Sleep-related breathing disorders and stroke
- Antonio Culebras, MD
Antonio Culebras, MD
- Professor of Neurology
- Upstate Medical University
Sleep-related breathing disorders, including obstructive sleep apnea (OSA), central sleep apnea (CSA), and Cheyne-Stokes breathing, are common in patients with stroke or transient ischemic attack and have been associated with adverse outcomes both in the general population and in patients with stroke. In addition, OSA may itself be an independent risk factor for stroke.
OSA is characterized by the intermittent cessation or reduction of airflow during sleep due to complete or partial upper airway obstruction, while CSA is characterized by the intermittent absence of airflow and ventilatory effort. Cheyne-Stokes breathing refers to cyclic crescendo-decrescendo airflow and respiratory effort during wakefulness or sleep, without upper airway obstruction. Cheyne-Stokes breathing is considered a type of CSA when the decrescendo effort is accompanied by apnea during sleep. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults".)
Clinical signs and symptoms of sleep-related breathing disorders are not reliable in patients with stroke, and diagnostic sleep testing with polysomnography or home sleep apnea testing is required to make the diagnosis. While clinical trials in the general population have demonstrated that treatment of OSA with continuous positive airway pressure (CPAP) or other therapies significantly reduces apneas and oxygen desaturation during sleep and other outcomes, data in stroke patients are more limited.
The association between OSA and stroke as well as the epidemiology, clinical features, diagnosis, and management of sleep-related breathing disorders following stroke or transient ischemic attack are discussed here. Other cardiovascular complications of OSA and other respiratory abnormalities that can occur after a stroke are described separately. (See "Obstructive sleep apnea and cardiovascular disease in adults" and "Stroke-related pulmonary complications and abnormal respiratory patterns", section on 'Abnormal respiratory patterns'.)
SLEEP APNEA AS A RISK FACTOR FOR STROKE
Obstructive sleep apnea (OSA) has been associated with an increased risk for ischemic stroke, independent of vascular risk factors . The risk of stroke in patients with other sleep-related breathing disorders, including central sleep apnea syndrome, is not well studied.
- Hermann DM, Bassetti CL. Role of sleep-disordered breathing and sleep-wake disturbances for stroke and stroke recovery. Neurology 2016; 87:1407.
- Yaggi HK, Concato J, Kernan WN, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005; 353:2034.
- Valham F, Mooe T, Rabben T, et al. Increased risk of stroke in patients with coronary artery disease and sleep apnea: a 10-year follow-up. Circulation 2008; 118:955.
- Arzt M, Young T, Finn L, et al. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005; 172:1447.
- Redline S, Yenokyan G, Gottlieb DJ, et al. Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med 2010; 182:269.
- Loke YK, Brown JW, Kwok CS, et al. Association of obstructive sleep apnea with risk of serious cardiovascular events: a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2012; 5:720.
- Marshall NS, Wong KK, Cullen SR, et al. Sleep apnea and 20-year follow-up for all-cause mortality, stroke, and cancer incidence and mortality in the Busselton Health Study cohort. J Clin Sleep Med 2014; 10:355.
- Campos-Rodriguez F, Martinez-Garcia MA, Reyes-Nuñez N, et al. Role of sleep apnea and continuous positive airway pressure therapy in the incidence of stroke or coronary heart disease in women. Am J Respir Crit Care Med 2014; 189:1544.
- Chang CC, Chuang HC, Lin CL, et al. High incidence of stroke in young women with sleep apnea syndrome. Sleep Med 2014; 15:410.
- Culebras A. Sleep apnea and stroke in young women: the many faces of the disorder. Sleep Med 2014; 15:377.
- Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA 2012; 307:2161.
- McEvoy RD, Antic NA, Heeley E, et al. CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. N Engl J Med 2016; 375:919.
- Beaudin AE, Pun M, Yang C, et al. Cyclooxygenases 1 and 2 differentially regulate blood pressure and cerebrovascular responses to acute and chronic intermittent hypoxia: implications for sleep apnea. J Am Heart Assoc 2014; 3:e000875.
- Behrens S, Spengos K, Hennerici M. Acceleration of cerebral blood flow velocity in a patient with sleep apnea and intracranial arterial stenosis. Sleep Breath 2002; 6:111.
- Neau JP, Paquereau J, Meurice JC, et al. Auditory event-related potentials before and after treatment with nasal continuous positive airway pressure in sleep apnea syndrome. Eur J Neurol 1996; 3:29.
- Somers VK, White DP, Amin R, et al. Sleep apnea and cardiovascular disease: an American Heart Association/american College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation 2008; 118:1080.
- Yaranov DM, Smyrlis A, Usatii N, et al. Effect of obstructive sleep apnea on frequency of stroke in patients with atrial fibrillation. Am J Cardiol 2015; 115:461.
- Ng CY, Liu T, Shehata M, et al. Meta-analysis of obstructive sleep apnea as predictor of atrial fibrillation recurrence after catheter ablation. Am J Cardiol 2011; 108:47.
- Beelke M, Angeli S, Del Sette M, et al. Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study. Sleep Med 2003; 4:219.
- Mojadidi MK, Bokhoor PI, Gevorgyan R, et al. Sleep Apnea in Patients with and without a Right-to-Left Shunt. J Clin Sleep Med 2015; 11:1299.
- Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med 2010; 6:131.
- Iranzo A, Santamaría J, Berenguer J, et al. Prevalence and clinical importance of sleep apnea in the first night after cerebral infarction. Neurology 2002; 58:911.
- Bassetti C, Aldrich MS. Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. Sleep 1999; 22:217.
- Bassetti C, Aldrich MS, Quint D. Sleep-disordered breathing in patients with acute supra- and infratentorial strokes. A prospective study of 39 patients. Stroke 1997; 28:1765.
- Bassetti CL, Milanova M, Gugger M. Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome. Stroke 2006; 37:967.
- Askenasy JJ, Goldhammer I. Sleep apnea as a feature of bulbar stroke. Stroke 1988; 19:637.
- Vingerhoets F, Bogousslavsky J. Respiratory dysfunction in stroke. Clin Chest Med 1994; 15:729.
- Brown DL, Chervin RD, Wolfe J, et al. Hypoglossal nerve dysfunction and sleep-disordered breathing after stroke. Neurology 2014; 82:1149.
- Ryan CM, Bayley M, Green R, et al. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke 2011; 42:1062.
- Joo BE, Seok HY, Yu SW, et al. Prevalence of sleep-disordered breathing in acute ischemic stroke as determined using a portable sleep apnea monitoring device in Korean subjects. Sleep Breath 2011; 15:77.
- Cadilhac DA, Thorpe RD, Pearce DC, et al. Sleep disordered breathing in chronic stroke survivors. A study of the long term follow-up of the SCOPES cohort using home based polysomnography. J Clin Neurosci 2005; 12:632.
- Kepplinger J, Barlinn K, Albright KC, et al. Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia. J Neurol 2013; 260:1343.
- Srijithesh PR, Shukla G, Srivastav A, et al. Validity of the Berlin Questionnaire in identifying obstructive sleep apnea syndrome when administered to the informants of stroke patients. J Clin Neurosci 2011; 18:340.
- Kotzian ST, Stanek JK, Pinter MM, et al. Subjective evaluation of sleep apnea is not sufficient in stroke rehabilitation. Top Stroke Rehabil 2012; 19:45.
- Alexandrov AV, Nguyen HT, Rubiera M, et al. Prevalence and risk factors associated with reversed Robin Hood syndrome in acute ischemic stroke. Stroke 2009; 40:2738.
- Boulos MI, Wan A, Im J, et al. Identifying obstructive sleep apnea after stroke/TIA: evaluating four simple screening tools. Sleep Med 2016; 21:133.
- Katzan IL, Thompson NR, Uchino K, Foldvary-Schaefer N. A screening tool for obstructive sleep apnea in cerebrovascular patients. Sleep Med 2016; 21:70.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.
- Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5:263.
- Coutts SB, Wein TH, Lindsay MP, et al. Canadian Stroke Best Practice Recommendations: secondary prevention of stroke guidelines, update 2014. Int J Stroke 2015; 10:282.
- Väyrynen K, Kortelainen K, Numminen H, et al. Screening sleep disordered breathing in stroke unit. Sleep Disord 2014; 2014:317615.
- Bravata DM, Concato J, Fried T, et al. Auto-titrating continuous positive airway pressure for patients with acute transient ischemic attack: a randomized feasibility trial. Stroke 2010; 41:1464.
- Parra O, Arboix A, Bechich S, et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Respir Crit Care Med 2000; 161:375.
- Slonkova J, Bar M, Nilius P, et al. Spontaneous improvement in both obstructive sleep apnea and cognitive impairment after stroke. Sleep Med 2017; 32:137.
- Bravata DM, Concato J, Fried T, et al. Continuous positive airway pressure: evaluation of a novel therapy for patients with acute ischemic stroke. Sleep 2011; 34:1271.
- Bassetti C, Aldrich MS, Chervin RD, Quint D. Sleep apnea in patients with transient ischemic attack and stroke: a prospective study of 59 patients. Neurology 1996; 47:1167.
- Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006; :CD001106.
- Patel SR, White DP, Malhotra A, et al. Continuous positive airway pressure therapy for treating sleepiness in a diverse population with obstructive sleep apnea: results of a meta-analysis. Arch Intern Med 2003; 163:565.
- McDaid C, Durée KH, Griffin SC, et al. A systematic review of continuous positive airway pressure for obstructive sleep apnoea-hypopnoea syndrome. Sleep Med Rev 2009; 13:427.
- Fava C, Dorigoni S, Dalle Vedove F, et al. Effect of CPAP on blood pressure in patients with OSA/hypopnea a systematic review and meta-analysis. Chest 2014; 145:762.
- Chirinos JA, Gurubhagavatula I, Teff K, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med 2014; 370:2265.
- Minnerup J, Ritter MA, Wersching H, et al. Continuous positive airway pressure ventilation for acute ischemic stroke: a randomized feasibility study. Stroke 2012; 43:1137.
- Parra O, Sánchez-Armengol A, Bonnin M, et al. Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Eur Respir J 2011; 37:1128.
- Parra O, Sánchez-Armengol Á, Capote F, et al. Efficacy of continuous positive airway pressure treatment on 5-year survival in patients with ischaemic stroke and obstructive sleep apnea: a randomized controlled trial. J Sleep Res 2015; 24:47.
- Hsu CY, Vennelle M, Li HY, et al. Sleep-disordered breathing after stroke: a randomised controlled trial of continuous positive airway pressure. J Neurol Neurosurg Psychiatry 2006; 77:1143.
- Khot SP, Davis AP, Crane DA, et al. Effect of Continuous Positive Airway Pressure on Stroke Rehabilitation: A Pilot Randomized Sham-Controlled Trial. J Clin Sleep Med 2016; 12:1019.
- Martínez-García MA, Soler-Cataluña JJ, Ejarque-Martínez L, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med 2009; 180:36.
- Martínez-García MA, Campos-Rodríguez F, Soler-Cataluña JJ, et al. Increased incidence of nonfatal cardiovascular events in stroke patients with sleep apnoea: effect of CPAP treatment. Eur Respir J 2012; 39:906.
- Palombini L, Guilleminault C. Stroke and treatment with nasal CPAP. Eur J Neurol 2006; 13:198.
- Watson NF. Stroke and sleep specialists: an opportunity to intervene? J Clin Sleep Med 2010; 6:138.
- Xie W, Zheng F, Song X. Obstructive sleep apnea and serious adverse outcomes in patients with cardiovascular or cerebrovascular disease: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2014; 93:e336.
- Kumar R, Suri JC, Manocha R. Study of association of severity of sleep disordered breathing and functional outcome in stroke patients. Sleep Med 2017; 34:50.
- Good DC, Henkle JQ, Gelber D, et al. Sleep-disordered breathing and poor functional outcome after stroke. Stroke 1996; 27:252.
- Román GC. Pathogenesis of cerebral small-vessel disease in obstructive sleep apnea. In: Sleep, Stroke and Cardiovascular Disease, Culebras A (Ed), Cambridge University Press, Cambridge 2013.
- Kim H, Yun CH, Thomas RJ, et al. Obstructive sleep apnea as a risk factor for cerebral white matter change in a middle-aged and older general population. Sleep 2013; 36:709.
- SLEEP APNEA AS A RISK FACTOR FOR STROKE
- Clinical evidence
- Effect of treatment
- PREVALENCE AFTER STROKE
- CONTRIBUTING FACTORS
- CLINICAL FEATURES
- Screening in post-stroke patients
- Timing and modality of diagnostic testing
- SUMMARY AND RECOMMENDATIONS