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NEUROLOGY 2009;73:1313-1322
© 2009 American Academy of Neurology
Views and Reviews

Sleep-related breathing and sleep-wake disturbances in ischemic stroke

Dirk M. Hermann, MD and Claudio L. Bassetti, MD

From the Department of Neurology (D.M.H.), University Hospital Essen, Germany; and Department of Neurology (C.L.B.), University Hospital Zurich, Switzerland.

Address correspondence and reprint requests to Prof. Dr. Dirk M. Hermann, Department of Neurology, University Hospital Essen, Hufelandstrasse 55, D-45122 Essen, Germany dirk.hermann{at}uk-essen.de; or Prof. Dr. Claudio L. Bassetti, Department of Neurology, University Hospital Zürich, Frauenklinikstrasse 26, CH-8091 Zürich, Switzerland claudio.bassetti{at}usz.ch

Background: Sleep-related breathing disturbances (SDB) and sleep-wake disturbances (SWD) are often neglected in stroke patients. Recent studies suggest that they are frequent and have an impact on stroke outcome.

Methods: We review current knowledge about frequency, clinical presentation, and consequences of poststroke SDB and SWD, and discuss treatment options.

Results: SDB, presenting with obstructive, central, or mixed apneas, is present in 50%–70% of stroke patients. We recommend screening for SDB in all stroke patients by respirography. Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive SDB, which reverses the vascular risk of the patients. In the absence of controlled trials, CPAP treatment should be reserved for patients with severe obstructive SDB, daytime symptoms (e.g., sleepiness), or high cardiovascular risk profile. Oxygen and adaptive servoventilation may be used for central SDB. SWD including insomnia, disturbances of wakefulness (hypersomnia, excessive daytime sleepiness, fatigue), sleep-related movement disorders (restless legs syndrome, periodic limb movements during sleep), and parasomnias (REM sleep behavior disorder) are found in 10%–50% of patients. SWD are associated with cognitive disturbances and may compromise neurologic recovery. Hypnotics and sedative antidepressants may aggravate SDB and neurologic recovery and should be used with caution. For disturbances of wakefulness, dopaminergic drugs, modafinil, or activating antidepressants may be considered. Poststroke sleep-related movement disorders can be treated with dopaminergic drugs; REM sleep behavior disorder with clonazepam.

Conclusions: Sleep-related breathing disturbances and sleep-wake disturbances are frequent conditions that affect stroke outcome. In view of existing treatment options, these conditions deserve the neurologist's awareness.

Abbreviations: AHI = apnea-hypopnea index; BMI = body mass index; CI = confidence interval; CPAP = continuous positive airway pressure; CSA = central sleep apnea; CSB = Cheyne-Stokes breathing; EDS = excessive daytime sleepiness; HR = hazard ratio; OSA = obstructive sleep apnea; PLMS = periodic limb movements in sleep; RLS = restless legs syndrome; SDB = sleep-related breathing disturbances; SWD = sleep-wake disturbances.

Received March 25, 2009. Accepted in final form July 28, 2009.

Disclosure: The authors report no disclosures.