1346 Dream Enactment Behaviors Triggered by Ruptured Pontine Cavernoma s/p Repair

Abstract Introduction REM sleep behavioral disorder (RBD) is largely associated and studied through the lens of alpha synucleinopathies. The literature on structural causes of RBD is sparse. Here, we present a novel case of new onset RBD after surgical resection of rupture pontine tegmental cavernoma. . This case highlights the anatomical importance of pons in regulating REM sleep and REM sleep related atonia. Report of case(s) The patient is a 70-year-old man with a history of tonsillar cancer s/p right radical dissection radiation chemotherapy. He presented to ER with acute onset left arm weakness and diplopia in 2023. Neuroimaging demonstrated symptomatic right ICA stenosis and an incidental pontine cavernoma (7x7x9 mm). He underwent trans carotid artery revascularization, with symptomatic improvements. One year later, he experienced worsening diplopia with gait imbalance. Repeat neuroimaging showed bleeding due to ruptured pontine cavernoma in the pons and he subsequently underwent surgical resection. He developed involuntary leg jerking/kicking during sleep 3 months after the procedure.. The abnormal movements were thought to be due to periodic limb movements, therefore ropinirole was attempted to assess response. Ropinirole was discontinued after one month due to worsening leg movements and sexual compulsions. As time progressed, he began displaying dream enactment behaviors such as punching, whole body thrashing, and vocalizations. Repeat MRI brain revealed residual post-operative scar tissue in the pons. Overall, his clinical picture remains highly suggestive of a pontine lesion induced RBD. To our knowledge, there is only one other case of non-ruptured pontine cavernoma related RBD in the literature. PSG for RBD confirmation and RSWA quantification is currently pending. The patient and spouse were instructed to complete a nightly journal of dream enactment behaviors. He had suboptimal response to melatonin. Given history of balance and baseline cognitive complaints after surgery, we decided against clonazepam. The patient expressed interest in trying sodium oxybate. We will assess the response to the treatment with RBD Episode Diary. Conclusion This case illustrates the critical role of the brainstem/pons in REM sleep regulation and REM sleep related atonia. The sub optimal response to melatonin and experimental treatment modalities also needs to be highlighted in this scenario. Support (if any)