Intracranial hypertension associated with obstructive sleep apnea: a discussion of potential etiologic factors

Reliability of Home Sleep Apnea Testing for Diagnosing Obstructive Sleep Apnea in Patients With Spontaneous Cerebrospinal Fluid Leaks

STUDY OBJECTIVES

 To establish the prevalence of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks and demonstrate the reliability of home sleep apnea testing (HSAT) to screen for OSA in this population.

METHODS

A literature review was performed to assess data on OSA prevalence in sCSF leaks. An institutional retrospective review was performed of 20 patients with sCSF leaks who met inclusion criteria. Patients without prior sleep studies were prospectively administered sleep studies, either HSAT or polysomnogram (PSG).

RESULTS

Twenty patients met the inclusion criteria. Two patients had prior sleep studies while 18 patients obtained prospective sleep studies following diagnosis and prior to management of sCSF leaks. Nineteen patients (95%) had evidence of mild or greater OSA.

CONCLUSIONS

 This study re-demonstrates the high prevalence of OSA in patients with sCSF leaks, consistent with current literature, and investigates the reliability of HSAT for diagnosis of OSA in this population.

Sleep and eye disease: A review

There is a growing body of literature on the effects of sleep disorders, in particular obstructive sleep apnoea (OSA), on ocular health, with consistent evidence of an increased risk of floppy eyelid syndrome, non-arteritic anterior ischaemic optic neuropathy, diabetic macular oedema, and other retinal vasculature changes in individuals with OSA. However, reports on OSA's associations with glaucoma, papilloedema, diabetic retinopathy, central serous chorioretinopathy, and keratoconus have been conflicting, while links between OSA and age-related macular degeneration have only been described fairly recently. Despite numerous suggestions that OSA treatment may reduce risk of these eye diseases, well-designed studies to support these claims are lacking. In particular, the ocular hypertensive effects of continuous positive airway pressure (CPAP) therapy for OSA requires further investigation into its potential impact on glaucoma risk and management. Reports of ocular surface complications secondary to leaking CPAP masks highlights the importance of ensuring good mask fit. Poor sleep habits have also been linked with increased myopia risk; however, the evidence on this association remains weak.

Obstructive sleep apnoea in women with idiopathic intracranial hypertension: a sub-study of the idiopathic intracranial hypertension weight randomised controlled trial (IIH: WT)

Objective

Obesity is a risk factor for idiopathic intracranial hypertension (IIH) and obstructive sleep apnoea (OSA). We aimed to determine the prevalence of OSA in IIH and evaluate the diagnostic performance of OSA screening tools in IIH. Additionally, we evaluated the relationship between weight loss, OSA and IIH over 12 months.

Methods

A sub-study of a multi-centre, randomised controlled parallel group trial comparing the impact of bariatric surgery vs. community weight management intervention (CWI) on IIH-related outcomes over 12 months (IIH:WT). OSA was assessed using home-based polygraphy (ApneaLink Air, ResMed) at baseline and 12 months. OSA was defined as an apnoea–hypopnoea index (AHI) ≥ 15 or ≥ 5 with excessive daytime sleepiness (Epworth Sleepiness Scale ≥11 ).

Results

Of the 66 women in the IIH: WT trial, 46 were included in the OSA sub-study. OSA prevalence was 47% (n = 19). The STOP-BANG had the highest sensitivity (84%) compared to the Epworth Sleepiness Scale (69%) and Berlin (68%) to detect OSA. Bariatric surgery resulted in greater reductions in AHI vs. CWI (median [95%CI] AHI reduction of  – 2.8 [ – 11.9, 0.7], p = 0.017). Over 12 months there was a positive association between changes in papilloedema and AHI (r = 0.543, p = 0.045), despite adjustment for changes in the body mass index (R² = 0.522, p = 0.017).

Conclusion

OSA is common in IIH and the STOP-BANG questionnaire was the most sensitive screening tool. Bariatric surgery improved OSA in patients with IIH. The improvement in AHI was associated with improvement in papilloedema independent of weight loss. Whether OSA treatment has beneficial impact on papilloedema warrants further evaluation.

Trial registration number

IIH: WT is registered as ISRCTN40152829 and on ClinicalTrials.gov as NCT02124486 (28/04/2014).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10700-9.

Cardiovascular Disease in Patients with Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnoea Syndrome and Overlap Syndrome

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea syndrome (OSAS) are among the most prevalent chronic respiratory disorders. Accumulating data suggest that there is a significant burden of cardiovascular disease (CVD) in patients with COPD and OSAS, affecting negatively patients' quality of life and survival. Overlap syndrome (OS), i.e. the co-existence of both COPD and OSAS in the same patient, has an additional impact on the cardiovascular system multiplying the risk of morbidity and mortality. The underlying mechanisms for the development of CVD in patients with either OSAS or COPD and OS are not entirely elucidated. Several mechanisms, in addition to smoking and obesity, may be implicated, including systemic inflammation, increased sympathetic activity, oxidative stress and endothelial dysfunction. Early diagnosis and proper management of these patients might reduce cardiovascular risk and improve patients' survival. In this review, we summarize the current knowledge regarding epidemiological aspects, pathophysiological mechanisms and present point-to-point specific associations between COPD, OSAS, OS and components of CVD, namely, pulmonary hypertension, coronary artery disease, peripheral arterial disease and stroke.

Total improvement after surgery for obstructive sleep apnea syndrome in a patient with concurrent malignant idiopathic intracranial hypertension

The association between idiopathic intracranial hypertension (IIH) and obstructive sleep apnea syndrome (OSAS) constitutes an interesting point of discussion regarding clinical approaches as well as the underlying pathophysiological mechanisms. Here, the case of a 42-year-old female with malignant IIH and OSAS is illustrated. Initially, the patient was treated with lumboperitoneal shunt surgery. However, OSAS surgery provided total recovery from the recurrent symptoms developing secondary to lumboperitoneal shunt malfunction. The authors point out the importance of identifying OSAS as a crucial causative agent in some IIH subtypes. Future studies are warranted to clarify this underestimated association.

Sleep Apnea and Hypopnea Events Detection Based on Airflow Signals Using LSTM Network

Sleep Apnea-Hypopnea Syndrome (SAHS) is a sleep-related breathing disorder which involves the reduction in breathing airway when patiens sleep. However, a large proportion of patients are usually undiagnosed and untreated which may lead to the risk of life. In this paper, we propose an automatic SAHS event detection method based on Long Short-Term Memory (LSTM) network via nasal airway pressure and temperature signals from clinical polysomnography (PSG) dataset. Focusing on time location of the events, we firstly segment the two channels of signals into a series of sequences by feature extraction. Secondly, a LSTM network is established and these sequences are subsequently fed into this LSTM network for SAHS event classification. The experimental results on both our clinical PSG dataset and public MIT-BIH PSG database show that our method is promising in terms of recall.

New daily persistent headache (NDPH) triggered by a single Valsalva event: A case series

OBJECTIVE

To describe a new subtype of new daily persistent headache that is triggered by a single Valsalva event.

METHODS

A case series of patients was evaluated in an academic headache clinic over a 3-year time period.

RESULTS

A total of seven patients (four female and three male) were diagnosed with this new subtype of new daily persistent headache. The headaches all began after a single Valsalva event. Average age at time of headache onset was 41 years (males: 39 years; females: 43 years) with an age range of 20-62 years. All patients developed their syndrome during the months of September to February with November and February being the most cited months (5/7 patients). Immediate worsening in the Trendelenburg position occurred in all patients and appeared to be an almost diagnostic test for the syndrome. No patient had papilledema on funduscopic exam. Five out of seven patients had no prior headache history including cough, exercise or migraine. Four of seven patients were of normal weight, while one was overweight and two were obese. A crowded posterior fossa was identified in five of seven patients on brain MRI. On cerebrospinal fluid pressure/volume lowering medication (acetazolamide, indomethacin and/or spironolactone), five out of seven patients achieved 90% plus improvement in headache frequency while three patients became pain free. Three patients were able to taper off medication without headache recurrence.

CONCLUSION

New daily persistent headache after a single Valsalva event appears to be a unique subtype of new daily persistent headache that is responsive to cerebrospinal fluid pressure/volume lowering medications. An abnormal reset of cerebrospinal fluid pressure/intracranial pressure to an elevated state is the presumed pathogenesis and may relate to the patient's baseline neuroanatomy of a crowded posterior fossa. There appears to be a circadian periodicity to the onset of the syndrome. Worsening in the Trendelenburg position is a probable diagnostic test. Defining new daily persistent headache subtypes by triggering event appears to be making a positive inroad in the understanding of this condition and helps present new effective therapies.

A New Subtype of Chronic Daily Headache Presenting in Older Women

OBJECTIVE

To describe a new subtype of chronic daily headache in women of a specific age group.

METHODS

Case series.

RESULTS

Eight patients were included in the presented case series. The average age of onset of this distinct headache condition is 57 years. All patients were either perimenopausal or in menopause when the headaches started. The syndrome is marked by bilateral head pain that starts daily from onset and is typically at its most severe intensity the first thing in the morning before arising or when in the supine position. Immediate worsening in Trendelenburg appears to be an almost diagnostic test for the syndrome and occurred in all patients. The majority of the patients had a history of episodic migraine, but the migraines were either very well controlled or had ceased by the time the new headache arose. The bulk of the patients (6/8) were either overweight or obese, although two patients were of normal body mass index (BMI). Neuroimaging showed no abnormalities. All patients responded to cerebrospinal fluid (CSF) pressure-/volume-lowering medications (acetazolamide or spironolactone), but only one patient was able to completely taper off treatment without headache recurrence.

CONCLUSION

This newly defined subtype of chronic daily headache appears to be caused by a state of elevated CSF pressure. It is hypothesized that a combination of an elevated BMI and the presence of cerebral venous insufficiency leads to this form of daily headache.

Peripapillary Choroidal Thickness and Retinal Nerve Fiber Layer in Untreated Patients with Obstructive Sleep Apnea-Hypopnea Syndrome: A Case-Control Study

PURPOSE

To evaluate peripapillary choroidal thickness (PPCT), central macular choroidal thickness (CMCT), and retinal nerve fiber layer (RNFL) thickness in untreated patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).

METHODS

This prospective, randomized, and comparative study was conducted in a university ophthalmology clinic. 106 eyes of 106 patients with OSAHS and 44 eyes of 44 healthy individuals were evaluated in this study. Only right eyes were evaluated. The patients with OSAHS were divided into three groups as mild (group 1), moderate (group 2), and severe (group 3) according to apnea-hypopnea index. The PPCT, CMCT, and RNFL measurements were performed by using spectral domain optical coherence tomography with enhanced depth imaging technique. The main parameters assessed were PPCT-Temporal, PPCT-Superior, PPCT-Nasal, PPCT-Inferior quadrants, CMCT, and RNFL thicknesses.

RESULTS

The PPCT of all quadrants was significantly thicker in the control group compared with the moderate and severe subgroups of OSAHS (p < 0.05). The PPCT-Superior and PPCT-Temporal were significantly thinner in the mild subgroup compared with the control group (p = 0.003 and p = 0.028, respectively). There was no difference between the control and mild groups regarding the RNFL thicknesses except nasal RNFL and inferotemporal RNFL which are thinner in the mild group. The RNFL thicknesses of all quadrants were significantly thicker in the control group compared with moderate and severe subgroups (p < 0.05). The CMCT was significantly thicker in the control group compared with all subgroups of OSAHS (p < 0.05).

CONCLUSIONS

In OSAHS patients, PPCT, CMCT, and RNFL were significantly thinner compared with the control group. These results may explain why OSAHS patients are prone to normotensive glaucoma.

Transverse Sinus Stenosis Is the Most Sensitive MR Imaging Correlate of Idiopathic Intracranial Hypertension

BACKGROUND AND PURPOSE

Patients with idiopathic intracranial hypertension have transverse sinus stenosis on gadolinium-bolused MRV, but other MR imaging signs are less consistently seen. Our aim was to demonstrate that transverse sinus stenosis could be identified on conventional MR imaging, and this identification would allow improved diagnostic sensitivity to this condition.

MATERIALS AND METHODS

MR imaging and MRV images from 63 patients with idiopathic intracranial hypertension and 96 controls were reviewed by using 3 independent procedures. MRV images were graded for the presence and degree of stenosis of the transverse sinus. Postgadolinium coronal T1-weighted sequences were evaluated independent of MRV. The dimensions of the proximal and distal transverse sinus were measured from the MRV examinations, and the cross-sectional area of the transverse sinus was calculated. Correlation among the 3 modes of evaluation of the transverse sinus was conducted by using Wilcoxon/Kruskal-Wallis, Pearson, and Spearman ρ nonparametric statistical techniques.

RESULTS

Transverse sinus stenosis was identified bilaterally on MRV in 94% of patients with idiopathic intracranial hypertension and in 3% of controls. On coronal T1 postgadolinium MR images, transverse sinus stenosis was identified in 83% of patients with idiopathic intracranial hypertension and 7% of controls. Previously described MR imaging signs of intracranial hypertension were identified in 8%-61% of patients with idiopathic intracranial hypertension. Correlation among the 3 modes of evaluation was highly significant (P < .0001).

CONCLUSIONS

Even without the assistance of an MRV sequence, neuroradiologists can validly identify bilateral transverse sinus stenosis in patients with intracranial hypertension more reliably than other previously described MR imaging findings in this condition. We conclude that transverse sinus stenosis is the most useful and sensitive imaging indicator of this disease state.

Ophthalmic Diseases in Patients With Obstructive Sleep Apnea

Symptomatic obstructive sleep apnea (OSA) affects 2% of women and 4% of men, but the prevalence of asymptomatic OSA is significantly higher. Several ophthalmic conditions are associated with OSA, including floppy eyelid syndrome, glaucoma, nonarteritic anterior ischemic optic neuropathy, papilledema, keratoconus, and central serous chorioretinopathy. The purpose of this review is to provide primary care physicians with a general knowledge of the signs, symptoms, and management of the ophthalmic diseases associated with OSA.