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Carosella CM, Gottesman RF, Kucharska-Newton A, Lutsey PL, Spira AP, Punjabi NM, Schneider ALC, Full KM, Johnson EL. Sleep apnea, hypoxia, and late-onset epilepsy: the Atherosclerosis Risk in Communities study. Sleep 2024; 47:zsad233. [PMID: 37672002 PMCID: PMC11168763 DOI: 10.1093/sleep/zsad233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/07/2023] [Indexed: 09/07/2023] Open
Abstract
STUDY OBJECTIVE Sleep apnea is associated with unexplained epilepsy in older adults in small studies. We sought to determine the relationship between sleep apnea and additional sleep characteristics and late-onset epilepsy (LOE), adjusting for comorbidities, using data from the large, prospective Atherosclerosis Risk in Communities (ARIC) Study cohort. METHODS We used Medicare claims to identify cases of LOE in ARIC participants. We used polysomnography data from 1309 ARIC participants who also participated in the Sleep Heart Health Study in 1995-1998, and demographic and comorbidity data from ARIC. Later risk of LOE was evaluated using survival analysis with a competing risk of death. We also used survival analysis in 2672 ARIC participants to identify the association between self-reported obstructive sleep apnea (2011-2013), and the risk of subsequent LOE. RESULTS Late-midlife oxygen desaturation to less than 80% during sleep was associated with subsequent development of LOE, adjusted subhazard ratio 3.28 (1.18-9.08), but the apnea-hypopnea index was not related. Participant report of diagnosis of sleep apnea in 2011-2013 was also associated with subsequent LOE, adjusted subhazard ratio 2.59 (1.24-5.39). CONCLUSIONS Sleep apnea and oxygen saturation nadir during sleep are associated with LOE, independently of hypertension and other comorbidities. These potentially modifiable risk factors could have large clinical implications for LOE.
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Affiliation(s)
| | - Rebecca F Gottesman
- National Institutes of Health, National Institute for Neurologic Disorders and Stroke Intramural Research Program, Bethesda, MD, USA
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
- Department of Epidemiology, University of Kentucky, Lexington, KY, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Adam P Spira
- Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins Center on Aging and Health, Baltimore, MD, USA
| | - Naresh M Punjabi
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Miami, Miami, FL, USA
| | - Andrea L C Schneider
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics Philadelphia, University of Pennsylvania, PA, USA
| | - Kelsie M Full
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Emily L Johnson
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Grigg-Damberger M, Foldvary-Schaefer N. Hypoxia not AHI in adults with sleep apnea midlife markedly increases risk of late-onset epilepsy-Carosella CM et al Sleep apnea, hypoxia, and late-onset epilepsy: the Atherosclerosis Risk in Communities study SLEEP-2023-0175.R1. Sleep 2024; 47:zsad252. [PMID: 37777197 DOI: 10.1093/sleep/zsad252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Indexed: 10/02/2023] Open
Affiliation(s)
| | - Nancy Foldvary-Schaefer
- Cleveland Clinic Neurological Institute, Cleveland Clinic Lerner College of Medicine, Sleep Disorders and Epilepsy Centers, Cleveland, OH, USA
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Wang S, Wu M, Wu S, Lin F, Ji X, Yan J. A polysomnographic study of slow-wave sleep loss in elderly patients with epilepsy. Heliyon 2024; 10:e25904. [PMID: 38379992 PMCID: PMC10877289 DOI: 10.1016/j.heliyon.2024.e25904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/02/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024] Open
Abstract
Objective The primary objective is to explore what causes slow-wave sleep loss in elderly patients with epilepsy. The secondary objective is to identify the PSG characteristics in elderly patients with epilepsy. The clinical demographics, sleep architecture, sleep-related events, and interictal epileptiform discharges are to be evaluated in the objectives. Methods The video electroencephalography (VEEG) and polysomnogram (PSG) data from 44 elderly patients with epilepsy and 52 elderly patients with sleep disorders but without definite central nervous system diseases were analysed. This was a case-control study. The differences in the PSG sleep architecture parameters (total sleep time (TST), sleep efficiency, wake after sleep onset, etc.) and sleep-related events (apnea hypopnea index, oxygen desaturation index (ODI), periodic limb movement index, etc.) between the epilepsy and control groups. As Additionally, these parameters were assessed within the elderly patients with epilepsy, comparing the slow-wave sleep existence and slow-wave sleep loss groups, using VEEG and PSG. Results The epileptic group exhibited significantly lower TST (343.477 ± 96.3046min vs 389.115 ± 61.5727min, p < 0.05), rapid eye movement (%) (13.011 ± 7.5384 vs 16.992 ± 6.7025, p < 0.05), non-rapid eye movement stage 3 (%) (1.35[0,7.225] vs 3.65[0.425,13.75], p < 0.05), and sleep efficiency (%) (69.482 ± 14.1771% vs 77.242 ± 10.6171%, p < 0.05). Conversely, the ODI (25.6[9.825,51.775] events/hour vs 16.85[5.3,30.425] events/hour, p < 0.05) and spontaneous arousal index (4.0455[2.1805,6.9609] events/hour vs 2.9709[1.4747,5.0554] events/hour, p < 0.05) were significantly higher in elderly patients with epilepsy. The prevalence of obstructive sleep apnea-hypopnea syndrome (OSAHS) was significantly higher in the slow-wave sleep loss group than in the slow-wave sleep existence group (100% vs 77.8%, p < 0.05). The incidence of slow-wave sleep loss was lower in patients with epilepsy aged between 75 and 85 years compared to those aged between 65 and 75 years. Conclusion Elderly patients with epilepsy exhibit higher levels of ODI and spontaneous arousal index. Our findings indicate that OSAHS could be a contributing factor to slow-wave sleep loss in this population. The incidence of slow-wave sleep loss was lower in patients aged above 75 years among elderly patients with epilepsy.
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Affiliation(s)
| | | | - Sangru Wu
- Department of Neurology and Sleep Medical Center, Fujian Provincial Governmental Hospital, Fuzhou, China
| | - Fang Lin
- Department of Neurology and Sleep Medical Center, Fujian Provincial Governmental Hospital, Fuzhou, China
| | - Xiaolin Ji
- Department of Neurology and Sleep Medical Center, Fujian Provincial Governmental Hospital, Fuzhou, China
| | - Jinzhu Yan
- Department of Neurology and Sleep Medical Center, Fujian Provincial Governmental Hospital, Fuzhou, China
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El Youssef N, Marchi A, Bartolomei F, Bonini F, Lambert I. Sleep and epilepsy: A clinical and pathophysiological overview. Rev Neurol (Paris) 2023; 179:687-702. [PMID: 37598088 DOI: 10.1016/j.neurol.2023.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 07/28/2023] [Accepted: 07/29/2023] [Indexed: 08/21/2023]
Abstract
The interaction between sleep and epilepsy is complex. A better understanding of the mechanisms linking sleep and epilepsy appears increasingly important as it may improve diagnosis and therapeutic strategies in patients with epilepsy. In this narrative review, we aim to (i) provide an overview of the physiological and pathophysiological processes linking sleep and epilepsy; (ii) present common sleep disorders in patients with epilepsy; (iii) discuss how sleep and sleep disorders should be considered in new therapeutic approaches to epilepsy such as neurostimulation; and (iv) present the overall nocturnal manifestations and differential diagnosis between epileptic seizures and parasomnia.
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Affiliation(s)
- N El Youssef
- AP-HM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France
| | - A Marchi
- AP-HM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France
| | - F Bartolomei
- AP-HM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France; Aix-Marseille University, Inserm, Inst Neurosci Syst (INS), Marseille, France
| | - F Bonini
- AP-HM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France; Aix-Marseille University, Inserm, Inst Neurosci Syst (INS), Marseille, France
| | - I Lambert
- AP-HM, Timone hospital, Sleep Unit, Epileptology and Cerebral Rhythmology, Marseille, France; Aix-Marseille University, Inserm, Inst Neurosci Syst (INS), Marseille, France.
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Al-Abri M, Al Asmi A, Rizvi S, Al-Mashaikhi T, Al Abri H, Al-Majrafi H, Gujjar AR. The Relationship Between Epilepsy Control and the Duration of Nighttime Sleep and Afternoon Siesta. Cureus 2023; 15:e39266. [PMID: 37342755 PMCID: PMC10278951 DOI: 10.7759/cureus.39266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2023] [Indexed: 06/23/2023] Open
Abstract
CONTEXT The association between epilepsy control and the duration of sleep among people with epilepsy (PWE) is not well studied in Middle Eastern countries such as Oman. AIMS To describe the sleep habits of PWE in Oman and explore the association of their sleep habits at night and afternoon siesta with the level of seizure control achieved and antiseizure medications (ASMs) consumed. METHODS The subjects of this cross-sectional study were adult epilepsy patients attending a neurology clinic. Their sleep parameters were measured for one week using actigraphy. Home sleep apnea testing for one night was conducted to rule out obstructive sleep apnea (OSA). RESULTS A total of 129 PWE completed the study. Their mean age was 29.8 ± 9.2 years, and their mean body mass index (BMI) was 27.1 kg/m2. There was no significant difference between the people with controlled and uncontrolled epilepsy as regards the duration of night sleep or afternoon siesta (p = 0.24 and 0.37, respectively). There was also no significant correlation between their nighttime sleep duration, afternoon siesta, and the number of ASMs they consumed (p = 0.402 and 0.717, respectively). CONCLUSION The study revealed that the sleep habits of PWE with uncontrolled epilepsy who consumed more ASMs were not significantly different from those with controlled epilepsy who consumed fewer ASMs.
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Affiliation(s)
| | | | - Syed Rizvi
- Family Medicine and Public Health, Sultan Qaboos University, Muscat, OMN
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Barone DA, Segal AZ. Obstructive Sleep Apnea and Positive Airway Pressure Usage in Populations with Neurological Disease. Sleep Med Clin 2022; 17:619-627. [DOI: 10.1016/j.jsmc.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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7
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Sleep and Epilepsy. Neurol Clin 2022; 40:769-783. [DOI: 10.1016/j.ncl.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Joyal KG, Kreitlow BL, Buchanan GF. The role of sleep state and time of day in modulating breathing in epilepsy: implications for sudden unexpected death in epilepsy. Front Neural Circuits 2022; 16:983211. [PMID: 36082111 PMCID: PMC9445500 DOI: 10.3389/fncir.2022.983211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death among patients with refractory epilepsy. While the exact etiology of SUDEP is unknown, mounting evidence implicates respiratory dysfunction as a precipitating factor in cases of seizure-induced death. Dysregulation of breathing can occur in epilepsy patients during and after seizures as well as interictally, with many epilepsy patients exhibiting sleep-disordered breathing (SDB), such as obstructive sleep apnea (OSA). The majority of SUDEP cases occur during the night, with the victim found prone in or near a bed. As breathing is modulated in both a time-of-day and sleep state-dependent manner, it is relevant to examine the added burden of nocturnal seizures on respiratory function. This review explores the current state of understanding of the relationship between respiratory function, sleep state and time of day, and epilepsy. We highlight sleep as a particularly vulnerable period for individuals with epilepsy and press that this topic warrants further investigation in order to develop therapeutic interventions to mitigate the risk of SUDEP.
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Affiliation(s)
- Katelyn G. Joyal
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Benjamin L. Kreitlow
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Medical Scientist Training Program, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Gordon F. Buchanan
- Interdisciplinary Graduate Program in Neuroscience, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Iowa Neuroscience Institute, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Medical Scientist Training Program, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- *Correspondence: Gordon F. Buchanan
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Silva FSL, Furlanetto KC, Neves LMT, Cipriano GFB, Accioly MF, Viana-Júnior AB, Alves TB, Moraes WRA, Lima ACGB, Ribeiro KB, Sobreira-Neto MA, Leite CF. Translation, transcultural adaptation, and validation of the Brazilian Portuguese version of the Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire. Sleep Breath 2022; 27:1195-1201. [DOI: 10.1007/s11325-022-02661-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 05/05/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022]
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10
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Gu L, Yu Q, Shen Y, Wang Y, Xu Q, Zhang H. The role of monoaminergic neurons in modulating respiration during sleep and the connection with SUDEP. Biomed Pharmacother 2022; 150:112983. [PMID: 35453009 DOI: 10.1016/j.biopha.2022.112983] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/04/2022] [Accepted: 04/14/2022] [Indexed: 11/25/2022] Open
Abstract
Sudden unexpected death in epilepsy (SUDEP) is the leading cause of death among epilepsy patients, occurring even more frequently in cases with anti-epileptic drug resistance. Despite some advancements in characterizing SUDEP, the underlying mechanism remains incompletely understood. This review summarizes the latest advances in our understanding of the pathogenic mechanisms of SUDEP, in order to identify possible targets for the development of new strategies to prevent SUDEP. Based on our previous research along with the current literature, we focus on the role of sleep-disordered breathing (SDB) and its related neural mechanisms to consider the possible roles of monoaminergic neurons in the modulation of respiration during sleep and the occurrence of SUDEP. Overall, this review suggests that targeting the monoaminergic neurons is a promising approach to preventing SUDEP. The proposed roles of SDB and related monoaminergic neural mechanisms in SUDEP provide new insights for explaining the pathogenesis of SUDEP.
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Affiliation(s)
- LeYuan Gu
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qian Yu
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Yue Shen
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - YuLing Wang
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - Qing Xu
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China
| | - HongHai Zhang
- Department of Anesthesiology, The Fourth Clinical School of Medicine, Zhejiang Chinese Medical University, Hangzhou 310006, China; Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310006, China; Westlake Laboratory of Life Sciences and Biomedicine, Hangzhou 310006, China.
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11
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Leschziner G. Seizures and Sleep: Not such strange bedfellows. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2022. [DOI: 10.47795/qtgn2231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
It has long been recognised that sleep and deprivation of it have important consequences for cortical excitability, the electroencephalogram and seizure control. However, in the management of people with epilepsy, it is also important to recognise that epilepsy and its treatment may also have significant implications for sleep. Lack of consideration for this bidirectional relationship between sleep and epilepsy may have negative consequences on individuals’ seizure control, quality of life, and other aspects of their health.
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Garg D, Charlesworth L, Shukla G. Sleep and Temporal Lobe Epilepsy – Associations, Mechanisms and Treatment Implications. Front Hum Neurosci 2022; 16:849899. [PMID: 35558736 PMCID: PMC9086778 DOI: 10.3389/fnhum.2022.849899] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
In this systematic review, we aim to describe the association between temporal lobe epilepsy (TLE) and sleep, with bidirectional links in mechanisms and therapeutic aspects. Sleep stages may variably impact seizure occurrence, secondary generalization and the development, frequency and distribution of interictal epileptiform discharges. Conversely, epilepsy affects sleep micro- and macroarchitecture. TLE, the most frequent form of drug resistant epilepsy (DRE), shares an enduring relationship with sleep, with some intriguing potential mechanisms specific to anatomic localization, linking the two. Sleep characteristics of TLE may also inform localizing properties in persons with DRE, since seizures arising from the temporal lobe seem to be more common during wakefulness, compared to seizures of extratemporal origin. Polysomnographic studies indicate that persons with TLE may experience excessive daytime somnolence, disrupted sleep architecture, increased wake after sleep onset, frequent shifts in sleep stages, lower sleep efficiency, decreased rapid eye movement (REM) sleep, and possibly, increased incidence of sleep apnea. Limited literature suggests that effective epilepsy surgery may remedy many of these objective and subjective sleep-related concerns, via multipronged effects, apart from reduced seizure frequency. Additionally, sleep abnormalities also seem to influence memory, language and cognitive-executive function in both medically controlled and refractory TLE. Another aspect of the relationship pertains to anti-seizure medications (ASMs), which may contribute significantly to sleep characteristics and abnormalities in persons with TLE. Literature focused on specific aspects of TLE and sleep is limited, and heterogeneous. Future investigations are essential to understand the pathogenetic mechanisms linking sleep abnormalities on epilepsy outcomes in the important sub-population of TLE.
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Affiliation(s)
- Divyani Garg
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | | | - Garima Shukla
- Division of Epilepsy and Sleep Medicine, Queen’s University, Kingston, ON, Canada
- *Correspondence: Garima Shukla,
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Effects of Obstructive Sleep Apnea on Epilepsy, and Continuous Positive Airway Pressure as a Treatment Option. J Clin Med 2022; 11:jcm11072063. [PMID: 35407671 PMCID: PMC8999241 DOI: 10.3390/jcm11072063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/17/2022] [Accepted: 04/02/2022] [Indexed: 02/05/2023] Open
Abstract
Purpose: To compare the characteristics of obstructive sleep apnea (OSA) between patients with epilepsy and patients without epilepsy and to investigate CPAP (Continuous Positive Airway Pressure) effect on seizures. Methods: Medical and polysomnography (PSG) data from 235 adult OSA patients with epilepsy (OE; 183 males; mean age, 49.8 years) and 268 age- and sex-matched OSA patients without epilepsy (OSE; 216 males; mean age, 51.3 years), obtained between March 2014 and May 2020 and housed in a database in a university-affiliated hospital, were retrospectively reviewed. All subjects completed surveys addressing comorbidities and medications, and sleep-related questionnaires including the Insomnia Severity Index, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Beck Depression Inventory-II. Results: Compared with the OSE group, the OE group reported fewer sleep-related complaints and less severe OSA-related PSG parameters, with a lower apnea-hypopnea index (24.9 vs. 33.4 events/h; p < 0.003), arousal index (23.3 vs. 30.8 events/h; p < 0.001), and oxygen desaturation index (19.6 vs. 28.8; p < 0.002). The OE group had fewer smokers and lower alcohol consumption but a higher body mass index (27.0 vs. 25.9 kg/m2; p < 0.001). No correlations were observed between OSA-related PSG parameters and epilepsy-related factors, such as age at seizure onset, seizure type, frequency of seizures, presence of nocturnal seizures, and number of antiseizure medications, in the OE group. Patients with OE who demonstrated good compliance with CPAP therapy exhibited a decrease in seizure frequency. Conclusions: The OE group exhibited less severe disease characteristics than their age- and sex-matched OSE counterparts. Nevertheless, because the coexistence of OSA and epilepsy is high, CPAP therapy can reduce the frequency of seizures. Therefore, it is important to evaluate the presence of OSA in patients with epilepsy and to treat the conditions concurrently.
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Szabó R, Voiță-Mekereș F, Tudoran C, Abu-Awwad A, Tudoran M, Mihancea P, Ilea CDN. Evaluation of Sleep Disturbances in Patients with Nocturnal Epileptic Seizures in a Romanian Cross-Sectional Study. Healthcare (Basel) 2022; 10:healthcare10030588. [PMID: 35327066 PMCID: PMC8950862 DOI: 10.3390/healthcare10030588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/13/2022] [Accepted: 03/17/2022] [Indexed: 01/25/2023] Open
Abstract
(1) Background: Based on the premise that epilepsy is frequently associated with hypnopathies, in this study we aim to analyze the prevalence of sleep disturbances among patients with epilepsy, with exclusively or predominantly nocturnal seizures, in relation to demographic factors as well as clinical and electroencephalography (EEG) aspects. (2) Methods: 69 patients with nocturnal epilepsy were included in our study. Sleep disturbances were measured with the Pittsburgh Sleep Quality Index (PSQI) questionnaire, followed by a long-term video-EEG monitoring during sleep. We analyzed the PSQI results in relation to patients' gender and age and determined the correlations between the PSQI scores and the modifications on video-EEG recordings, in comparison to a control group of 25 patients with epilepsy but without nocturnal seizures. (3) Results: We found a statistically significant difference between the PSQI of patients with nocturnal seizures compared to those without nocturnal epileptic manifestations. In the experimental group, the mean PSQI score was 7.36 ± 3.91 versus 5.04 ± 2.56 in controls. In women, the average PSQI score was 8.26, whilst in men it only reached 6.41, highlighting a statistically significant difference between genders (p ˂ 0.01). By examining the relationships between the PSQI scores and certain sleep-related factors, evidenced on the nocturnal video-EEG, we found a statistically significant difference between PSQI values of patients who reached the N2 stage, and those who reached the N3 stage of nonrapid eye movement (NREM) sleep, highlighting that those with a more superficial nocturnal sleep also had higher PSQI scores. There were no statistically significant differences regarding the PSQI scores between patients with or without interictal epileptiform discharges, and also in the few patients with nocturnal seizures where we captured ictal activity. (4) Conclusions: we evidenced in this study a poor quality of sleep in patients with nocturnal epilepsy, mostly in women, independent of age. We observed that sleep disturbances were due to superficial and fragmented sleep with frequent microarousals, not necessarily caused by the electrical epileptiform activity.
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Affiliation(s)
- Réka Szabó
- Department of Neurological Rehabilitation, Municipal Clinical Hospital, 410469 Oradea, Romania;
- Doctoral School, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Square, 410068 Oradea, Romania; (P.M.); (C.D.N.I.)
| | - Florica Voiță-Mekereș
- Department of Morphology, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Square, 410068 Oradea, Romania
- Correspondence: (F.V.-M.); (C.T.); Tel.: +40-747-432-197 (F.V.-M.); +40-722-669-086 (C.T.)
| | - Cristina Tudoran
- Department VII, Internal Medicine II, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania;
- Center of Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- County Emergency Hospital, L. Rebreanu Str., Nr. 156, 300723 Timisoara, Romania
- Correspondence: (F.V.-M.); (C.T.); Tel.: +40-747-432-197 (F.V.-M.); +40-722-669-086 (C.T.)
| | - Ahmed Abu-Awwad
- Department XV—Orthopedics Traumatology, Urology, and Medical Imaging Internal Medicine II, Faculty of Medicine, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania;
| | - Mariana Tudoran
- Department VII, Internal Medicine II, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania;
- Center of Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, University of Medicine and Pharmacy “Victor Babes” Timisoara, E. Murgu Square, Nr. 2, 300041 Timisoara, Romania
- County Emergency Hospital, L. Rebreanu Str., Nr. 156, 300723 Timisoara, Romania
| | - Petru Mihancea
- Doctoral School, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Square, 410068 Oradea, Romania; (P.M.); (C.D.N.I.)
| | - Codrin Dan Nicolae Ilea
- Doctoral School, Faculty of Medicine and Pharmacy, University of Oradea, 1 December Square, 410068 Oradea, Romania; (P.M.); (C.D.N.I.)
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Bonilla-Jaime H, Zeleke H, Rojas A, Espinosa-Garcia C. Sleep Disruption Worsens Seizures: Neuroinflammation as a Potential Mechanistic Link. Int J Mol Sci 2021; 22:12531. [PMID: 34830412 PMCID: PMC8617844 DOI: 10.3390/ijms222212531] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 12/13/2022] Open
Abstract
Sleep disturbances, such as insomnia, obstructive sleep apnea, and daytime sleepiness, are common in people diagnosed with epilepsy. These disturbances can be attributed to nocturnal seizures, psychosocial factors, and/or the use of anti-epileptic drugs with sleep-modifying side effects. Epilepsy patients with poor sleep quality have intensified seizure frequency and disease progression compared to their well-rested counterparts. A better understanding of the complex relationship between sleep and epilepsy is needed, since approximately 20% of seizures and more than 90% of sudden unexpected deaths in epilepsy occur during sleep. Emerging studies suggest that neuroinflammation, (e.g., the CNS immune response characterized by the change in expression of inflammatory mediators and glial activation) may be a potential link between sleep deprivation and seizures. Here, we review the mechanisms by which sleep deprivation induces neuroinflammation and propose that neuroinflammation synergizes with seizure activity to worsen neurodegeneration in the epileptic brain. Additionally, we highlight the relevance of sleep interventions, often overlooked by physicians, to manage seizures, prevent epilepsy-related mortality, and improve quality of life.
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Affiliation(s)
- Herlinda Bonilla-Jaime
- Departamento de Biología de la Reproducción, Área de Biología Conductual y Reproductiva, Universidad Autónoma Metropolitana-Iztapalapa, Ciudad de Mexico CP 09340, Mexico;
| | - Helena Zeleke
- Neuroscience and Behavioral Biology Program, College of Arts and Sciences, Emory University, Atlanta, GA 30322, USA;
| | - Asheebo Rojas
- Department of Pharmacology and Chemical Biology, School of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Claudia Espinosa-Garcia
- Department of Pharmacology and Chemical Biology, School of Medicine, Emory University, Atlanta, GA 30322, USA
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Nobili L, Beniczky S, Eriksson SH, Romigi A, Ryvlin P, Toledo M, Rosenzweig I. Expert Opinion: Managing sleep disturbances in people with epilepsy. Epilepsy Behav 2021; 124:108341. [PMID: 34619543 DOI: 10.1016/j.yebeh.2021.108341] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 12/21/2022]
Abstract
Poor sleep and daytime sleepiness are common in people with epilepsy. Sleep disorders can disrupt seizure control and in turn sleep and vigilance problems can be exacerbated by seizures and by antiepileptic treatments. Nevertheless, these aspects are frequently overlooked in clinical practice and a clear agreement on the evidence-based guidelines for managing common sleep disorders in people with epilepsy is lacking. Recently, recommendations to standardize the diagnostic pathway for evaluating patients with sleep-related epilepsies and comorbid sleep disorders have been presented. To build on these, we adopted the Delphi method to establish a consensus within a group of experts and we provide practical recommendations for identifying and managing poor night-time sleep and daytime sleepiness in people with epilepsy. We recommend that a comprehensive clinical history of sleep habits and sleep hygiene should be always obtained from all people with epilepsy and their bed partners. A psychoeducational approach to inform patients about habits or practices that may negatively influence their sleep or their vigilance levels should be used, and strategies for avoiding these should be applied. In case of a suspected comorbid sleep disorder an appropriate diagnostic investigation should be performed. Moreover, the possible presence of sleep fragmentation induced by sleep-related seizures should be ruled out. Finally, the dose and timing of antiepileptic medications and other co-medications should be optimized to improve nocturnal sleep and avoid daytime sedation.
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Affiliation(s)
- Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy; Child Neuropsychiatry Unit, Istituto G. Gaslini, Genoa, Italy.
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre and Aarhus University Hospital, Denmark.
| | - Sofia H Eriksson
- Department of Clinical and Experiential Epilepsy, UCL Institute of Neurology, University College London, London, UK.
| | | | - Philippe Ryvlin
- Department of Clinical Neurosciences, Vaud University Hospital Center, Lausanne, Switzerland
| | - Manuel Toledo
- Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Ivana Rosenzweig
- Sleep and Brain Plasticity Centre, Kings College London and Sleep Disorders Centre, GSTT NHS Trust, London, UK.
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Perceived quality of life (QOLIE-31-P), depression (NDDI-E), anxiety (GAD-7), and insomnia in patients with epilepsy attended at a refractory epilepsy unit in real-life clinical practice. Neurol Sci 2021; 43:1955-1964. [PMID: 34524559 PMCID: PMC8440152 DOI: 10.1007/s10072-021-05595-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/06/2021] [Indexed: 11/26/2022]
Abstract
Objectives This study aims to evaluate the relationship between psychiatric comorbidity (anxiety and depression), somnolence, and quality of life, using validated scales in patients with epilepsy in real-life clinical practice and clinical and demographic variables. Methods A cross-sectional observational study was conducted. Self-administered scales of anxiety disorders (GAD-7), depression (NDDI-E), somnolence (Epworth Sleepiness Scale (ESS)), and quality of life (QOLIE-31-P) in patients with epilepsy treated in the refractory epilepsy unit of a tertiary hospital were employed. Results Eighty-four patients, 44.3 ± 17.4 years, 48.2% women, epilepsy duration 21.5 ± 15.9 years, and number of antiepileptic drugs 1.9 ± 1.2 were included. Severe anxiety was present in 14.3%, depression in 20.2%, and somnolence in 14.3% of patients. QOLIE-31-P score was 62.0 ± 19.2. Depression and focal epilepsy (OR = 4.5[1.3, 20.7], p = 0.029), as well as anxiety and temporal lobe epilepsy (OR = 4.3 [1.0, 18.1], p = 0.044), were associated. Moreover, relationships between worse quality of life and higher scores from NDDI-E (β = − 1.42, adjusted p = 0.006) and GAD-7 (β = − 1.21, adjusted p = 0.006), especially in drug-resistant epilepsy (β = − 8.08, adjusted p = 0.045) and female sex (β = − 7.83, adjusted p = 0.034), were identified. Statistically significant negative associations were observed between problems to fall asleep and overall quality of life score (β = − 11.64, adjusted p = 0.022), sleep disturbance and energy (β = − 14.78, adjusted p = 0.027), and mood (β = 12.40, adjusted p = 0.027) scores. Conclusions The multidimensional evaluation revealed that higher levels of anxiety and depression are associated with worse quality of life in real clinical practice in patients with epilepsy, especially in females and drug-resistant epilepsy. In addition, sleep disturbances are associated with particular aspects of the quality of life. Further studies with longitudinal follow-up would be useful to adequately manage these comorbidities in patients with epilepsy. Supplementary Information The online version contains supplementary material available at 10.1007/s10072-021-05595-3.
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18
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Zaccara G, Bartolini E, Tramacere L, Lattanzi S. Drugs for patients with epilepsy and excessive daytime sleepiness. Epilepsy Behav 2021; 124:108311. [PMID: 34534876 DOI: 10.1016/j.yebeh.2021.108311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
Excessive daytime sleepiness (EDS) and attentional deficits are often observed in people with epilepsy. They may be the consequence of seizures and subclinical discharges as well as of comorbid conditions as obstructive sleep apnea/hypopnea syndrome (OSAS), attention deficit hyperactivity disorder (ADHD), or other less frequent disorders. Excessive daytime sleepiness may also be caused or worsened by antiseizure medications (ASMs). Several meta-analyses suggested that lamotrigine, lacosamide, and perhaps eslicarbazepine are less sedative than other traditional and new ASMs and, in patients prone to somnolence, might be preferred over ASMs with more sedative properties. In patients with severe EDS and/or ADHD, advantages and risks of a treatment with a psychostimulant need to be considered. Methylphenidate, modafinil, armodafinil, pitolisant, and solriamfetol are authorized for use in ADHD and EDS in patients with narcolepsy and some of them also in OSAS. These agents are off-label for the treatment of EDS associated with epilepsy. They do not have proconvulsant effects, although there are several possible risks for patients with epilepsy. The risks of cardiovascular events and psychiatric symptoms should be carefully evaluated as such disorders can coexist with epilepsy and be triggered by these agents. Finally, combination of psychostimulants with ASMs may be associated with several pharmacokinetic drug-drug interactions.
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Affiliation(s)
| | - Emanuele Bartolini
- USL Centro Toscana, Neurology Unit, Nuovo Ospedale Santo Stefano, Prato, Italy
| | - Luciana Tramacere
- USL Centro Toscana, Neurology Unit, Ospedale San Giovanni di Dio, Firenze, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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Serafini R. How much can medical management alone improve the outcome of adult drug-resistant epilepsy? An exploratory study on possibilities and limitations of combining multiple therapeutic actions. Epilepsy Behav 2021; 122:108065. [PMID: 34243142 DOI: 10.1016/j.yebeh.2021.108065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 05/03/2021] [Accepted: 05/08/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Failure to control epileptic seizures with two medications, adequately chosen and dosed, indicates drug-resistant epilepsy (DRE). The chance of pharmacologically controlling seizures is low for patients with DRE and uncontrolled seizures who are not candidates for surgery, who have already undergone surgery, or who already had a vagus nerve stimulator (VNS) placed. Patients experiencing these conditions must instead rely on medical management of their seizures, and there is no breakthrough solution on the horizon. Medical care of DRE might be optimized by systematically considering factors that promote and inhibit breakthrough seizures. For example, seizure control could be enhanced through measures such as increasing the frequency of follow-up visits, tracking treatment plan compliance, treating sleep disorders, rational polypharmacy, adjusting drug administration to achieve higher levels when seizures are more likely and educating patients on seizure triggers. A systematic and simultaneous implementation of all of these measures is likely to yield a sizable, clinically relevant, improvement. This paper presents an exploratory study on the effects of implementing such an approach, specifically evaluating this method's impact on seizure frequency. METHODS I performed a retrospective chart review of 659 consecutive adult patients with epilepsy followed up at the University of Utah and at the Salt Lake City VA Medical center using the multimodal approach described above. I identified 27 patients who had DRE and uncontrolled seizures and in whom a medical management optimization protocol was implemented. I measured these patients' seizure frequency at the beginning and the end of the study period and compared the results with those of a matching control group of 48 patients. RESULTS The optimization protocol did not increase the number of seizure-free patients with DRE; however, it was effective in minimizing seizure frequency in patients whose seizures remained uncontrolled. Among these patients, the median seizure frequency dropped by 64% in the optimization group but did not change in the control group. CONCLUSIONS Despite the high occurrence of DRE, there is no accepted protocol for the related medical management. This paper describes an effective approach that can be implemented in a clinically relevant and readily achievable manner.
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Affiliation(s)
- Ruggero Serafini
- Department of Neurology, University of Utah Clinical Neuroscience Center, George E. Wahlen VA Medical Center, 175 North Medical Drive East, 5th Floor, Salt Lake City, UT 84132, USA.
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20
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Yeh WC, Lin PJ, Chuang YC, Hsu CY. Quantitative evaluation of the microstructure of rapid eye movement sleep in refractory epilepsy: a preliminary study using electroencephalography and heart rate variability analysis. Sleep Med 2021; 85:239-245. [PMID: 34364095 DOI: 10.1016/j.sleep.2021.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patients with epilepsy have a disturbed sleep architecture. Polysomnographic studies have shown that patients with refractory epilepsy have decreased rapid eye movement (REM) sleep and longer REM latency than those with medically controlled epilepsy. However, little is known about the differences in the REM sleep microstructure between these patient groups. METHODS We conducted a retrospective case-control study of 20 patients with refractory epilepsy (refractory group) and 28 patients with medically controlled epilepsy (medically controlled group). All patients completed sleep questionnaires and underwent overnight in-lab polysomnography. Five-minute electroencephalogram recordings at the C3 and C4 electrodes from each REM sleep were selected for spectral analysis, and 5-min electrocardiogram segments recorded during REM sleep were used for heart rate variability analysis. The groups' scores on the sleep questionnaires, polysomnographic sleep parameters, indices of sleep-related breathing disorders, and REM sleep electroencephalogram spectra were compared. RESULTS The refractory group had decreased REM sleep (p < 0.001) and longer REM latency (p = 0.0357) than those of the medically controlled group. Moreover, electroencephalogram spectral analysis revealed that the refractory group had decreased absolute beta power (p = 0.0039) and relative beta power (p = 0.0035) as well as increased relative delta power (p = 0.0015) compared with the medically controlled group. CONCLUSIONS Differences in the polysomnographic macrostructure and REM sleep microstructure between the study groups suggest REM sleep dysregulation in patients with refractory epilepsy.
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Affiliation(s)
- Wei-Chih Yeh
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
| | - Pei-Jung Lin
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan; Department of Neurology, Da-Sin Hospital, Pingtung County, Taiwan.
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan.
| | - Chung-Yao Hsu
- Department of Neurology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan; Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
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Grigg-Damberger M, Foldvary-Schaefer N. Bidirectional relationships of sleep and epilepsy in adults with epilepsy. Epilepsy Behav 2021; 116:107735. [PMID: 33561767 DOI: 10.1016/j.yebeh.2020.107735] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 11/15/2020] [Accepted: 12/19/2020] [Indexed: 12/14/2022]
Abstract
This targeted review addresses the best accepted and most intriguing recent observations on the complex relationships between sleep and epilepsy. Ten to 15% of all epilepsies are sleep-related. Included in these is sleep-related hypermotor epilepsy, renamed from nocturnal frontal lobe epilepsy by a 2016 consensus conference since 30% of cases are extra-frontal, seizures are related to sleep rather than clock time, and the predominant semiology is hypermotor. Stereo-EEG is providing crucial insights into network activation in sleep-related epilepsies and definition of the epileptogenic zone. Pathologic high-frequency oscillations, a promising biomarker for identifying the epileptogenic zone, are most frequent in NREM sleep, lowest in wakefulness and REM sleep, similar to interictal epileptiform discharges (IEDs). Most sleep-related seizures are followed by awakening or arousal and IEDs cause arousals and increase after arousals, likely contributing to sleep/wake complaints. Sleep/wake disorders are 2-3 times more common in adults with epilepsy than the general population; these comorbidities are associated with poorer quality of life and may impact seizure control. Treatment of sleep apnea reduces seizures in many cases. An emerging area of research is in circadian biology and epilepsy. Over 90% of people with epilepsy have seizures with circadian periodicity, in part related to sleep itself, and the majority of SUDEP cases occur in sleep. Recognizing these bidirectional relationships is important for patient and caregiver education and counseling and optimizing epilepsy outcomes.
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Affiliation(s)
| | - Nancy Foldvary-Schaefer
- Sleep Disorders and Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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22
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Yeh WC, Lai CL, Wu MN, Lin HC, Lee KW, Li YS, Hsu CY. Rapid eye movement sleep disturbance in patients with refractory epilepsy: A polysomnographic study. Sleep Med 2021; 81:101-108. [PMID: 33647761 DOI: 10.1016/j.sleep.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE/BACKGROUND Patients with epilepsy have disrupted sleep architecture and a higher prevalence of sleep disturbance. Moreover, obstructive sleep apnea (OSA) is more common among patients with refractory epilepsy. Few studies have compared subjective sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and those with medically controlled epilepsy. Therefore, this study aimed to evaluate the differences in sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and patients with medically controlled epilepsy. PATIENTS This retrospective case-control study included 38 patients with refractory epilepsy and 96 patients with medically controlled epilepsy. Sleep parameters and indices of sleep-related breathing disorders were recorded by standard in-laboratory polysomnography. The scores from sleep questionnaires on sleep quality and daytime sleepiness were compared between the two groups. RESULTS Patients with refractory epilepsy versus medically controlled epilepsy had statistically significantly decreased rapid eye movement (REM) sleep (13.5 ± 6.1% vs. 16.2 ± 6.1%) and longer REM latency (152.2 ± 84.1 min vs. 117.2 ± 61.9 min). Further, no differences were found in the prevalence of sleep-related breathing disorders, subjective sleep quality, prevalence of daytime sleepiness, and quality of life. Although not statistically significant, patients with refractory epilepsy have a lower rate of OSA compared with those with medically controlled epilepsy (21.1% vs. 30.2%). CONCLUSIONS Patients with refractory epilepsy had more disrupted REM sleep regulation than those with medically controlled epilepsy. Although patients with epilepsy have a higher risk of OSA, in this study patients with refractory epilepsy were not susceptible to OSA.
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Affiliation(s)
- Wei-Chih Yeh
- Department of Neurology, Kaohsiung Medical University Hospital, 100, Tzyou 1st Rd., Kaohsiung City, 80754, Taiwan; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City, 80708, Taiwan.
| | - Chiou-Lian Lai
- Department of Neurology, Kaohsiung Medical University Hospital, 100, Tzyou 1st Rd., Kaohsiung City, 80754, Taiwan; Department of Neurology, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City, 80708, Taiwan.
| | - Meng-Ni Wu
- Department of Neurology, Kaohsiung Medical University Hospital, 100, Tzyou 1st Rd., Kaohsiung City, 80754, Taiwan; Department of Neurology, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City, 80708, Taiwan.
| | - Hsun-Chang Lin
- Department of Neurology, Health and Welfare Ministry Pingtung Hospital, No. 270, Ziyou Rd., Pingtung City, Pingtung County, 900, Taiwan.
| | - Kuo-Wei Lee
- Department of Neurology, Kaohsiung Municipal Siaogang Hospital, No. 482, Shanming Rd., Siaogang Dist., Kaohsiung City, 812, Taiwan.
| | - Ying-Sheng Li
- Department of Neurology, Kaohsiung Medical University Hospital, 100, Tzyou 1st Rd., Kaohsiung City, 80754, Taiwan.
| | - Chung-Yao Hsu
- Department of Neurology, Kaohsiung Medical University Hospital, 100, Tzyou 1st Rd., Kaohsiung City, 80754, Taiwan; Department of Neurology, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung City, 80708, Taiwan.
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Jaseja H, Goyal M, Mishra P. Drug-Resistant Epilepsy and Obstructive Sleep Apnea: Exploring a Link Between the Two. World Neurosurg 2021; 146:210-214. [PMID: 33248305 DOI: 10.1016/j.wneu.2020.11.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 02/05/2023]
Abstract
Drug-resistant epilepsy accounts for approximately one third of all epilepsy cases; yet its exact etiopathogenesis still remains under intense exploration. Several factors have been advocated for predicting drug resistance in patients with epilepsy. Obstructive sleep apnea (OSA) is a commonly prevalent sleep disorder that exhibits a bidirectional and strong comorbidity with epilepsy. The exact pathophysiology of this comorbidity is not yet clearly explained. This study analyzes the relationship between drug-resistant epilepsy and OSA, and the findings indicate a strong role of rapid eye movement sleep (REMS) in the pathogenesis of this relationship. It also emerges from the study that REMS reduction is a prominent feature of OSA, and drug resistance in patients with epilepsy and treatment of OSA has been shown to restore REMS in several studies with concomitant improvement in seizure control.
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Affiliation(s)
| | - Manish Goyal
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India.
| | - Priyadarshini Mishra
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
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24
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Şenel GB, Karadeniz D. Factors determining the long-term compliance with PAP therapy in patients with sleep-related epilepsy. Clin Neurol Neurosurg 2021; 202:106498. [PMID: 33476884 DOI: 10.1016/j.clineuro.2021.106498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 01/11/2021] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In adult patients with epilepsy, treatment of comorbid obstructive sleep apnea syndrome (OSAS) by positive airway pressure (PAP) therapy results in improvements in the control of seizures. This is the first study investigating the long-term compliance with PAP therapy in patients with sleep-related epilepsy and OSAS. METHODS In this longitudinal study, patients with sleep-related epilepsy and OSAS were followed-up for five years. The compliance with PAP therapy was defined as the use of PAP therapy for at least four hours per night for more than 70 % of nights. RESULTS A total of 58 patients with sleep-related epilepsy and OSAS completed study protocol. Eleven patients (19.0 %) refused PAP treatment for OSAS, and 13 patients (22.3 %) showed irregular use. Remaining 34 patients (58.7 %) were compliant with PAP therapy. Females were found to be more compliant than males (p = 0.027), while the age was not found to correlate with the compliance (p = 0.721). Epilepsy-related factors including the types of seizures, whether pure sleep-related or mixed (p = 0.403), localization (p = 0.920) or lateralization (p = 0.697) of discharges, showed no effect on the compliance with PAP therapy. On the other hand, patients with a lower number of seizures (p = 0.042) or with a lower seizure frequency (p = 0.048) showed better compliance with PAP therapy. Polysomnographic parameters including severity of OSAS failed to show a significant correlation. CONCLUSION Our findings showed that about two thirds of the study population was compliant with PAP therapy after a mean follow-up duration of almost three years. Newly-diagnosed patients, mostly females, with a lower number of total seizures and lower seizure frequency seem to be more compliant with PAP therapy, which implies the significance of investigation and treatment of OSAS as early as possible in the patients with sleep-related seizures.
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Affiliation(s)
- Gülçin Benbir Şenel
- Istanbul University - Cerrahpasa, Cerrahpasa Faculty of Medicine, Department Neurology, Division of Clinical Neurophysiology, Istanbul, Turkey.
| | - Derya Karadeniz
- Istanbul University - Cerrahpasa, Cerrahpasa Faculty of Medicine, Department Neurology, Division of Clinical Neurophysiology, Istanbul, Turkey
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25
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Mishra P, Jaseja H, Goyal M. A critical analysis of the purported role of hypoxaemia in the comorbidity of obstructive sleep apnoea and epilepsy. Clin Physiol Funct Imaging 2021; 41:4-9. [PMID: 33068455 DOI: 10.1111/cpf.12672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023]
Abstract
Obstructive sleep apnoea (OSA) is a globally prevalent sleep disorder of significant health concern and confounded with several comorbidities resulting in adverse effect(s) on quality of life in patients afflicted with it. Of particular interest is the enigmatic high comorbidity of OSA with epilepsy, the exact underlying pathophysiology of which remains elusive despite a multitude of research performed in the last four decades. Hypoxaemia, which is an important characteristic feature found in OSA during apnoeic spells, has been implicated in the high comorbidity of OSA with epilepsy, the basis of which rests upon hypoxaemia-mediated brain damage, subcortical release phenomenon, oxidative stress and neuroinflammatory reactions. However, several studies present contradictory evidences that potentially refute the hypoxaemia-based mechanism. Additionally, the role of hypercapnia thatgenerally accompanies hypoxaemia during apnoeic spells, cannot be overlooked and is known to be potentially protective against neuronal hyperexcitability. Thus, hypoxaemia theory implicated in the high comorbidity of OSA and epilepsy appears weak and refutable. This brief paper studies and critically analyses the role of hypoxaemia in conjunction with hypercapnia in the underlying pathophysiology of the comorbidity.
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Affiliation(s)
- Priyadarshini Mishra
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | | | - Manish Goyal
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, India
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26
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Goyal M, Mishra P, Jaseja H. Significance of rapid eye movement sleep in the comorbidity of obstructive sleep apnea and epilepsy. Med Hypotheses 2020; 144:109949. [PMID: 32534338 DOI: 10.1016/j.mehy.2020.109949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/02/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Manish Goyal
- Department of Physiology, AIIMS Bhubaneswar, Odisha, India.
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27
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Bergmann M, Prieschl M, Stefani A, Heidbreder A, Walser G, Frauscher B, Unterberger I, Högl B. A prospective controlled study about sleep disorders in drug resistant epilepsy. Sleep Med 2020; 75:434-440. [DOI: 10.1016/j.sleep.2020.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/20/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
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28
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Nobili L, de Weerd A, Rubboli G, Beniczky S, Derry C, Eriksson S, Halasz P, Högl B, Santamaria J, Khatami R, Ryvlin P, Rémi J, Tinuper P, Bassetti C, Manni R, Koutroumanidis M, Vignatelli L. Standard procedures for the diagnostic pathway of sleep-related epilepsies and comorbid sleep disorders: A European Academy of Neurology, European Sleep Research Society and International League against Epilepsy-Europe consensus review. J Sleep Res 2020; 29:e13184. [PMID: 32959468 DOI: 10.1111/jsr.13184] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Some epilepsy syndromes (sleep-related epilepsies [SRE]) have a strong link with sleep. Comorbid sleep disorders are common in patients with SRE and can exert a negative impact on seizure control and quality of life. PURPOSES To define the standard procedures for the diagnostic pathway of patients with possible SRE (scenario 1) and the general management of patients with SRE and comorbidity with sleep disorders (scenario 2). METHODS The project was conducted under the auspices of the European Academy of Neurology (EAN), the European Sleep Research Society (ESRS) and the International League against Epilepsy (ILAE) Europe. The framework of the document entailed the following phases: conception of the clinical scenarios; literature review; statements regarding the standard procedures. For literature search a step-wise approach starting from systematic reviews to primary studies was applied. Published studies were identified from the National Library of Medicine's MEDLINE database and Cochrane Library. RESULTS Scenario 1: despite a low quality of evidence, recommendations on anamnestic evaluation, tools for capturing the event at home or in the laboratory are provided for specific SRE. Scenario 2: Early diagnosis and treatment of sleep disorders (especially respiratory disorders) in patients with SRE are likely to be beneficial for seizures control. CONCLUSIONS Definitive procedures for evaluating patients with SRE are lacking. We provide advice that could be of help for standardising and improving the diagnostic approach of specific SRE. The importance of identifying and treating specific sleep disorders for the management and outcome of patients with SRE is underlined.
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Affiliation(s)
- Lino Nobili
- Child Neuropsychiatry, IRCCS G. Gaslini Institute, Genoa, Italy.,Department of Neuroscience - Rehabilitation-Ophthalmology - Genetics - Child and Maternal Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Al de Weerd
- Stichting Epilepsie Instellingen Nederland, Zwolle, Netherlands
| | - Guido Rubboli
- Danish Epilepsy Centre, Dianalund, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - Sándor Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher Derry
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,Department of Clinical Neurosciences and Sleep Medicine, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Sofia Eriksson
- Department of Clinical and Experimental Epilepsy, National Hospital for Neurology and Neurosurgery and Institute of Neurology, University College London, London, UK
| | - Peter Halasz
- National Institute of Clinical Neuroscience, Budapest, Hungary
| | - Birgit Högl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Joan Santamaria
- Multidisciplinary Sleep Unit, Neurology Service, Hospital Clínic, Barcelona, Spain
| | - Ramin Khatami
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.,Barmelweid Academy, Center of Sleep Medicine, Sleep Research and Epilepsy, Klinik Barmelweid, Barmelweid, Switzerland
| | - Philippe Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Rémi
- Epilepsy Center, Department of Neurology, University of Munich Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - Paolo Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
| | - Claudio Bassetti
- Neurology Department, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Raffaele Manni
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy
| | | | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
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29
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Peter‐Derex L, Klimes P, Latreille V, Bouhadoun S, Dubeau F, Frauscher B. Sleep Disruption in Epilepsy: Ictal and Interictal Epileptic Activity Matter. Ann Neurol 2020; 88:907-920. [DOI: 10.1002/ana.25884] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/27/2020] [Accepted: 08/16/2020] [Indexed: 12/29/2022]
Affiliation(s)
- Laure Peter‐Derex
- Analytical Neurophysiology Lab Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
- Center for Sleep Medicine and Respiratory Diseases Lyon University Hospital, Lyon 1 University Lyon France
- Lyon Neuroscience Research Center, CNRS UMR5292 / INSERM, U1028 Lyon France
| | - Petr Klimes
- Analytical Neurophysiology Lab Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
- Institute of Scientific Instruments, The Czech Academy of Sciences Brno Czech Republic
| | - Véronique Latreille
- Analytical Neurophysiology Lab Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
| | - Sarah Bouhadoun
- Analytical Neurophysiology Lab Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
| | - François Dubeau
- Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
| | - Birgit Frauscher
- Analytical Neurophysiology Lab Montreal Neurological Institute and Hospital, McGill University Montreal QC Canada
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30
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Nobili L, de Weerd A, Rubboli G, Beniczky S, Derry C, Eriksson S, Halasz P, Högl B, Santamaria J, Khatami R, Ryvlin P, Rémi J, Tinuper P, Bassetti C, Manni R, Koutroumanidis M, Vignatelli L. Standard procedures for the diagnostic pathway of sleep-related epilepsies and comorbid sleep disorders: an EAN, ESRS and ILAE-Europe consensus review. Eur J Neurol 2020; 28:15-32. [PMID: 32959446 DOI: 10.1111/ene.14468] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/01/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Some epilepsy syndromes (sleep-related epilepsies, SREs) have a strong link with sleep. Comorbid sleep disorders are common in patients with SRE and can exert a negative impact on seizure control and quality of life. Our purpose was to define the standard procedures for the diagnostic pathway of patients with possible SRE (scenario 1) and the general management of patients with SRE and comorbidity with sleep disorders (scenario 2). METHODS The project was conducted under the auspices of the European Academy of Neurology, the European Sleep Research Society and the International League Against Epilepsy Europe. The framework entailed the following phases: conception of the clinical scenarios; literature review; statements regarding the standard procedures. For the literature search a stepwise approach starting from systematic reviews to primary studies was applied. Published studies were identified from the National Library of Medicine's MEDLINE database and Cochrane Library. RESULTS Scenario 1: Despite a low quality of evidence, recommendations on anamnestic evaluation and tools for capturing the event at home or in the laboratory are provided for specific SREs. Scenario 2: Early diagnosis and treatment of sleep disorders (especially respiratory disorders) in patients with SRE are likely to be beneficial for seizure control. CONCLUSIONS Definitive procedures for evaluating patients with SRE are lacking. Advice is provided that could be of help for standardizing and improving the diagnostic approach of specific SREs. The importance of identifying and treating specific sleep disorders for the management and outcome of patients with SRE is underlined.
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Affiliation(s)
- L Nobili
- Child Neuropsychiatry, IRCCS G. Gaslini Institute, Genoa, Italy.,Department of Neuroscience - Rehabilitation - Ophthalmology - Genetics - Child and Maternal Health (DINOGMI), University of Genoa, Italy
| | - A de Weerd
- Stichting Epilepsie Instellingen Nederland, Zwolle, The Netherlands
| | - G Rubboli
- Danish Epilepsy Centre, Dianalund, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - S Beniczky
- Department of Clinical Neurophysiology, Danish Epilepsy Centre, Dianalund, Denmark.,Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - C Derry
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.,Department of Clinical Neurosciences and Sleep Medicine, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - S Eriksson
- Department of Clinical and Experimental Epilepsy, National Hospital for Neurology and Neurosurgery and Institute of Neurology, University College London, London, UK
| | - P Halasz
- National Institute of Clinical Neuroscience, Budapest, Hungary
| | - B Högl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Santamaria
- Multidisciplinary Sleep Unit, Neurology Service, Hospital Clínic, Barcelona, Spain
| | - R Khatami
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.,Barmelweid Academy, Center of Sleep Medicine, Sleep Research and Epilepsy, Klinik Barmelweid AG, Barmelweid, Switzerland
| | - P Ryvlin
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - J Rémi
- Epilepsy Center, Department of Neurology, University of Munich Hospital, Ludwig-Maximilians-University, Munich, Germany
| | - P Tinuper
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
| | - C Bassetti
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland.,Neurology Department, Sechenov First Moscow State Medical University, Moscow, Russia
| | - R Manni
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy
| | - M Koutroumanidis
- Department of Neurology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - L Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Ospedale Bellaria, Bologna, Italy
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Are the International Classification of Functioning, Disability and Health (ICF) domains considered in the obstructive sleep apnea instruments? An integrative review. Sleep Breath 2020; 25:1089-1100. [PMID: 32865728 DOI: 10.1007/s11325-020-02173-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Obstructive Sleep Apnea (OSA) is related to cardiovascular, metabolic, and neurocognitive diseases. Furthermore, OSA symptoms, such as excessive sleepiness, fatigue, and mood disorders, may interfere in functioning. The assessment of this aspect in patients with OSA is not frequent and no specific instrument is available in the literature. Our aim is to identify if the International Classification of Functioning, Disability and Health (ICF) domains are considered in the validated instruments used to assess patients with OSA. METHODS In this integrative literature review, three databases were searched: Pubmed, Embase, and LILACS. Bibliographic survey was carried out in 2020, between March and July. Articles published in English, Portuguese, and Spanish with validated tools to assess OSA in adults were included. RESULTS Thirty instruments have undergone a process of concept extraction and coding according to the ICF, generating a total of 769 significant concepts. It was observed that the function domain was the most prevalent, making 42% (n = 323) of the concepts, followed by domains of activity (16%), participation (10%), environmental factors (5%), personal factor (5%), and structure (1%). Only one instrument, the "Sleep Apnea Quality of Life Index (SAQLI)," encompasses all domains of the ICF in its constructs. CONCLUSION In the analyzed instruments, the function domain prevails, with most concepts related to sleep functions. Only one validated instrument included in this research covered all the ICF domains. This instrument closely matched the recommended way of assessing functioning, though it approached the domains in an unbalanced way.
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32
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Grigg-Damberger M, Andrews N, Wang L, Bena J, Foldvary-Schaefer N. Subjective and objective hypersomnia highly prevalent in adults with epilepsy. Epilepsy Behav 2020; 106:107023. [PMID: 32213453 DOI: 10.1016/j.yebeh.2020.107023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/03/2020] [Accepted: 03/04/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Sleepiness is among the most common complaints of people with epilepsy, but objective documentation is lacking. We systematically investigated subjective and objective sleepiness in an observational cross-sectional cohort of adults with epilepsy (AWE). METHODS This is a prospective study of AWE consecutively recruited without foreknowledge of sleep/wake complaints. Polysomnography (PSG) with 18-channel electroencephalography (EEG) followed by multiple sleep latency testing (MSLT) was performed. Patients completed the Epworth Sleepiness Scale (ESS), a single-item question assessing excessive daytime sleepiness (EDS), and a 7-day sleep and seizure diary. Multivariable linear models were used to assess the association between MSLT mean sleep latency (MSL) and interests with adjustment of covariates of interest. Receiver operating characteristics (ROC) analysis was performed to evaluate the discrimination capability of ESS on MSL < 8 min and <5 min and investigate the optimal cutpoints. RESULTS Among 127 AWE (mean age: 38.7 ± 13.7 years), abnormal MSL (<8 min) was observed in 49.6% and MSL <5 min in 31.5%. While 78% reported feeling sleepy during the day on a single-item question, only 24% had elevated scores on the ESS (>10/24). The ESS score was associated with MSL even after adjusting for seizure frequency, antiseizure medication (ASM) standardized dose and number, age, gender, depression and insomnia symptom severity, and apnea-hypopnea index (HPI) and total sleep time on PSG (coefficients [95% confidence interval (CI)]: -0.26 [-0.48, -0.05], p = 0.018). The area under the curve (AUC) of the ESS ROC predicting MSL < 8 min and MSL < 5 min were similar: 0.62 (95%CI: 0.52-0.72) and 0.62 (95%CI: 0.51-0.74). CONCLUSIONS This is the largest prospective cross-sectional observational study to date using MSLT in AWE. We found subjective and objective daytime sleepiness highly prevalent in AWE and not explained by seizure frequency, ASM burden, symptoms of insomnia/depression, or PSG findings although those with MSL < 5 min were more likely to have obstructive sleep apnea (OSA). Pathologic sleepiness with MSL < 8 min was present in half of AWE. Nearly one-third of AWE unselected for sleep/wake complaints had MSL < 5 min, a range typical of narcolepsy.
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Affiliation(s)
- Madeleine Grigg-Damberger
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, United States of America
| | - Noah Andrews
- Department of Neurology, Sleep Disorders and Epilepsy Centers, Cleveland Clinic, Cleveland, OH, United States of America
| | - Lu Wang
- Cleveland Clinic Quantitative Health Sciences, Cleveland, OH, United States of America
| | - James Bena
- Cleveland Clinic Quantitative Health Sciences, Cleveland, OH, United States of America
| | - Nancy Foldvary-Schaefer
- Department of Neurology, Sleep Disorders and Epilepsy Centers, Cleveland Clinic, Cleveland, OH, United States of America.
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33
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Whyte A, Gibson D. Adult obstructive sleep apnoea: Pathogenesis, importance, diagnosis and imaging. J Med Imaging Radiat Oncol 2019; 64:52-66. [PMID: 31788980 DOI: 10.1111/1754-9485.12978] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/15/2019] [Indexed: 01/10/2023]
Abstract
Obstructive sleep apnoea (OSA) is a serious worldwide health problem. Moderate-to-severe OSA has been found in up to 50% of men and 25% of women in the middle-aged population. It results in a fourfold increase in all causes of mortality. The prevalence of OSA is underestimated, partly due to absence of symptoms but also lack of knowledge amongst the population at large as well as sectors of the medical profession. Imaging, performed predominantly by clinicians and research scientists, has been integral to evaluating the anatomical basis of OSA. Increased nasal resistance and a narrowed and elongated oropharynx lead to increased collapsibility of the upper airway, predisposing to airway collapse and apnoea during sleep when there is reduction in tone of the pharyngeal dilator muscles. Unfortunately, a significantly narrowed upper airway is usually ignored by radiologists: it is not part of their reporting 'check-list'. The imaging findings in the upper airway that are strongly associated with OSA and its sequelae in various organ systems are discussed. Imaging can strongly suggest OSA; the diagnosis requires a polysomnogram for confirmation. Treatment of moderate-to-severe disease is primarily with positive airway pressure applied by a nasal or oral mask which splints the upper airway. Although highly effective, compliance is limited and other treatment modalities are increasingly being utilized.
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Affiliation(s)
- Andy Whyte
- Perth Radiological Clinic, Perth, Western Australia, Australia.,University of Western Australia, Perth, Western Australia, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Daren Gibson
- Medical Imaging, Fiona Stanley Hospital, Perth, Western Australia, Australia
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34
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Late-onset unexplained epilepsy: What are we missing? Epilepsy Behav 2019; 99:106478. [PMID: 31481308 DOI: 10.1016/j.yebeh.2019.106478] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/02/2019] [Accepted: 08/02/2019] [Indexed: 01/22/2023]
Abstract
With the aging of the US population, the incidence of epilepsy will increase, with 25 to 50% of new cases with no identifiable etiology diagnosed as late-onset unexplained epilepsy (LOUE). In the current targeted review, we discuss the possible role of cerebral small vessel ischemic disease, accumulation of amyloidβ and hyperphosphorylated tau, and sleep apnea as potential pathophysiologic mechanisms explaining LOUE. We highlight the impact of these processes on cognition and avenues for diagnosis and treatment.
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35
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Stefanatou M, Gatzonis S, Peskostas A, Paraskevas G, Koutroumanidis M. Drug-responsive versus drug-refractory mesial temporal lobe epilepsy: a single-center prospective outcome study. Postgrad Med 2019; 131:479-485. [PMID: 31513436 DOI: 10.1080/00325481.2019.1663126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objectives: To evaluate clinical, electrophysiological, and neuroradiological factors which correlate with the prognosis in patients with mesial temporal lobe epilepsy (MTLE). Methods: This was a single-center prospective outcome study in patients with MTLE. The patients' family history, clinical characteristics, neurophysiological data (electroencephalography - EEG), neuroimaging, antiepileptic therapy, and outcome were collected and analyzed. The population was divided into four groups depending on the frequency of the seizures when they attended their last follow up. All variables and outcome measures were compared between the four groups. Results: In total 83 consecutive patients were included within the four groups. Group 1 (seizure-free) consisted of 7 patients, (9%), Group 2 (rare seizures) consisted of 15 patients (18%), Group 3 (often seizures) consisted of 30 patients (36%), and Group 4 (very often seizures) consisted of 31 patients (37%). The groups did not differ significantly in demographic characteristics. There was a strong positive correlation between resistance to therapy and sleep activation on EEG (p = 0.005), occurrence of focal to bilateral seizures (p = 0.007), automatisms (p = 0.004), and the number of previously used antiepileptic drugs (AEDs) (p = 0.002). There was no association between febrile convulsions (FC), hippocampal sclerosis (HS), and the outcome that was found. Conclusion: MTLE is a heterogeneous syndrome. Establishing the factors responsible for, and associated with, drug resistance is important for optimal management and treatment, as early identification of drug resistance should then ensure a timely referral for surgical treatment is made. This prospective study shows that sleep activation on EEG, ictal automatisms, occurrence of focal to bilateral tonic-clonic seizures, and increased number of tried AEDs are negative prognostic factors.
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Affiliation(s)
- Maria Stefanatou
- 1st Department of Neurology, National and Kapodistrian University of Athens, Aeginition Hospital , Athens , Greece.,Department of Clinical Neurophysiology and Epilepsies, Guy's and St. Thomas' NHS Foundation Trust , London , UK
| | - Stylianos Gatzonis
- 1st Department of Neurosurgery, Epilepsy Centre, National and Kapodistrian University of Athens, "Evangelismos" Hospital , Athens , Greece
| | - Antonis Peskostas
- Department of Statistics and Insurance Science, University of Piraeus , Piraeus , Greece
| | - George Paraskevas
- 1st Department of Neurology, National and Kapodistrian University of Athens, Aeginition Hospital , Athens , Greece
| | - Michael Koutroumanidis
- Department of Clinical Neurophysiology and Epilepsies, Guy's and St. Thomas' NHS Foundation Trust , London , UK
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36
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Somboon T, Grigg-Damberger MM, Foldvary-Schaefer N. Epilepsy and Sleep-Related Breathing Disturbances. Chest 2019; 156:172-181. [DOI: 10.1016/j.chest.2019.01.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 01/12/2019] [Accepted: 01/16/2019] [Indexed: 12/18/2022] Open
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37
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The Interface Between Sleep and Epilepsy. CURRENT SLEEP MEDICINE REPORTS 2019. [DOI: 10.1007/s40675-019-00139-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Reddy DS, Chuang SH, Hunn D, Crepeau AZ, Maganti R. Neuroendocrine aspects of improving sleep in epilepsy. Epilepsy Res 2018; 147:32-41. [PMID: 30212766 PMCID: PMC6192845 DOI: 10.1016/j.eplepsyres.2018.08.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/27/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Abstract
Sleep plays an intricate role in epilepsy and can affect the frequency and occurrence of seizures. With nearly 35% of U.S. adults failing to obtain the recommended 7 h of sleep every night, understanding the complex relationship between sleep and epilepsy is of utmost relevance. Sleep deprivation is a common trigger of seizures in many persons with epilepsy and sleep patterns play a role in the occurrence of seizures. Some patients have their first seizure or repeated seizures after an "all-nighter" at college or after a long period of chronic sleep deprivation. The strength of the relationship between sleep and seizures varies between patients, but improving sleep and optimizing seizure control can have significant positive effects on the quality of life for all these patients. Research has shown that the changes in the brain's electrical and hormonal activity occurring during normal sleep-wake cycles can be linked to both sleep and seizure patterns. Many questions remain to be answered about sleep and epilepsy. How can sleep deprivation trigger an epileptic seizure? How do circadian and hormonal changes influence sleep pattern and seizure occurrence? Can hormones or sleeping pills help with sleep in epilepsy? In this article we discuss these and many other questions on sleep in epilepsy, with an emphasis on sleep architecture, hormone changes, mechanistic factors, and possible prevention strategies.
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Affiliation(s)
- Doodipala Samba Reddy
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center College of Medicine, Bryan, TX 77807, USA.
| | - Shu-Hui Chuang
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center College of Medicine, Bryan, TX 77807, USA
| | - Dayton Hunn
- Department of Neuroscience and Experimental Therapeutics, Texas A&M University Health Science Center College of Medicine, Bryan, TX 77807, USA
| | - Amy Z Crepeau
- Department of Neurology, Mayo Clinic Hospital, Phoenix, AZ 85054, USA
| | - Rama Maganti
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
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39
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Deceleration and acceleration capacities of heart rate in patients with drug-resistant epilepsy. Clin Auton Res 2018; 29:195-204. [PMID: 30328033 DOI: 10.1007/s10286-018-0569-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 10/08/2018] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Epilepsy and seizures can have dramatic effects on cardiac function. The aim of the present study was to investigate deceleration capacity, acceleration capacity and their 24-h fluctuations of heart rate variability in patients with drug-resistant epilepsy. METHODS Deceleration capacity, acceleration capacity of heart rate and their 24-h dynamics derived from the phase rectified signal averaging method as well as traditional measures were analyzed in 39 patients with drug-resistant epilepsy and 33 healthy control subjects using 24-h electrocardiogram recordings. The discriminatory power of heart rate variability measures were validated by assessment of the area under the receiver operating characteristic curve. Net reclassification improvement and integrated discrimination improvement models were also estimated. RESULTS Both deceleration capacity and absolute values of acceleration capacity were significantly lower in patients with drug-resistant epilepsy. The abnormal suppression of absolute deceleration capacity and acceleration capacity values were observed throughout the 24-h recording time (peaked at about 3 to 5 A.M.). Deceleration capacity had the greatest discriminatory power to differentiate the patients from the healthy controls. Moreover, in both net reclassification improvement and integrated discrimination improvement models, the combination of acceleration capacity or deceleration capacity with traditional heart rate variability measures has greater discriminatory power than any of the single heart rate variability features. INTERPRETATION Drug-resistant epilepsy was associated with a significant inhibition of vagal modulation of heart rate, which was more pronounced during the night than during the day. These findings indicate that phase rectified signal averaging method may serve as a complementary approach for characterizing and understanding the neuro-pathophysiology in epilepsy, and may provide a new clue to sudden unexpected death in epilepsy.
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40
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Popkirov S, Stone J, Derry CP. Abnormal sleep in patients with epileptic or dissociative (non-epileptic) seizures: a polysomnography study. Eur J Neurol 2018; 26:255-260. [DOI: 10.1111/ene.13798] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/28/2018] [Indexed: 11/27/2022]
Affiliation(s)
- S. Popkirov
- Department of Neurology; University Hospital Knappschaftskrankenhaus; Ruhr University Bochum; Bochum Germany
| | - J. Stone
- Centre for Clinical Brain Sciences; Western General Hospital; University of Edinburgh; Edinburgh UK
| | - C. P. Derry
- Centre for Clinical Brain Sciences; Western General Hospital; University of Edinburgh; Edinburgh UK
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41
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Co-morbid sleep disorders and epilepsy: A narrative review and case examples. Epilepsy Res 2018; 145:185-197. [PMID: 30048932 DOI: 10.1016/j.eplepsyres.2018.07.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/08/2018] [Accepted: 07/14/2018] [Indexed: 01/03/2023]
Abstract
Co-morbid sleep disorders, including sleep apnea, insomnia, restless legs syndrome, and the parasomnias, occur frequently in people with epilepsy. This article reviews the cardinal presenting symptoms and diagnostic features of each of these disorders to enable epileptologists to readily screen and identify sleep co-morbidities in their patients. It summarizes current evidence concerning the reciprocal relationship between sleep disturbances and epilepsy and available treatment options for common sleep disorders in people with epilepsy. Several illustrative cases demonstrate the practical consequences of co-morbid sleep disorders in epilepsy patients and suggest diagnostic and treatment approaches that may improve daytime functioning, alertness, quality of life, and seizure burden.
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42
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Latreille V, Bubrick EJ, Pavlova M. Positive Airway Pressure Therapy Is Challenging for Patients With Epilepsy. J Clin Sleep Med 2018; 14:1153-1159. [PMID: 29991426 DOI: 10.5664/jcsm.7214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 03/29/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To investigate whether patients with epilepsy and comorbid obstructive sleep apnea (OSA) are more likely to be nonadherent to positive airway pressure (PAP) therapy than adults with OSA but without epilepsy. METHODS This retrospective study included patients with epilepsy diagnosed with OSA and age-, sex-, and apnea-hypopnea index (AHI)-matched controls with OSA but without epilepsy who started PAP treatment between February 2014 and August 2017. Subjects' adherence to PAP therapy was continuously recorded electronically, and comparisons were made at 1 month, 3 months, and 1 year following PAP initiation. Predictors to poor adherence were also evaluated. RESULTS Patients with epilepsy (n = 23) were less adherent to PAP than controls (n = 23) during the first month of treatment (13% versus 78%, P = .03). During this first month, average PAP use was lower in patients with epilepsy (4.7 ± 2.1 hours) relative to controls (6.1 ± 1.2 hours, P = .03). Despite sustained PAP treatment, patients with epilepsy had a greater residual AHI and were five times more likely than controls to have residual apnea events above normal range at 3-month and 1-year follow-up. However, no clinical characteristics could significantly predict poor adherence in patients. CONCLUSIONS Patients with epilepsy are less likely to be adherent to PAP therapy during the first month of treatment, as compared to adults with OSA but no epilepsy. Moreover, PAP therapy could not sufficiently reduce AHI in up to 72% of patients. These findings highlight the need for careful monitoring of PAP treatment in patients with epilepsy, as untreated OSA may worsen seizure burden.
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Affiliation(s)
- Véronique Latreille
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ellen J Bubrick
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Milena Pavlova
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW Sleep-disordered breathing encompasses a broad spectrum of sleep-related breathing disorders, including obstructive sleep apnea (OSA), central sleep apnea, as well as sleep-related hypoventilation and hypoxemia. Diagnostic criteria have been updated in the International Classification of Sleep Disorders, Third Edition and the American Academy of Sleep Medicine Manual for Scoring Sleep and Associated Events. Neurologic providers should have basic knowledge and skills to identify at-risk patients, as these disorders are associated with substantial morbidity, the treatment of which is largely reversible. RECENT FINDINGS OSA is the most common form of sleep-disordered breathing and is highly prevalent and grossly underdiagnosed. Recent studies suggest that prevalence rates in patients with neurologic disorders including epilepsy and stroke exceed general population estimates. The physiologic changes that occur in OSA are vast and involve complex mechanisms that play a role in the pathogenesis of cardiovascular and metabolic disorders and, although largely unproven, likely impact brain health and disease progression in neurologic patients. A tailored sleep history and examination as well as validated screening instruments are effective in identifying patients with sleep-disordered breathing, although sleep testing is necessary for diagnostic confirmation. While continuous positive airway pressure therapy and other forms of noninvasive positive pressure ventilation remain gold standard treatments, newer therapies, including mandibular advancement, oral appliance devices, and hypoglossal nerve stimulation, have become available. Emerging evidence of the beneficial effects of treatment of sleep-disordered breathing on neurologic outcomes underscores the importance of sleep education and awareness for neurologic providers. SUMMARY Sleep-disordered breathing is highly prevalent and grossly underrecognized. The adverse medical and psychosocial consequences of OSA and other sleep-related breathing disorders are considerable. The impact of sleep therapies on highly prevalent neurologic disorders associated with substantial morbidity and health care costs is becoming increasingly recognized.
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Sivathamboo S, Perucca P, Velakoulis D, Jones NC, Goldin J, Kwan P, O’Brien TJ. Sleep-disordered breathing in epilepsy: epidemiology, mechanisms, and treatment. Sleep 2018; 41:4830560. [DOI: 10.1093/sleep/zsy015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Shobi Sivathamboo
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
| | - Piero Perucca
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dennis Velakoulis
- Department of Psychiatry, Neuropsychiatry Unit, Royal Melbourne Hospital, Victoria, Australia
| | - Nigel C Jones
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Goldin
- Department of Respiratory and Sleep Disorders Medicine, Royal Melbourne Hospital, Victoria, Australia
| | - Patrick Kwan
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J O’Brien
- Department of Medicine, University of Melbourne, Victoria, Australia
- Department of Neurology, Royal Melbourne Hospital, Victoria, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Brunetti V, Ferilli MAN, Vollono C, Della Marca G. Sleep apneas trigger epilepsy. Sleep Med 2017; 39:23-24. [DOI: 10.1016/j.sleep.2017.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/04/2017] [Accepted: 08/11/2017] [Indexed: 11/30/2022]
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Annual review of selected scientific literature: Report of the committee on scientific investigation of the American Academy of Restorative Dentistry. J Prosthet Dent 2017; 118:281-346. [DOI: 10.1016/j.prosdent.2017.04.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/27/2017] [Accepted: 04/27/2017] [Indexed: 01/19/2023]
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Ferini-Strambi L, Lombardi GE, Marelli S, Galbiati A. Neurological Deficits in Obstructive Sleep Apnea. Curr Treat Options Neurol 2017; 19:16. [DOI: 10.1007/s11940-017-0451-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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