Assenza, Giovanni

Di Lazzaro, Vincenzo

Giambattistelli, Federica

Pravatà, Emanuele

Journal of Neurology Neurosurgery & Psychiatry

English

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Brachial palsy after deep sleepA young student presented with left forearm numbness andproximal arm palsy after awaking from benzodiazepine andalcohol consumption-induced deep sleep. The patient had fallenasleep while sitting with the neck leaning on a laptop screenand head tilted left (figure 1). Prior medical history was negativefor diabetes mellitus, trauma, neuropathy, chronic alcohol con-sumption, renal failure or autoimmune disorders. There was nofamily history of neuropathy. Examination revealed paralysis ofthe left deltoid, biceps and brachioradialis muscles, mild tricepsweakness (4/5 MRC scale), absent biceps tendon reflex andC5–C6 dermatomal hypoesthesia suggesting involvement of theC5–C6–C7 roots or the upper and middle primary trunks ofthe brachial plexus. Electromyography, performed 3 days afterthe onset of symptoms, showed no motor unit voluntary recruit-ment in deltoid, biceps or brachioradialis, and reduced recruit-ment in triceps. Bilateral upper limb sensory, including lateralantebrachial cutaneous nerve, and motor nerve conductionstudies (NCS) were unremarkable. The amplitudes and latenciesof compound muscle action potentials recorded from left andright biceps and deltoid muscles were normal and symmetricaleven after brachial plexus stimulation at Erb’s point.Nevertheless, a conduction block in nerve segments proximal toErb’s point, not evaluable with conventional NCS,1 could notbe excluded. Proximal structures can be explored using eithermagnetic resonance (MR) neurography2 or nerve ultrasonog-raphy. The latter is sensitive and less expensive and so it couldbe considered as the preferable investigation.3 However, ultra-sonography accuracy is highly operator-dependent, and, thus,the choice of imaging technique should also take into consider-ation local expertise. We decided to perform MR neurography.This revealed hyperintensity and slight swelling of C5–C6–C7roots and of the middle trunk (figure 2). Somatosensory evokedpotentials evoked by upper limb nerve stimulation could alsocontribute to the functional evaluation of the cervical roots;however, because in our patient MR neurography provideddirect evidence of cervical root and brachial plexus involvement,this test was not performed. Genetic analysis for hereditaryneuropathy with liability to pressure palsy was negative. Becauseof the severity of deficits, the patient was treated for 5 days with1 g/day intravenous methylprednisolone, even though immuno-therapy efficacy is not established for nerve lesions due to mech-anical factors.4 There was no improvement. After 3 weeks,electromyography showed sporadic fibrillation potentials withminimal recruitment in deltoid, biceps and brachioradialis, andslightly reduced recruitment in triceps. Sensory and motor NCSwere unremarkable, suggesting a conduction block with minimalaxonal injury in nerve segments proximal to Erb’s point. Threemonths later, the patient showed a pronounced improvement indeltoid, biceps and brachioradialis strength (4/5 MRC) withcomplete recovery of triceps strength and sensory deficits.Deltoid, biceps and brachioradialis electromyography showed aslightly reduced recruitment. Triceps electromyography wasnormal.While sleeping after heavy drinking, arms may be kept inunusual positions, and if they are in contact with a hard surfacethe pressure can cause peripheral nerve damage. The mostcommon form is the so-called ‘Saturday night palsy’ in which acompressive lesion of the radial nerve is caused by keeping thearm over the handle of a chair. While a few other cases ofpressure-induced brachial plexus lesions have been reported,5this is the first report of a compressive lesion located proximallyto the brachial plexus with the involvement of the cervical rootsrevealed by MR neurography.Figure 1 Delayed pressure urticaria (arrow) appeared in left neckarea exposed to the maximal pressure.Figure 2 Cervical roots and brachial plexus MRI. Brachial plexus magnetic resonance (MR) neurography was obtained by using maximumintensity-projected short-tau-inversion-recovery (STIR) T2-weighted coronal images. Increased signal and slight swelling of the left brachial plexus C5,C6 and C7 roots (empty arrowheads in A) and middle trunk (arrow in A) indicate oedematous changes. Slight thickening of nerve roots and STIRsignal changes are also demonstrated on the corresponding structural T1-weighted (arrowheads in B) and T1/STIR fusion (empty arrowheads in C)images. (MR STIR and T1 images were acquired on a 1.5 T system (Siemens Aera, Erlangen, Germany) with the following parameters: repetitiontime=5540/700 ms; echo time=47/21 ms; inversion time=160/- ms; slice thickness=3.0 mm; gap=0.3 mm. The percent range of the rendered T2intensity values in C is represented on a colour scale.)Di Lazzaro V, et al. J Neurol Neurosurg Psychiatry December 2014 Vol 85 No 12 1409Neurological picture on 23 July 2018 by guest. Protected by copyright.http://jnnp.bmj.com/J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2013-306637 on 12 March 2014. Downloaded from Vincenzo Di Lazzaro,1,2 Federica Giambattistelli,1 Emanuele Pravatà,3Giovanni Assenza11Institute of Neurology Campus Bio-Medico University Via Alvaro del Portillo, Rome,Italy2Fondazione Alberto Sordi, Research Institute for Ageing, Rome, Italy3Neurocenter of Southern Switzerland, via Tesserete 46, Lugano, SwitzerlandCorrespondence to Professor Vincenzo Di Lazzaro, Institute of Neurology, CampusBio-Medico University, Via Alvaro del Portillo, 200, Rome 00128, Italy;v.dilazzaro@unicampus.itContributors Drafting/revising the manuscript for content, including medicalwriting for content, study concept or design, and study supervision or coordination:VDL. Analysis or interpretation of data: VDL, FG, EP and GA. Acquisition of data:VDL, FG, EP and GA.Patient consent Obtained.Provenance and peer review Not commissioned; externally peer reviewed.To cite Di Lazzaro V, Giambattistelli F, Pravatà E, et al. J Neurol NeurosurgPsychiatry 2014;85:1409–1410.Received 26 August 2013Revised 11 February 2014Accepted 16 February 2014Published Online First 12 March 2014J Neurol Neurosurg Psychiatry 2014;85:1409–1410.doi:10.1136/jnnp-2013-306637REFERENCES1 Vucic S, Black K, Siao Tick Chong P, et al. Cervical nerve root stimulation. Part II:findings in primary demyelinating neuropathies and motor neuron disease. ClinNeurophysiol 2006;117:398–404.2 Luigetti M, Pravata E, Colosimo C, et al. MRI neurography findings in patients withidiopathic brachial plexopathy: correlations with clinical-neurophysiological data ineight consecutive cases. Intern Med 2013;52:2031–9.3 Hobson-Webb LD. Neuromuscular ultrasound in polyneuropathies and motor neurondisease. Muscle Nerve 2013;47:790–804.4 Staff NP, Engelstad J, Klein CJ, et al. Post-surgical inflammatory neuropathy. Brain2010;133:2866–80.5 Fourcade G, Taieb G, Renard D, et al. Brachial plexus sleep palsy. Rev Neurol2011;167:522–5.1410 Di Lazzaro V, et al. J Neurol Neurosurg Psychiatry December 2014 Vol 85 No 12Neurological picture on 23 July 2018 by guest. Protected by copyright.http://jnnp.bmj.com/J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2013-306637 on 12 March 2014. Downloaded from 

Brachial palsy after deep sleep

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