Disclosures: Hannah Uhlig-Reche: No financial relationships or conflicts of interest

Case Description: This TBI resulted from a helmeted dirt bike accident in which the patient experienced a hypothalamic stroke and right-sided intraparenchymal hemorrhage requiring neurosurgical decompression. He began levetiracetam to prevent generalized convulsive seizures and underwent inpatient rehabilitation for 3 months. He has since followed regularly with outpatient PM&R for management of spasticity, left-sided hypertonia, and pseudobulbar affect. He also follows with a psychiatrist for behavioral issues and has been prescribed various pharmacotherapies. Five years post-TBI, the patient experienced weekly “wilting” episodes associated with a loss of tone and intact consciousness. Videography of an episode was captured on home surveillance footage and shared in his clinic visit.

Setting: Outpatient PM&R and Neurology Clinics.

Patient: Caucasian male who sustained a traumatic brain injury (TBI) at the age of 25. Assessment/

Results: The patient was referred to an epilepsy and sleep medicine neurologist. He was averaging 8 hours of sleep daily without excessive daytime fatigue. A diagnosis of symptomatic cataplexy was made. Behavioral etiology for these episodes was also a consideration. Levetiracetam was replaced by oxcarbazepine to help with mood stability. Electroencephalogram demonstrated rare interictal activity in the right hemisphere. He continued to have cataplexy attacks, some of which were preceded by crying. Venlafaxine was added, because of case reports demonstrating efficacy in primary cataplexy. The combination of oxcarbazepine and venlafaxine led to relative mood stability and resolution of cataplexy.

Discussion: The diagnosis of post-TBI cataplexy is uncommon and, in this case, is most likely due to the hypothalamic injury. SSRIs may occasionally worsen REM-wake transition symptoms like cataplexy. However, venlafaxine, an SNRI, led to resolution of secondary cataplexy.

Conclusion: Although brain injury patients may experience sleep disturbances, the emergence of secondary cataplexy is relatively rare and may be confused with other paroxysmal episodes. The successful management of post-TBI cataplexy should involve an interdisciplinary consideration to ensure medication optimization.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/post-traumatic-brain-injury-epilepsy-with-cataplexy-a-case-report/