MRI and polysomnographic findings of patients affected by post-stroke sleep apnea

Maria Luisa Sacchetti, Maria Teresa Di Mascio, Marco Fiorelli, Giacomo Della Marca, Anna Losurdo, Gennaro Russo, Danilo Toni, Antonio Minni, Emanuele Tinelli, Francesca Caramia

Department of Neurology and Psychiatry, Sapienza University, Rome, Italy;.
Department of Sensory Organs, Sapienza University of Rome, Rome, Italy.
Sleep Unit, Institute of Neurology, Catholic University, Rome, Italy.

DOI: 10.4236/health.2013.58A2008                

Abstract

Aim: The aim of our study was to compare characteristics of stroke patients who presented Obstructive Sleep Apnea/Hypopnea (OSAH) to those of cases that presented Central Sleep Apnea/Hypopnea (CSAH) events at PSG, and to investigate relationships between the type of breathing disturb during sleep and the location of brain damage. Methods: Thirty four patients were submitted to clinical, neuroradiological and polisomnographyc study (PSG) after 4 months of stroke. A Sleep Disordered Breathing (SDB) was diagnosed in all cases with an AHI > 5. Patients were classified as affected by predominantly OSAH (pOSAH), or predominantly CSAH (pCSAH). Comparisons were made among the groups and correlation analyses were done in each group. Significance was set at p < 0.005. Results: Twenty six patients with ischemic strokes had a SDB during sleep (56% embolic, 31% lacunar, 8% large artery, 8% with undetermined cause). The 61% of them showed pOSAH. Except for age, no statistical differences were found between the two groups as to clinical findings, risk factors for stroke, PSG data, or location of brain lesion. Correlation analysis outlined that in pOSAH cases the time interval from stroke to PSG (Δt) was inversely related to both TST (p = 0.017) and TSP (p = 0.039); in pCSAHs it was inversely related to SE Index (p = 0.021) and directly related to both ODI (p = 0.016) and with the n. of arrhythmias/h sleep (p = 0.033). In pCSAH, AHI did not correlate with ODI. Conclusions: Our data suggest that among cases with post stroke SDB is included 3 different subgroups of cases: OSAHs who terminate the obstruction by arousal, OSAHs who do not arise and alternate obstructive to central events, and CSAHs due to the direct effect of stroke on the breathing network; in a forth subgroup of cases， the microstructure of sleep might be altered, with the consequent occurrence of sleep-related events. Further studies are needed to clarify these hypotheses as well as the role of poststroke depression on the nature and occurrence of SDB after stroke.

Keywords

Sleep Apnea-Stroke; Magnetic Risonance Imaging-Polysomnography

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Johnson, K.G. and Johnson, D.C. (2010) Frequency of sleep apnea in stroke and TIA patients: A meta-analysis. Journal of Clinical Sleep Medicine, 6, 131-137.
[2]	Bassetti, C. and Aldrich, M.S. (1999) Sleep apnea in acute cerebrovascular diseases: Final report on 128 patients. Sleep, 22, 217-223.
[3]	Sacchetti, M.L., Mascio, M.T.D., DellaMarca, G., Minni, A., Ottaviani, S., Toni, D. and Fiorelli, M. (2013) Sleep disordered breathing after stroke: Clinical profile of patients with obstructiveas opposed to central-sleep apnea. Journal of Sleep Disorders & Therapy, 2, 113-116.
[4]	Muir, K.W., Weir, C.J., Murray, G.D., Povey, C. and Lees, K.R. (1996) Comparison of neurological scales and scoring systems for acute stroke prognosis. Stroke, 27, 1817-1820. doi:10.1161/01.STR.27.10.1817
[5]	Pezzella, F.R., Picconi, O., De Luca, A., Lyden, P.D. and Fiorelli, M. (2009) Development of the Italian version of the National Institutes of Health Stroke Scale: It-NIHSS. Stroke, 40, 2557-2559. doi:10.1161/STROKEAHA.108.534495
[6]	Madden, K.P., Karanjia, P.N., Adams, H.P. and Clarke, W.R. (1995) Accuracy of initial stroke subtype diagnosis in the TOAST study. Trial of ORG 10172 in Acute Stroke Treatment. Neurology, 45, 1975-1979. doi:10.1212/WNL.45.11.1975
[7]	Johns, M.W. (1991) A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540-545.
[8]	Thorpy, M.J. (American Academy of Sleep Medicine) (2005) International classification of sleep disorders. 2nd Edition, Diagnostic and Coding Manual American Academy of Sleep Medicine, Westchester.
[9]	Kushida, C.A., Littner, M.R., Morgenthaler, T., Alessi, C.A., Bailey, D., Coleman, J., Friedman, L., Hirshkowitz, M., Kapen, S., Kramer, M., Lee-Chiong, T., Loube, D.L., Owens, J., Pancer, J.P. and Wise, M. (2005) Practice parameters for the indications for polysomnography and re-lated procedures: An update for 2005. Sleep, 28, 499-521.
[10]	Iber, C.A., Chesson, A. and Quan, S.F (The American Academy of Sleep Medicine) (2007) The AASM manual for the scoring of sleep and associated events: Rules, terminology and technical specifications.
[11]	Bonnet, M., et al. (1992) “EEG arousals: Scoring rules and examples: A preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association. Sleep, 15, 173-184.
[12]	Guilleminault, C., Connolly, S.J. and Winkle, R.A. (1983) Cardiac arrhythmia and conduction disturbances during sleep in 400 patients with sleep apnea syndrome. The American Journal of Cardiology, 52, 490-494. doi:10.1016/0002-9149(83)90013-9
[13]	Lee, M.C., Klassen, A.C., Hearney, L.M. and Perch, J.A. (1976) Respiratory rate and pattern disturbances in acute brain stem infarction. Stroke, 7, 382-385. doi:10.1161/01.STR.7.4.382
[14]	Levin, B.E. and Margolis, G. (1977) Respiration seconddary to a unilateral brain stem infarction. Annals of Neurology, 1, 583-586. doi:10.1002/ana.410010612
[15]	Askenasy, J.M. and Goldhamer, I. (1988) Sleep apnea as a feature of bulbar stroke. Stroke, 19, 637-639. doi:10.1161/01.STR.19.5.637
[16]	Parra, O., Arboix, A., Bechich, S., García-Eroles, L., Montserrat, J.M., López, J.A., Ballester, E., Guerra, J.M. and Sopena, J.J. (2000) Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. American Journal of Respiratory and Critical Care Medicine, 161, 375-380. doi:10.1164/ajrccm.161.2.9903139
[17]	Bassetti, C., Aldrich, M.S. and Quint, D. (1997) Sleep disordered breathing in patients with acute supra-and infratentorial stroke: A prospective study of 39 patients. Stroke, 28, 1765-1772. doi:10.1161/01.STR.28.9.1765
[18]	Shelton, K.E., Gay, S.B., Hollowell, D.E., Woodson, H. and Suratt, P.M. (1993) Mandible enclosure of upper airway and weight in obstructive sleep apnea. American Review of Respiratory Disease, 148, 195-200. doi:10.1164/ajrccm/148.1.195
[19]	Dziewas, R., Humpert, M., Hopmann, B., Kloska, S.P., Lüdemann, P., Ritter, M., Dittrich, R., Ringelstein, E.B., Young, P. and Nabavi, D.G. (2005) Increased prevalence of sleep apnea in patients with recurring ischemic stroke compared with first stroke victims. Journal of Neurology, 252, 1394-1398. doi:10.1007/s00415-005-0888-7
[20]	Levy, P. and Pepin, J.L. (2011) CPAP treatment of sleep apnoea in the early phase of stroke: Growing evidence of effectiveness. European Respiratory Journal, 37, 997-999. doi:10.1183/09031936.00182810
[21]	Parra, O., Sánchez-Armengol, A., Bonnin, M., Arboix, A., Campos-Rodríguez, F., Pérez-Ronchel, J., Durán-Cantolla, J., de la Torre, G., González Marcos, J.R., de la Pena, M., Carmen Jiménez, M., Masa, F., Casado, I., Luz Alonso, M. and Macarrón, J.L. (2011) Early treatment of obstructive apnoea and stroke outcome: A randomised controlled trial. European Respiratory Journal, 37, 1128-1136. doi:10.1183/09031936.00034410
[22]	Sands, S.A., Edwards, B.A., Kee, K., Turton, A., Skuza, E.M., Roebuck, T., O’Driscoll, D.M., Hamilton, G.S., Naughton, M.T. and Berger, P.J. (2011) Loop gain as a means to predict a positive airway pressure suppression of cheyne-stokes respiration in patients with heart failure. American Journal of Respiratory and Critical Care Medicine, 184, 1067-1075. doi:10.1164/rccm.201103-0577OC
[23]	Ryan, C.M., Bayley, M., Green, R., Murray, B.J. and Bradley, T.D. (2011) Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke, 42, 1062-1067. doi:10.1161/STROKEAHA.110.597468
[24]	Martinez-Garcia, M.A., Soler-Cataluna, J.J., EjarqueMartinez, L., Soriano, Y., Roman-Sanchez, P., Illa, F.B., Canal, J.M. and Duran-Cantolla, J. (2009) Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: A 5-year follow-up study. American Journal of Respiratory and Critical Care Medicine, 180, 36-41. doi:10.1164/rccm.200808-1341OC
[25]	Farina, B., Della Marca, G., Grochocinski, V.J., Mazza, M., Buysse, D.J., Di Giannantonio, M., Francesco Mennuni, G., De Risio, S., Kupfer, D.J. and Frank, E. (2003) Microstructure of sleep in depressed patients according to the cyclic alternating pattern. Journal of Affective Disorders, 77, 227-235. doi:10.1016/S0165-0327(02)00147-7
[26]	Paolucci, S. (2008) Epidemiology and treatment of poststroke depression. Journal of Neuropsychiatric Disease and Treatment, 4, 145-154.
[27]	Paolucci, S., Antonucci, G., Grasso, M.G., Morelli, D., Troisi, E., Coiro, P., De Angelis, D., Rizzi, F. and Bragoni, M. (2011) Post-stroke depression, antidepressant treatment and rehabilitation results. A case-control study. Cerebrovascular Diseases, 12, 264-271. doi:10.1159/000047714
[28]	Hackett, M.L., Anderson, C.S., House, A. and Xia, J. (2008) Interventions for treating depression after stroke. Cochrane Database of Systematic Reviews, 4, CD003437.
[29]	Thomas, R.J., Terzano, M.G., Parrino, L. and Weiss, J.W. (2004) Obstructive sleep-disordered breathing with a dominant cyclic alternating pattern—A recognizable polysomnographic variant with practical clinical implications. Sleep, 27, 229-234.
[30]	Parrino, L., Ferri, R., Bruni, O. and Terzano, M.G. (2012) Cyclic alternating pattern (CAP): The marker of sleep instability. Sleep Medicine Reviews, 16, 27-45. doi:10.1016/j.smrv.2011.02.003