whiplash patients with daytime sleepiness. Extensive evaluation of pretrauma behavior supported the conclusion that the onset of symptomatic sleep-disordered breathing was associated with the trauma. The patients who showed a "compulsive presleep behavior" were severely impaired in performing their daily activities.

CONCLUSIONS: A systematic approach is required when dealing with patients complaining of hypersomnia following a head–neck trauma.

Key words: Daytime somnolence—Legal problems—Head–neck trauma—Sleep-disordered breathing—Apathetic syndrome

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