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Neurovascular disease

Lucid dreams, an atypical sleep disturbance in

anterior and mediodorsal thalamic strokes
Les reves lucides, un trouble du sommeil atypique dans les
infarctus thalamiques anterieur et medio-dorsal
S. Sagnier a,b, P. Coulon c, C. Chaufton b,c, M. Poli a, S. Debruxelles a,
P. Renou a, F. Rouanet a, S. Olindo a, I. Sibon a,b,*
a
Unite neurovasculaire, CHU de Bordeaux, 146, rue Leo-Saignat, 33076 Bordeaux, France
b
Unite neurovasculaire, pole de neurosciences cliniques, hopital Pellegrin, universite Bordeaux-Segalen,
CHU de Bordeaux, 146, rue Leo-Saignat, 33076 Bordeaux, France
c
Service dexplorations fonctionnelles du systeme nerveux, clinique du sommeil, CHU de Bordeaux, 146,
rue Leo-Saignat, 33076 Bordeaux, France

info article abstract

Article history: Background. Cognitive, affective, and behavioural disturbances are commonly reported
Received 21 December 2014 following thalamic strokes. Conversely, sleep disorders are rarely reported in this context.
Received in revised form Observations. Herein, we report the cases of two young patients admitted for an ischemic
26 July 2015 stroke located in the territories of the left pre-mammillary and paramedian arteries.
Accepted 10 August 2015 Together with aphasia, memory complaint, impaired attention and executive functions,
Available online xxx they reported lucid dreams with catastrophic content or conflicting situations.
Conclusion. Lucid dreams are an atypical presentation in thalamic strokes. These cases
Keywords: enlarge the clinical spectrum of sleep-wake disturbances potentially observed after an acute
Thalamic stroke cerebrovascular event.
Sleep-wake disturbances # 2015 Elsevier Masson SAS. All rights reserved.
Lucid dreams
Cortico-thalamo-limbic network
r e s u m e
Mots cles :
Introduction. Les troubles cognitifs, affectifs et du comportement sont bien connus apres
Infarctus thalamique
un infarctus thalamique. Au contraire, les troubles du sommeil sont plus rarement rap-
Troubles du cycle veillesommeil
portes dans ce contexte.
Reves lucides
Observations. Nous rapportons les cas de deux jeunes patients ayant presente des infarc-
Reseau cortico-thalamo-limbique
tus dans les territoires des arteres pre-mamillaire et paramediane gauches. En plus des
troubles phasiques, mnesiques, de lattention et des fonctions executives, des reves lucides
ayant un contenu catastrophique ou de situations conflictuelles etaient rapportes.

Cet article est publie en partenariat avec Orphanet et disponible sur le site www.orpha.net. # 2007 Orphanet. Publie par Elsevier
Masson SAS. Tous droits reserves.
* Corresponding author.
E-mail address: [email protected] (I. Sibon).
http://dx.doi.org/10.1016/j.neurol.2015.08.005
0035-3787/# 2015 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Sagnier S, et al. Lucid dreams, an atypical sleep disturbance in anterior and mediodorsal thalamic strokes.
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Conclusion. Les reves lucides sont une presentation atypique dans les infarctus thalami-
ques. Ces observations elargissent le spectre clinique des troubles du cycle veillesommeil
pouvant etre observes apres un evenement cerebro-vasculaire a la phase aigue.
# 2015 Elsevier Masson SAS. Tous droits reserves.

history of smoking, depression, asthma, spontaneous pneu-

1. Introduction mothorax, and her sole medication was a contraceptive pill.
She was right-handed and did not have any history of sleep
Cognitive and behaviour impairment, together with sensitive disturbance. The National Institute Health Stroke Scale
and motor deficits, are commonly observed following thala- (NIHSS) was 1 based on persistent gait ataxia. Brain Magnetic
mic strokes [13]. Cognitive, memory, arousal and mood Resonance Imaging (MRI) showed on diffusion weighted
disorders are mostly observed following stroke involving the imaging (DWI) sequences a recent ischemic stroke located
anterior and the mediodorsal nuclei, that are respectively in the left anterior and mediodorsal thalamus, an area
supplied by the pre-mamillary and paramedian arteries [1,4]. supplied by the pre-mamillary artery (Fig. 1). Computed
Despite the strong involvement of the thalamus in the arousal tomography angiography of cervical and intracranial arteries
pathways, sleep disorders have been rarely reported after was normal. Electrocardiogram (ECG) and 24 hours ECG-Holter
thalamic infarcts, but most frequently after bilateral para- were normal. Transthoracic and transesophageal echocardio-
median lesions [2,5]. The main clinical presentations were graphy (TTE/TEE) showed a patent foramen oval with a
hypersomnia, increased daytime sleep and drowsiness, significant right-to-left shunt, suggesting a possible cardioem-
nocturnal awakenings [2,57], and in some patients reported bolic stroke. Biological serum evaluations were normal: there
by Bassetti et al. [6], unusually frequent nightmares, post- were no inflammatory syndrome, no antiphospholipid anti-
arousal confusion, and daytime oneiric states. To our bodies or coagulation factor deficiency. Urine screen for drug
knowledge, lucid dreams, defined by dreams in which the abuse was negative. A treatment by antiplatelet was started.
subject is aware that he is dreaming, have never been reported One of her main complaint was sleep disorders with lucid
in the context of unilateral thalamic stroke. Herein, we report dream sensations, increased nightmares and nocturnal
two cases and discuss the potential pathophysiological awakenings. Her lucid dreams occurred in the morning hours,
mechanisms of this unusual presentation [3,4]. she could control them and she distinguished them from
nightmares. They were about people she saw during her
hospitalisation such as the nursing and medical staff, or about
2. Observations situations she experienced during the daytime, but always in a
catastrophic way. For example, she dreamt that medical staff
2.1. Patient 1 was aggressive towards patients, or that the hospital
helicopter took off and crashed next to her bedroom window.
A 26-year-old woman was admitted to our stroke unit for Besides, it should be noted that the day before her stroke, she
headache, mild gait ataxia, and binocular diplopia. She had a witnessed a fight implicating her friend. A post-traumatic

Fig. 1 Left anterior and mediodorsal thalamic stroke in the pre-mamillary artery territory on DWI (A) and T1 weighed
imaging (B) sequences.

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stress disorder linked to stroke was ruled out as she did not bank manager. He had no significant medical history, no
have DSM-IV symptoms of trauma reliving, avoidance reac- history of sleep disturbances, did not take any medication and
tion to stimuli associated to trauma, or persistent neurove- was right-handed. Brain MRI showed an isolated left medio-
getative symptoms. No sleep recording was performed during dorsal thalamic stroke in the paramedian artery territory
the acute phase but we observed that she slept about 12 hours (Fig. 2). The etiologic investigation, including cervical arteries
a day, going to bed towards midnight and getting up towards and polygon of Willis evaluation, ECG, 24 hours ECG-Holter,
midday. She did not have daytime sleepiness, parasomnia, TTE, TEE, urine screen and CSF examination were normal.
motor or respiratory sleep disorders. Biological serum evaluations were also normal with neither
The neuropsychological evaluation performed four days inflammatory syndrome nor thrombophilia. A stroke of
after stroke identified global intellectual impairment (MOCA undetermined origin was diagnosed and a treatment by
was 12 with 5 points lost on memory, deterioration of antiplatelet was started.
visuospatial and executive functions, language, attention, Apart from his persisting right side sensory loss, he
abstraction, delayed recall, and orientation). Isaacs Set Test complained about a nonrestorative sleep, with lucid dreams
and Number Spans evaluations showed reduction of sponta- and nocturnal awakenings, without increase of nightmares.
neous speech, naming problems, and difficulties in categorical His lucid dreams occurred mainly in the morning hours, he
word access. Grober and Buschke and Rey Figure Recall was able to control them and to wake up spontaneously. The
showed alteration of encoding as well as anterograde, content of his dreams was always difficult situations requiring
episodic, historic, semantic and visual memory. Zazzos choices and strategic decision making, similar to situations he
Blocking test, Weschlers Codes, Trail Making and Stroop had to face in his job. We observed that he went to bed towards
tests respectively demonstrated attention disturbances, low 23 hours and he woke up towards 6 hours. He did not have
processing speed, impairment of mental flexibility and parasomnia, motor nor respiratory sleep disorders. The
executive functions. The Hospital Anxiety and Depression neuropsychological evaluation performed one day after stroke
(HAD) scale revealed a severe anxiety syndrome (anxiety identified memory, attention and language disturbances, and
subscore: 15 and depression subscore: 4) but she did not take reduced spontaneous speech and processing speed. The HAD
any antidepressant medication nor anxiolytics. scale revealed a moderate anxiety syndrome (anxiety sub-
Three months later, her sleep improved with fewer score: 9 and depression subscore: 1) but he did not wish to start
nightmares and nocturnal awakenings, and no more lucid a treatment. Three months later, he had no more lucid
dreams. The polysomnography was normal, with a sleep dreams; the quality of his sleep improved and he felt less tired.
efficiency at 95.6% whereas she was not in sleep deprivation, a His neuropsychological evaluation improved, allowing him to
Micro-awakenings Index at 11.8 per hour, and no desaturation. get back to work, despite memory and attention complaints.
Her cognitive performances improved (MOCA 23/30) but there
were still language, delayed recall and orientation alterations.
3. Discussion
2.2. Patient 2
Post-stroke sleep-wake disorders are well known entities,
A 36-year-old man was admitted to our stroke unit for although often neglected [8]. They have a large range of clinical
headache with sudden right sensorimotor loss and facial expressions from insomnia, disturbances of wakefulness,
paralysis, which improved partially, making the NIHSS to 1 sleep-related movement disorders and Rapid Eye Movement
due to a persisting sensory loss. This neurological deficit (REM) sleep behaviour disorder [8]. Few associations were
appeared at his workplace while he was starting his job of reported between stroke location and post-stroke sleep

Fig. 2 Left mediodorsal thalamic stroke in the paramedian artery territory on DWI (A) and T1 weighed imaging sequences (B).

Please cite this article in press as: Sagnier S, et al. Lucid dreams, an atypical sleep disturbance in anterior and mediodorsal thalamic strokes.
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disorders. Some data suggest a potential association between observations are insufficient to support this hypothesis. In
REM sleep behaviour disorder and small brainstem infarcts [9], the review of De Witte et al. [2], 7 of the 75 patients with
while disturbances of wakefulness such as hypersomnia and affective-behavioural alterations had sleep disorders and all
alternated irregular episodes of sleep and wakefulness during had bithalamic lesions. The authors confirmed a lateralisation
day and night are typical features of paramedian thalamic of neurolinguistic processes at the thalamic level, but latera-
stroke [6,10,11]. These manifestations could be related to the lisation of neurocognitive processes was more uncertain.
lesion of the reticular and intralaminar thalamic nuclei
located in the anterior and mediodorsal thalamus which are
part of the arousal system and are strongly involved in the 4. Conclusion
sleep circadian rhythm control through their connexions to
the reticular nucleus, the hypothalamus, the striatum, and Lucid dreams represent an unusual and possibly underdia-
cortico-limbic structures [3,7,10,12,13]. gnosed disorder following thalamic stroke. Its description
The thalamus has a crucial role in Non-REM sleep (NREM), enlarges the clinical spectrum of sleepwake disturbances
especially in spindle formation [13], and in slow-wave sleep potentially observed after an acute cerebrovascular event.
generation [12]. Polysomnographic studies performed in
patients with thalamic stroke in the acute and post-acute
phase (after 2 months, 12 months and beyond) [11] reported Disclosure of interest
increased stage 1 sleep, reduced stage 2 sleep with reduced
spindles and K-complexes, reduced slow-wave sleep and The authors declare that they have no competing interest.
reduced REM sleep, which match with a disorganization of
sleep [5,6,10,11]. Nevertheless, our first patients polysomno- references
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Please cite this article in press as: Sagnier S, et al. Lucid dreams, an atypical sleep disturbance in anterior and mediodorsal thalamic strokes.
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Please cite this article in press as: Sagnier S, et al. Lucid dreams, an atypical sleep disturbance in anterior and mediodorsal thalamic strokes.
Revue neurologique (2015), http://dx.doi.org/10.1016/j.neurol.2015.08.005