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Sleep and neurology

AWAKE group meeting 11/05/2008 Eric Frenette MD FRCP(C) ‏ Neurologist and Sleep medicine Stanford Sleep Clinic. Sleep and neurology. Sleep and neurology. Sleep is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment

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Sleep and neurology

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  1. AWAKE group meeting 11/05/2008 Eric Frenette MD FRCP(C)‏ Neurologist and Sleep medicine Stanford Sleep Clinic Sleep and neurology

  2. Sleep and neurology • Sleep is a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment Carskadon and Dement, Principles and practice of sleep medicine, 4th edition, Elsevier-Saunders, p. 13

  3. Sleep and neurology • We record sleep during an all-night sleep study, called polysomnography (PSG). • We analyze • Brain waves (EEG)‏ • Eye movements • Breathing (flow and effort)‏ • Muscle tone • Heart rhythm • Oxygen saturation • Leg movements

  4. Sleep and neurology • Normal sleep for an adult • Between 7-9 hours • 4-5 sleep cycles • Sleep cycle • Consists of NREM and REM sleep • 4 stages of NREM sleep (1-2-3-4) and then REM • More slow-wave sleep at beginning of the night (3-4)‏ • More REM sleep at the end of the night

  5. Sleep and neurology • STROKE • Defintion • Sudden brain dysfunction induced by a blood flow disruption • Strokes can be either ischemic (lack of blood flow) of hemorragic (blood vessel rupture)‏ • Anatomy • There are four major blood vessels supplying the brain: 2 carotids and 2 vertebral arteries. • The carotids supply the major part of the brain, while the vertebral arteries supply the brainstem, cerebellum and posterior part of the brain.

  6. Sleep and neurology • STROKE • Epidemiology • Prevalence of stroke is about 1% • 3rd cause of mortality and major cause of disability • Significant proportion of strokes occur during sleep • Obstructive sleep apnea (OSA) and ischemic stroke • Moderate to severe OSA increases risk of stroke by up to 2-3 folds compared to control groups • OSA is an independent risk factor for stroke • OSA is present in up to 60 % of patients in the post-stroke period and 50% at 3 months

  7. Sleep and neurology • STROKE • Treatment • Using CPAP reduces the markers of atherosclerosis in severe OSA • Take home message • OSA is a potentially reversible risk factor for stroke • Risk is significantly increased for moderate-severe OSA • Mild OSA?

  8. Sleep and neurology • EPILEPSY • Definition • Electrical brain dysfunction that manifests itself by seizures • Seizures can be simple, complex, generalized • Epidemiology • Prevalence is 1% of population • OSA is not, per se, a risk factor for epilepsy, although untreated OSA can affect seizure frequency.

  9. Sleep and neurology • EPILEPSY • Treatment • CPAP usage in patient with OSA and poorly controlled epilepsy reduces the number of seizures without the need of changing the antiepileptic drug regimen • How? • Reducing sleep fragmentation • Increasing blood oxygen saturation

  10. Sleep and neurology • EPILEPSY • Seizures frequently occur during sleep and may manifest themselves as: • Confusional arousal • Bizarre behavior • Sleep walking (wandering)‏ • All these manifestations can be mistaken for parasomnia, especially in children • Polysomnogram plus EEG monitoring might be required to make the distinction

  11. Sleep and neurology • EPILEPSY • Take home message • Undertreated OSA can exacerbate epilepsy (seizure frequency)‏ • Nightime manifestations of seizures may mimic parasomnias • PSG and EEG monitoring might be necessary to differentiate one from another

  12. Sleep and neurology • PARKINSON • Definition • Neurodegenarative disease caused by an overall reduction of dopamine production, particularly by the substantia nigra • Epidemiology • Affects 1 in 100 person above 70 yo • Clinical manifestations • Tremor (rest)‏ • Rigidity (cog-wheeling)‏ • Akinesia • Posture changes

  13. Sleep and neurology • PARKINSON • REM sleep behavior disorder • Sleep symptoms can be prominent particularly REM sleep behavior disorder, or RBD • RBD occurs in REM sleep and can be characterized by acting-out dreams, especially dreams with aggressive overtones. • Normally, in REM sleep, there is a loss of muscle tone except for the diaphragm and the eyes

  14. Sleep and neurology • PARKINSON • Diagnosis is made with the help of the clinical history (bed partner)‏ • In RBD, the muscle tone is increased in REM sleep, leading to muscle twitches and sometimes to the full blown syndrome • This can be documented with PSG • Treatment • Clonazepam is the drug of choice

  15. Sleep and neurology • MULTIPLE SCLEROSIS • Definition • Intermittent and recurrent affection of the central nervous system nerve sheaths, probably caused by an immune disorder, that creates neurological symptoms. • Epidemiology • Affects predominantly women • Peak age of onset between 20-40 yo. • Prevalence is 1 or 2 per 1000

  16. Sleep and neurology • MULTIPLE SCLEROSIS • Clinical manifestations • Loss of vision (optic neuritis)‏ • Balance problems (ataxia)‏ • Leg spasticity, sphincter problems, tingling (transverse myelitis)‏ • Fatigue is a common symptom, even in otherwise unaffected individuals • Sleep disruption common (insomnia, pain, leg movements)‏ • Treatment is symptomatic

  17. Sleep and neurology • NEUROMUSCULAR DISORDERS • Amyotrophic Lateral Sclerosis (ALS, Lou Gehrig)‏ • Myotonic dystrophy (Steinert)‏ • Sleep disordered breathing common • Sleep related hypoventilation also seen with weakness of respiratory muscles • Bilevel a better choice than CPAP • Some report evidence of secondary narcolepsy (MD)‏

  18. Sleep and neurology • SUMMARY • Sleep disorders very common in neurological diseases • Patients with sleep disorders (OSA, RBD) at risk for neurological problems (stroke, Parkinson)‏ • Treating the sleep problem may help avoid the neurological consequences

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