Sleep disorders in anti-NMDAR encephalitis

Helena Ariño, Amaia Muñoz-Lopetegi, Eugenia Martinez-Hernandez, Thaís Armangue, Mireia Rosa-Justicia, Domingo Escudero, Nuria Matos, Francesc Graus, Gisela Sugranyes, Josefina Castro-Fornieles, Albert Compte, Josep Dalmau, Joan Santamaria
Neurology 2020 June 23

OBJECTIVE: To describe the sleep disorders in anti-NMDA receptor encephalitis (anti-NMDARe).

METHODS: Patients recovering from anti-NMDARe were invited to participate in a prospective observational single center study including comprehensive clinical, video-polysomnography (V-PSG) sleep assessment and neuropsychological evaluation. Age and sex-matched healthy participants served as controls.

RESULTS: Eighteen patients (89% female, median age 26 years, IQR 21-29) and 21 controls (81% female, median age 23 years, IQR 18-26) were included. In the acute stage, 16 (89%) patients reported insomnia and 2 hypersomnia; nightmares occurred in 7. After the acute stage, 14 (78%) had hypersomnia. At study-admission (median 183 days after disease onset, IQR 110-242) 8 patients still had hypersomnia, 1 insomnia, and 9 normal sleep duration. Patients had more daytime sleepiness than controls (higher Barcelona Sleepiness Index, p=0.02, and Epworth Sleepiness Score, p=0.04). On V-PSG, sleep efficiency was similar in both groups, but patients had more frequently multiple and longer confusional arousals in NREM sleep (videos provided). Additionally, 13 (72%) patients had cognitive deficits, 12 (67%) psychological, social, or occupational disability, and 33% depression or mania. Compared with controls, patients had a higher body mass index (median, IQR: 23.5, 22.3-30.2 vs. 20.5, 19.1-21.1; p=0.007). Between disease onset and last follow-up, 14 (78%) patients developed hyperphagia, and 6 (33%) hypersexuality (2 requiring hospitalization), all associated with sleep dysfunction.

CONCLUSIONS: Sleep disturbances are frequent in anti-NMDARe. They show a temporal pattern (predominantly insomnia at onset; hypersomnia during recovery), associate with behavioral and cognitive changes, and can occur with confusional arousals during NREM sleep.

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