A 67-year-old woman presents with symptoms of symptoms of daytime fatigue and sleeplessness at night due to excessive nighttime movements over the course of three months. Her husband is concerned that she could be having seizures. Her past medical history is significant for hypertension, for which she has been prescribed antihypertensive medication in the past. She stopped taking the medication when she and her husband both retired two years ago; the pharmacy where she picked up her prescriptions was in the building where she used to work.
Five years ago, she slipped and fell on the ice while walking to get her mail. She sustained a herniated lumbar disk and a sprained ankle, resulting in persistent neck and back pain. Her ankle gradually improved over the course of five months after the injury, but she frequently takes generic over-the-counter non-steroidal anti-inflammatory medications (NSAIDS) for back pain, often taking up to 10 pills per day.
The patient was alert, oriented, cooperative, and in no acute distress. She moved her legs almost constantly during the examination. When questioned about it, both she and her husband said that these movements are typical for her, but neither could not recall when the movements began. She explained that her legs often feel an “inner itch,” and the sensation is relieved when she moves them. This sensation has never been associated with a rash or any other visible lesions.
Cardiac, respiratory, and abdominal examination were normal, but blood pressure was high (150/90). She had a normal cranial nerve examination. On neurological examination, strength, reflexes, and coordination were normal in all four extremities. Sensory examination was normal for light touch, pinprick, vibration, and proprioception. Gait was also normal, and she was able to walk heel to toe without limitations. She had a negative Romberg test.
Diagnosis: Restless Legs Syndrome, Subacute Hemorrage
An electroencephalogram (EEG) showed localized focal slowing in the right cerebral hemisphere corresponding to one lead, and there was no suggestion of an epileptic focus or post-ictal changes.
A complete blood count (CBC) and blood chemistry to explore the cause of RLS in this patient were normal. As a follow-up to the focal abnormality on her EEG, a brain MRI showed evidence of a subacute hemorrhage in the right basal ganglia.
Based on her history and physical examination, a tentative diagnosis of restless legs syndrome (RLS) was made. This patient likely had a hemorrhagic stroke due to her untreated hypertension and overuse of NSAIDS, many of which are blood thinners. FDA-approved medications for the treatment of RLS include gabapentin enacarbil (an anticonvulsant), as well as ropinirole, pramipexole, and rotigotine (dopamine agonists).
1. Tuo H, Tian Z, Ma X, et al. Clinical and radiological characteristics of restless legs syndrome following acute lacunar infarction. Sleep Med. 2019;53:81-87.
2. Shiina T, Suzuki K, Okamura M, et al. Restless legs syndrome and its variants in acute ischemic stroke. Acta Neurol Scand. 2018 Nov [Epub ahead of print].