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January 11, 2019
Letter to the Editor

Prevalence of sleep-disordered breathing after stroke and TIA
A meta-analysis

Andrea Seiler, MD, Millene Camilo, MD, PhD, Lyudmila Korostovtseva, MD, PhD, Alan G. Haynes, PhD, Anne-Kathrin Brill, MD, Thomas Horvath, MD, Matthias Egger, MD, and Claudio L. Bassetti, MDAuthors Info & Affiliations
February 12, 2019 issue
92 (7) e648-e654
https://doi.org/10.1212/WNL.0000000000006904
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Abstract

Objective

To perform a systematic review and meta-analysis on the prevalence of sleep-disordered breathing (SDB) after stroke.

Methods

We searched PubMed, Embase (Ovid), the Cochrane Library, and CINAHL (from their commencements to April 7, 2017) for clinical studies reporting prevalence and/or severity of SDB after stroke or TIA. Only sleep apnea tests performed with full polysomnography and diagnostic devices of the American Academy of Sleep Medicine categories I–IV were included. We conducted random-effects meta-analysis. PROSPERO registration number: CRD42017072339.

Results

The initial search identified 5,211 publications. Eighty-nine studies (including 7,096 patients) met inclusion criteria. Fifty-four studies were performed in the acute phase after stroke (after less than 1 month), 23 studies in the subacute phase (after 1–3 months), and 12 studies in the chronic phase (after more than 3 months). Mean apnea-hypopnea index was 26.0/h (SD 21.7–31.2). Prevalence of SDB with apnea-hypopnea index greater than 5/h and greater than 30/h was found in 71% (95% confidence interval 66.6%–74.8%) and 30% (95% confidence interval 24.4%–35.5%) of patients, respectively. Severity and prevalence of SDB were similar in all examined phases after stroke, irrespective of the type of sleep apnea test performed. Heterogeneity between studies (I2) was mostly high.

Conclusion

The high prevalence of SDB after stroke and TIA, which persists over time, is important in light of recent studies reporting the (1) feasibility and (2) efficacy of SDB treatment in this clinical setting.

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Letters to the Editor
14 January 2019
Reader response: Prevalence of sleep-disordered breathing after stroke and TIA: A meta-analysis
Razieh Bidhendi Yarandi, Biostatistician | Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences (Tehran, Iran)

I read the interesting meta-analysis article by Seiler et al.1 I assessed the methodologic quality using the 16-item AMSTAR 2 appraisal tool.2 It scored 13 items out of 16 while losing points from items 9, 12, and 13 that are related to the issue of risk of bias (ROB). ROB was not assessed with an appropriate tool in this article;1 its results were not taken into account by appropriate analysis nor into the discussion when interpreting the results. The authors carried out an adequate investigation of publication bias and discussed its likely impact, but no adjusting method was applied (e.g., trim and fill).3

Seiler et al. also mentioned, "A limitation of our method is the statistical approach to a meta-analysis of average counts, which have been treated as if they were normally distributed rather than Poisson distributed. As this was caused by a lack of alternative approaches, we could not correct for this." Metaprop, a statistical program implemented to perform meta-analyses of proportions in Stata, could overcome this issue if applied.4

References

  1. Seiler A, Camilo M, Korostovtseva L, et al. Prevalence of sleep-disordered breathing after stroke and TIA. A meta-analysis. Neurology Epub 2019 Jan 11.
  2. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008.
  3. Duval S, Tweedie R. A Nonparametric "Trim and Fill" Method of Accounting for Publication Bias in Meta-Analysis. J Am Stat Assoc 2000;95:89–98.
  4. Nyaga VN, Arbyn M, Aerts M. Metaprop: a Stata command to perform meta-analysis of binomial data. Arch Public Health 2014;72:39.

Footnotes

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 92 • Number 7 • February 12, 2019
Pages: e648-e654
PubMed: 30635478

Copyright

© 2019 American Academy of Neurology.

Publication History

Received: March 9, 2018
Accepted: December 14, 2018
Published online: January 11, 2019
Published in print: February 12, 2019

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Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Study Funding

Swiss National Science Foundation grants 320030-149752 and 320030-125069.

Authors

Affiliations & Disclosures

Andrea Seiler, MD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) Swiss National Science Foundation grant 320030-149752 (financial support). (2) Swiss Nataional Science Foundation grant 320030-125069 (financial support). Both are stated in the manuscript.
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
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Millene Camilo, MD, PhD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
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1.
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Lyudmila Korostovtseva, MD, PhD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Arterial Hypertension, scientific editor, since 2013.
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
(1) Russian Scientific Foundation, grant 17-75-10099 (2017-2019) (2) International Society of Hypertension, travel grant for the congress 2018
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
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Alan G. Haynes, PhD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
(1) DSMB statistician for the MasterDAPT trial
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
AGH is affiliated with CTU Bern, University of Bern, which has a staff policy of not accepting honoraria or consultancy fees. However, CTU Bern is involved in design, conduct, or analysis of clinical studies funded by not-for-profit and for-profit organizations. In particular, pharmaceutical and medical device companies provide direct funding to some of these studies. For an up-to-date list of CTU Bern?s conflicts of interest see http://www.ctu.unibe.ch/research/declaration_of_interest/index_eng.html.
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
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Anne-Kathrin Brill, MD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
(1) Department of Pulmonary Medicine of the University Hospital Bern, sleep studies and CPAP treatment, 20%
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
(1) University Hospital Bern, research grant no. 84800857
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
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1.
NONE
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1.
NONE
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NONE
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Thomas Horvath, MD
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
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Matthias Egger, MD*
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
PLoS Medicine, Specialty Consulting Editor, 2015 to present. Journal of Epidemiology and Community Health, member of Editorial Board, 2012 to present International Journal of Epidemiology, Editor, 2005-2015
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Swiss National Science Foundation, grant number 174281, principal investigator, 2017-2020.
Research Support, Academic Entities:
1.
NONE
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Claudio L. Bassetti, MD*
From the Sleep Wake Epilepsy Center (A.S., M.C., L.K., A.-K.B., T.H., C.L.B.), and Departments of Neurology (A.S., M.C., L.K., T.H., C.L.B.) and Pulmonary Medicine (A.-K.B.), Bern University Hospital, University of Bern, Switzerland; Neurology Division (M.C.), Department of Neuroscience and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Brazil; Hypertension Department (L.K.), Somnology Group, Almazov National Medical Research Center, St. Petersburg, Russia; and CTU Bern (A.G.H.), and Institute of Social and Preventive Medicine (A.G.H., M.E.), University of Bern, Switzerland.
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Clinical and Translational Neuroscience Journal of Sleep Research Sleep Sleep Medicine Somnology Neurobiology of Sleep and Circadian Rhythms European Neurology Belgian Neurological Journal
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Swiss National Science Foundation
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Swiss Heart Foundation Tropos Foundation
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Notes

Correspondence Prof. Bassetti [email protected]
*
These authors contributed equally to this work as last authors.
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

A. Seiler: study concept and design, acquisition, analysis and interpretation of data, writing of the manuscript. M. Camilo: study concept and design, acquisition of data, revision of the manuscript. L. Korostovtseva: study concept and design, acquisition of data, revision of the manuscript. A.G. Haynes: statistical analysis, interpretation of data. A.-K. Brill: study concept and design, interpretation of data, revision of the manuscript. T. Horvath: study concept and design, interpretation of data, revision of the manuscript. M. Egger: study concept and design, interpretation of data, revision of the manuscript. C.L. Bassetti: study concept and design, analysis and interpretation of data, revision of the manuscript. All authors have seen and approved the final version.

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