Central sleep apnoea and unilateral diaphragmatic paralysis associated with vertebral artery compression of the medulla oblongata

Journal of Neurology -     

Central sleep apnea and partial obstruction of the upper airway

Seven men with central sleep apnea underwent polygraphic monitoring during sleep for at least 3 nights, in combination with other tests. Five patients had complaints of disturbed sleep; the other 2 were selected because they had central sleep apnea caused by bilateral brainstem lesions. The first 5 had a small upper airway, documented by cephalometric roentgenograms. Nasal continuous positive airway pressure, administered to improve the suspected respiratory load during sleep, eliminated the central sleep apnea in the first 5 patients but had, as expected, no positive effect on the central apnea of the 2 patients with brainstem lesions.     

Central sleep apnea is uncommon after stroke

Objective/backgroundStroke is often considered a risk factor for central sleep apnea (CSA). The goal of this study was to determine the prevalence and clinical correlates of CSA in patients with ischemic stroke.Patients/methodsIn this analysis, 1346 participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Respiratory events during sleep were classified as central apneas, obstructive apneas, or hypopneas. Central apnea index (CAI) was defined as number of central apneas divided by recording time. CSA was defined as CAI ≥5/hour with at least 50% of all scored respiratory events classified as central apneas. Demographics and co-morbidities were ascertained from the medical record.ResultsMedian CAI was 0/hour. Nineteen participants (1.4%) met criteria for CSA. Participants with CSA were more likely to be male, and had lower prevalence of obesity than participants without CSA. There was no association between CSA and other co-morbidities.ConclusionsCSA was uncommon in this large cohort of patients with recent ischemic stroke.     

Effect of below-the-knee compression stockings on severity of obstructive sleep apnea

BackgroundOvernight fluid shift from the legs to the neck may narrow the upper airway and contribute to obstructive sleep apnea (OSA) pathogenesis. We hypothesized that below-the-knee compression stockings will decrease OSA severity in a general OSA population by decreasing daytime leg fluid accumulation and overnight fluid shift and increasing upper-airway size.MethodsPatients with OSA (apnea–hypopnea index ≥10) were randomized to wear compression stockings during the daytime or to a control group for 2 weeks. Overnight polysomnography with measurement of leg and neck fluid volumes and upper-airway cross-sectional area before and after sleep was performed at baseline and follow-up. The primary outcome was change in the apnea–hypopnea index.ResultsTwenty-two patients randomized to compression stockings and 23 to control completed the study. The apnea–hypopnea index decreased significantly more in the compression stockings than in the control group (from 32.4 ± 20.0 to 23.8 ± 15.5 vs. from 31.2 ± 25.0 to 30.3 ± 23.8, p = 0.042), in association with a significantly greater reduction in the overnight decrease in leg fluid volume (p = 0.028), and a significantly greater increase in morning upper-airway cross-sectional area (p = 0.006). Overnight change in neck fluid volume was unchanged.ConclusionThese observations suggest that in, a general OSA population, below-the-knee compression stockings decrease OSA severity modestly via attenuation of overnight fluid shift and consequent upper-airway dilatation.     

Arnold-Chiari malformation associated with sleep apnea and central dysregulation of arterial pressure

The natural history of symptomatic adult type I Arnold-Chiari (ACM1) malformation is variable. Patients with this condition frequently develop corticospinal and sensory deficits, together with cerebellar signs and lower cranial nerve palsies in various combinations. In the present report we describe a patient with ACM1 in whom sleep apnea together with disturbances in the central regulation of arterial pressure were a major component of the symptomatology. These paroxysmal blood pressure changes has not been previously reported. The decompression of our patient's medulla, which contains the primary respiratory centers and baroreceptors, resulted in a marked improvement and indicate that the origin may have been on a central basis.     

Vertebral artery compression of the medulla

BACKGROUND: Intracranial arteries in the subarachnoid space may compress the brain parenchyma and cranial nerves. Most arterial compressive lesions have been attributed to dolichoectasia in the vertebral-basilar system, and prior reports have concentrated on the pressure effects of basilar artery ectasia. Much less is known about vertebral artery compression of the medulla. OBJECTIVE: To describe a series of patients with vertebral arteries compressing the medulla oblongata. DESIGN: Prospective case studies. SETTING: Tertiary care center. PATIENTS: Nine symptomatic patients, 4 men and 5 women, between the ages of 32 and 79 years. MAIN OUTCOME MEASURES: Clinical phenomena, radiographic findings, treatment, and outcomes. RESULTS: We found that compression most commonly occurs at the ventrolateral surface. The clinical features can be transient or permanent and are predominantly motor and cerebellar or vestibular, but a poor correlation exists between the clinical findings and the severity or extent of impingement. The vertebral arteries were angulated, tortuous, or dilated but not necessarily dolichoectatic to cause obvious indentation. Seven patients were treated with antiplatelets and anticoagulants or analgesics, whereas 2 underwent microvascular decompression, resulting in temporary or no relief. One surgical patient developed cranial nerve complications. Among the medically treated patients, none had progression of deficits, and those with single episodes had no recurrence of symptoms. CONCLUSION: This study is the largest collection, to our knowledge, of patients with medullary vascular compression. Further studies are needed to estimate its frequency, natural course, and preferred management.     

Central sleep apnea after acute coronary syndrome and association with ticagrelor use

Study objectivesBy modifying the apneic threshold, the antiplatelet agent ticagrelor could promote central sleep apnea hypopnea syndrome (CSAHS). We aimed to assess the association between CSAHS and ticagrelor administration.MethodsPatients were prospectively included within 1 year after acute coronary syndrome (ACS), if they had no heart failure (and left ventricular ejection fraction ≥ 45%) and no history of sleep apnea. After an overnight sleep study, patients were classified as “normal” with apnea hypopnea index (AHI) < 15, “CSAHS patients” with AHI ≥ 15 mostly with central sleep apneas, and “obstructive sleep apnea hypopnea syndrome (OSAHS) patients” with AHI ≥ 15 mostly with obstructive sleep apneas.ResultsWe included 121 consecutive patients (mean age 56.8 ± 10.8, 88% men, mean body mass index 28.3 ± 4.4 kg/m², left ventricular ejection fraction 56 ± 5%, at a mean of 67 ± 60 days (median 40 days, interquartile range: 30–80 days) after ACS. In total, 49 (45.3%) patients had AHI ≥ 15 (27 [22.3%] CSAHS %, 22 [18.2%] OSAHS).For 80 patients receiving ticagrelor, 24 (30%) had CSAHS with AHI ≥ 15, and for 41 patients not taking ticagrelor, only 3 (7.3%) had CSAHS with AHI ≥ 15 (chi-square = 8, p = 0.004). On multivariable analysis only age and ticagrelor administration were associated with the occurrence of CSAHS, (p = 0.0007 and p = 0.0006).ConclusionCSA prevalence after ACS is high and seems promoted by ticagrelor administration. Results from monocentric study suggest a preliminary signal of safety.Clinical trials.gov idNCT03540459.     

Alcohol, snoring and sleep apnea.

We studied the effect of alcohol ingestion on sleep-induced breathing abnormalities and arterial oxyhaemoglobin saturation in seven patients with a range of sleep-induced upper airway occlusion. The characteristics of each patient's sleep-induced breathing abnormality was established on one or more control all-night studies, and then a further all-night study was done immediately following alcohol ingestion. Alcohol increased the duration and frequency of the occlusive episodes in five patients with obstructive sleep apnoea, and resulted in a marked increase in the degree of hypoxaemia in the first hour of sleep. In two patients with benign chronic snoring, alcohol induced frank obstructive sleep apnoea during the first hour of sleep. We suggest that the increased tendency to develop obstructive apnoea after alcohol is the result of alcohol-induced oropharyngeal muscle hypotonia, while the increased duration of obstructive apnea is the result of alcohol-induced depression of arousal mechanisms.     

Central sleep apnea in children: experience at a single center

ObjectiveCentral sleep apnea (CSA) syndromes are rare in children and data in children over one year of age are scarce. The aim of the study was to describe the sleep characteristics, underlying disorders, management, and outcome of children with CSA.Patients/MethodsA retrospective chart review of all children >1 year of age, diagnosed with CSA on a laboratory sleep study during a 20-month period, was performed. CSA was defined by a central apnea index (CAI) >5 events/h. The clinical management and the patient's outcome were analyzed.ResultsEighteen of 441 (4.1%) patients recorded during the study period had CSA. The median CAI, pulse oximetry, and oxygen desaturation index were 13/h (range 6–146), 96% (93–98%), and 18/h (6–98), respectively. Neurosurgical pathologies represented the most common underlying disorders with Arnold–Chiari malformation in four and ganglioglioma in three patients. Other underlying disorders were Prader–Willi syndrome (N = 3), achondroplasia (N = 2), and Down syndrome, with one patient having an achondroplasia and a Down syndrome. The remaining six patients had other genetic diseases. The most common investigation was brain magnetic resonance imaging (MRI). Individualized management with neurosurgery and/or chemotherapy, continuous positive airway pressure (in two patients having associated obstructive events), or noninvasive ventilation resulted in an improvement in CSA and the clinical presentation in 11 patients.ConclusionCSA is rare in children >1 year of age. Underlying disorders are dominated by neurosurgical disorders. Individualized management is able to improve CSA and the clinical condition in most patients.     

Central sleep apnea is associated with increased risk of ischemic stroke in the elderly

Muñoz R, Durán‐Cantolla J, Martinez‐Vila E, Gállego J, Rubio R, Aizpuru F, De La Torre G, Barbé F. Central sleep apnea and risk of stroke in the elderly.
Acta Neurol Scand: 2012: 126: 183–188.
© 2011 John Wiley & Sons A/S. Objectives – Sleep apnea/hypopnea syndrome is a well‐recognized independent risk factor for stroke in middle‐aged population, but controversy remains in older subjects. We examined the possible association between different respiratory parameters and risk of stroke in a prospective population‐based cohort of 394 stroke‐free elderly subjects. Material and Methods – Fully overnight polysomnography was performed at baseline. Over the 6 year follow‐up period, 20 ischemic strokes occurred. Differences in stroke‐free survival between subjects according to central apnea index (CAI) were assessed. Results – We just observed association with incident ischemic stroke on central sleep apnea (CSA) episodes. Obstructive sleep apnea, time passed under 90% oxygen saturation, or arousal index were not associated. The event‐free survival was lowest in the highest CAI group. This association was independent of any other vascular risk factors. Conclusions – CSA is the specific respiratory event associated with stroke in the elderly. Additionally, CSA could be a marker of silent brain ischemia, as a sign of disturbed regulation of central respiratory mechanisms, tentatively of ischemic origin.     

Association between severe obstructive sleep apnea and incident arterial hypertension in the older people population

ObjectivesThe impact of sleep-related breathing disorders on the incidence of arterial hypertension (AHT) in the older adults is not well-established. The aim of our study was to test the link between severe obstructive sleep apnea (OSA) and the occurrence of hypertension in older subjects after 3 years.Methods372 normotensive subjects with a mean age of 68.2 years were included in our longitudinal study. All participants had a ventilatory polygraphic recording and an ambulatory blood pressure (BP) monitoring at baseline and after 3 years. Severe OSA was defined by an apnea–hypopnea index (AHI) of ⩾30 per hour. A new onset of hypertension was defined according to a mean 24-hour value >140 mmHg for systolic BP and >85 mmHg for diastolic BP or the use of antihypertensive medication.ResultsThe baseline factors significantly associated with an increased risk for new-onset hypertension were male gender, obesity, diabetes mellitus (DM), dyslipidemia, and OSA. Multiple logistic regression analyses showed that an AHI ⩾ 30 per hour was independently associated with incident hypertension after 3 years (P = .02; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1–2.8).ConclusionsThe presence of severe OSA is associated with new-onset AHT in normotensive elderly (mean age, 68.2 y) subjects.     

Central type of sleep apnea syndrome caused by unilateral lateral medullary infarction]

We reported here a 64-year-old man with a central apnea resulted from unilateral medullary infarction. He was admitted because of cerebellar ataxia, dysarthria and dysphasia of abrupt onset. After the injection of diazepam for alcohol forbidden syndrome, he induced complete apnea and required the endotracheal intubation. At the spontaneous respiration under room air, his arterial blood gas showed hypercapnea without hypoxemia, and he fell into severe hypoventilation when hypnotic drug was injected. Respisomnogram revealed the frequent presence of central apnea both while he was awake and asleep. MRI demonstrated an abnormal high intensity area on T2 weighted image at the right lateral medulla just below the ponto-medullary junction. At autopsy, areas of the infarction were limited within the right lateral medulla, including lateral portion of the medullary reticular formation, the ambigual nucleus, one part of the solitary nuclear complex, the inferior cerebellar peduncle and the spinal trigeminal nucleus. However, the dorsomotor nucleus of vagus was completely free from the infarct lesion. There was no other lesion within central nervous system. Such a distribution seemed the minimal extent of the lesion responsible for central, apnea compared to the previous reports. We suggest that central apnea occurs not infrequently in the cases of Wallenberg's syndrome.     

Obstructive sleep apnea syndrome. A review

Obstructive sleep apnea syndrome (OSAS) is a complex disorder characterized by a sleep-related collapse of the upper airway. The most likely candidate for the common pathway linking various abnormalities casually associated with OSAS (such as adenotonsillar hypertrophy, obesity, retro- or micrognathia, acromegaly, or more subtle structural anomalies) is an abnormally small upper airway lumen. Symptoms of OSAS that appear during sleep include snoring, abnormal motor activity, disturbed nocturnal sleep, a sensation of choking, heartburn, nocturia, nocturnal enuresis, and heavy sweating. Daytime waking symptoms are dominated by often profound sleepiness, which may secondarily be associated with automatic behavior, retrograde amnesia, hypnagogic hallucinations, personality changes, sexual difficulties, and headaches. Careful evaluation, both sleeping and waking, are essential to select appropriate treatment. Treatments include nasal continuous positive airway pressure, tracheostomy, weight loss, uvulopalatopharyngoplasty, mandibular advancement, and so forth.     

Epilepsy and obstructive sleep apnea

A few publications documented the coexistence of epilepsy and obstructive sleep apnea (OSA). The extent, nature, and clinical relevance of this association remain poorly understood. We retrospectively reviewed the database of our sleep center to identify patients with both sleep apnea and epilepsy. Characteristics of epilepsy, sleep history, presence of excessive daytime sleepiness [Epworth Sleepiness Scale (ESS)] and polysomnographic data were assessed. The effect of continuous positive airway pressure (CPAP) on seizure reduction was prospectively analyzed after a median interval of 26 months (range: 2-116 months) from the diagnosis of OSA. OSA was found in 29 epilepsy patients (25 men and 4 women) with a median age of 56 years (range: 37-79). The median apnea hypopnea index was 33 (range: 10-85), the oxygen desaturation index was 12 (range 0-92), and 52% of the patients had an ESS score >10. In 27 patients, epilepsy appeared 1 month to 44 years prior to the diagnosis of OSA. In 21 patients, the appearance of OSA symptoms coincided with a clear increase in seizure frequency or the first appearance of a status epilepticus. Treatment with CPAP was continued with good compliance in 12 patients and led to a significant reduction of both ESS scores and seizure frequency in 4 patients. Our data suggest the importance of considering diagnosis and treatment of OSA in epilepsy patients with poor seizure control and/or reappearance of seizures after a seizure-free interval.     

The eye and sleep apnea

Several eye disorders have been found in association with obstructive sleep apnea (OSA). This paper reviews the current state of knowledge of eye disorders associated with OSA. OSA is associated with a number of eye disorders including floppy eyelid syndrome (FES), optic neuropathy, glaucoma, non-arteritic anterior ischemic optic neuropathy and papilledema secondary to raised intracranial pressure. FES patients have a very high incidence of OSA and a causal relationship may exist, but amongst patients with OSA, FES is uncommon but commoner than in the general population. Treatment of OSA may help floppy eyelid syndrome, halt progression of associated glaucoma or optic neuropathy, and reduce intracranial pressure in patients with associated papilledema. Sleep apnea patients should be asked about ocular symptoms and appropriately examined or referred for assessment as some of the associated eye disorders may permanently impair vision. Ophthalmologists should be aware of the association of sleep apnea with these eye disorders and consider referral to a sleep physician for investigation and possible treatment.     

Neuropsychological effects of pediatric obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a fairly common nocturnal breathing disorder, affecting 2-4% of individuals. Although OSA is associated with medical morbidity, its most functionally disruptive effects in adults appear to be neuropsychological in nature. Research on the neuropsychological effects of pediatric OSA has been limited. This study compared the neuropsychological functioning of school-aged children with OSA to that of healthy children. The primary goal was to clarify the presence and pattern of neuropsychological morbidity associated with pediatric OSA. Sleep was assessed with parent-report questionnaires and laboratory sleep studies. Neuropsychological functioning was assessed by formal tests and parent- and teacher-report questionnaires. Data indicated OSA-related cognitive and behavioral impairment that was particularly marked on measures of behavior regulation and some aspects of attention and executive functioning. Minimal effects were observed on measures of intelligence, verbal memory, or processing speed. Exploratory analyses failed to indicate any clear relationship between neuropsychological functioning and objective indexes of hypoxia or sleep disruption, though the sample was small. These data add to a growing literature which suggests that significant neuropsychological deficits are associated with pediatric OSA. Findings suggest a pattern of neuropsychological morbidity that is similar but not identical to that seen in adult OSA.