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Case Reports
. 2022 Mar 1;18(3):945-948.
doi: 10.5664/jcsm.9762.

REM sleep behavior disorder with predominant nightmares in a patient with ischemic pontine lesions

Francesco Biscarini  1 , Angelica Montini  1 , Elena Antelmi  2 , Stefano Vandi  1   3 , Fabio Pizza  1   3 , Giuseppe Plazzi  3   4
Affiliations
Case Reports

REM sleep behavior disorder with predominant nightmares in a patient with ischemic pontine lesions

Francesco Biscarini et al. J Clin Sleep Med. .

Abstract

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia typically associated with synucleinopathy and evolving to neurodegenerative disorders. RBD is caused by impairment of brainstem nuclei controlling REM sleep muscle atonia. Rarely, focal lesions of the brainstem can cause secondary RBD. We present the case of a 74-year-old patient, previously evaluated at age 70 years for insomnia and periodic limb movements during sleep, who then rapidly developed unpleasant dreams with minor motor behavior, affecting his sleep quality. Polysomnography recorded REM sleep without atonia and motor behaviors in REM sleep. Ischemic lesions in the pons were detected by magnetic resonance imaging. Clinical, biological, and instrumental biomarkers of neurodegeneration were repeatedly negative at 2 years' follow-up. Although rare, a lesional cause of RBD must be considered in cases of atypical presentation and without evidence of neurodegeneration. The complaint of unpleasant dreams suggests a possible role of brainstem nuclei controlling REM sleep atonia in affecting oneiric content.

Citation: Biscarini F, Montini A, Antelmi E, Vandi S, Pizza F, Plazzi G. REM sleep behavior disorder with predominant nightmares in a patient with ischemic pontine lesions. J Clin Sleep Med. 2022;18(3):945-948.

Keywords: REM sleep without atonia; lesional REM sleep behavior disorder; pons lesion.

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Conflict of interest statement

All authors have seen and approved this manuscript. Work for this study was performed at IRCCS Istituto delle Scienze Neurologiche di Bologna, Bellaria Hospital, Bologna, Italy. G.P. is a member of the Advisory Board for Jazz Pharmaceuticals, Takeda, Idorsia, and Bioprojet. F.P. received honoraria from Jazz Pharmaceuticals for speaking at a course. The other authors report no conflicts of interest.

Figures

Figure 1
Figure 1. Brain MRI.
T2-FLAIR sequences of brain MRI showing hyperintense lesions in medial rostral pontine tegmentum (white arrow in A, B, D) and in left rostral pontine tegmentum (black arrow in C). MRI = magnetic resonance imaging.
See this image and copyright information in PMC

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