Disclosures: Salman Aljilani, DO: No financial relationships or conflicts of interest
Case Description: Despite being functionally independent and cognitively intact prior, during hospitalization, patient remained hyper-somnolent and unarousable during waking hours, with intermittent periods of participation (lasting 10-20 minutes). Night time behavior was characterized by consistent periods of wakefulness and participation, with episodes of agitation, requiring Olanzapine. Physical Medicine and Rehabilitation was consulted for recommendations on agitation and cognition/ arousal.
Setting: Tertiary Care Hospital
Patient: 81 year old male with history of Dilated Cardiomyopathy, AVR, complete heart block s/p AICD placement, Atrial Fibrillation, and Subarachnoid Hemorrhage two years prior presents with acute onset of altered mental status and somnolence. Assessment/
Results: Exam during waking hours was significant for impaired extra-ocular movements with only lateral abduction preserved, unreactive pupils, ptosis, dysarthria, and diffuse hyperreflexia. Cognitively on exam patient was somnolent and unarousable. Per Neurology, exam was concerning for a stroke with brainstem pathology, but findings unable to be confirmed by CT head, and patient was unable to undergo an MRI brain due to AICD placement. Lumbar Puncture and CT chest unremarkable. Patient’s sequelae of symptoms were likely thought to be due to “Top of the Basilar Syndrome”, causing an inversion of the patient’s sleep wake cycle.
Discussion: Although uncommon, basilar artery occlusion comprises 27% of posterior circulation strokes. Top of the Basilar Syndrome can result in impairments in the thalamus and brainstem which could consequently impair the reticular activating system. As a result, the sleep-wake cycle is altered which prevents consistent participation from patients throughout the day.
Conclusion: Arousal and cognition cannot be treated the same in these patients as in other strokes due to the changes in sleep-wake cycle. Modifications must be made to regimens for sleep and arousal congruently to promote participation as this is a barrier to acute inpatient rehabilitation.
Level of Evidence: Level V
To cite this abstract in AMA style:
Aljilani S, Appavu AJ, Kasi R, Bhagavat B, Fred E, Aljilani S. Abnormal Sleep Wake Cycle Management in Top of the Basilar Syndrome: Case Report [abstract]. PM R. 2020; 12(S1)(suppl 1). https://pmrjabstracts.org/abstract/abnormal-sleep-wake-cycle-management-in-top-of-the-basilar-syndrome-case-report/. Accessed May 16, 2025.« Back to AAPM&R Annual Assembly 2020
PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/abnormal-sleep-wake-cycle-management-in-top-of-the-basilar-syndrome-case-report/