1605 - ‘Follow your dreams’ taken too literally: A case report of TBI and multiple fractures from sleepwalking

Case Diagnosis: Traumatic Basilar Subarachnoid Hemorrhage (SAH)

Case Description: We present a 68-year-old male with a past medical history of alcohol abuse, Herpes virus, and somnambulism who presented to acute rehabilitation after multiple skull and facial fractures following a fall while sleepwalking. Imaging revealed basilar subarachnoid hemorrhage, and fractures of the orbital floor, zygomatic arch, and temporal bone. The patient was managed non-operatively and arrived at rehab with severe headaches, facial droop, hearing loss, poor sleep, and deficits in working memory and attention. The hospital course was complicated by concern for a CSF leak and two episodes of abnormal vocalizations while sleeping.

Discussions: While sleep is a concern after brain injury, this case report serves as a novel mechanism of injury from disordered sleep itself. The patient’s headache and sleep were managed with mirtazapine, magnesium oxide, and Tylenol after failing amitriptyline. Opioids were avoided given his prior alcohol abuse history. The patient subjectively reported that mirtazapine provided a deep, restful sleep. Cognitive deficits were targeted with methylphenidate, therapy, and a memory log, with notable improvement. Education and counseling on environmental strategies to avoid sleepwalking were discussed, such as night lights, locking doors, and stress management. The presence of hearing loss, further caused distress to the patient, as his career was within the music industry. His hearing did not improve despite a short steroid taper. The patient's multi-trauma presentation emphasizes the importance of a thorough initial assessment and continued counseling and monitoring of symptoms.

Conclusions: This case illustrates the importance of ongoing surveillance of symptoms in patients with traumatic brain injuries, especially those with multiple, complex fractures that can contribute to headaches and cognitive dysfunction. Our patient experienced almost complete improvement in facial nerve function and headache severity. He will follow a multidisciplinary plan for further outpatient recovery and incorporate environmental home controls to prevent future falls.