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Maniaci A, Lavalle S, Parisi FM, Barbanti M, Cocuzza S, Iannella G, Magliulo G, Pace A, Lentini M, Masiello E, La Via L. Impact of Obstructive Sleep Apnea and Sympathetic Nervous System on Cardiac Health: A Comprehensive Review. J Cardiovasc Dev Dis 2024; 11:204. [PMID: 39057624 PMCID: PMC11277108 DOI: 10.3390/jcdd11070204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 06/22/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
A prevalent condition linked to an elevated risk of cardiovascular disease is sleep apnea. This review examines the connections between cardiac risk, the sympathetic nervous system, and sleep apnea. The increased risk of hypertension, arrhythmias, myocardial infarction, and heart failure was highlighted in the pathophysiology of sleep apnea and its effect on sympathetic activation. It is also important to consider potential processes such as oxidative stress, inflammation, endothelial dysfunction, and autonomic imbalance that may relate sleep apnea-induced sympathetic activation to cardiac risk. With implications for creating innovative diagnostic and treatment approaches to lessen the cardiovascular effects of sleep apnea, the goal of this investigation is to improve the understanding of the intricate link between sympathetic activity, cardiac risk, and sleep apnea. This study aimed to clarify the complex relationship between cardiovascular health and sleep apnea by synthesizing the available research and highlighting the crucial role played by the sympathetic nervous system in moderating this relationship. Our thorough investigation may have important therapeutic ramifications that will direct the creation of focused therapies to enhance cardiovascular outcomes in sleep apnea sufferers.
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Affiliation(s)
- Antonino Maniaci
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (M.B.)
| | - Salvatore Lavalle
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (M.B.)
| | - Federica Maria Parisi
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (F.M.P.); (S.C.)
| | - Marco Barbanti
- Department of Medicine and Surgery, University of Enna “Kore”, 94100 Enna, Italy; (A.M.); (M.B.)
| | - Salvatore Cocuzza
- Department of Medical, Surgical Sciences and Advanced Technologies “GF Ingrassia” ENT Section, University of Catania, 95123 Catania, Italy; (F.M.P.); (S.C.)
| | - Giannicola Iannella
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 00161 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Giuseppe Magliulo
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 00161 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Annalisa Pace
- Otorhinolaryngology Department, Sapienza University of Rome, Policlinico Umberto I, Viale del Policlinico, 00161 Rome, Italy; (G.I.); (G.M.); (A.P.)
| | - Mario Lentini
- ASP Ragusa-Hospital Giovanni Paolo II, 97100 Ragusa, Italy;
| | - Edoardo Masiello
- Radiology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Luigi La Via
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico–San Marco”, 95123 Catania, Italy
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Yook S, Park HR, Joo EY, Kim H. Predicting the impact of CPAP on brain health: A study using the sleep EEG-derived brain age index. Ann Clin Transl Neurol 2024; 11:1172-1183. [PMID: 38396240 DOI: 10.1002/acn3.52032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/17/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE This longitudinal study investigated potential positive impact of CPAP treatment on brain health in individuals with obstructive sleep Apnea (OSA). To allow this, we aimed to employ sleep electroencephalogram (EEG)-derived brain age index (BAI) to quantify CPAP's impact on brain health and identify individually varying CPAP effects on brain aging using machine learning approaches. METHODS We retrospectively analyzed CPAP-treated (n = 98) and untreated OSA patients (n = 88) with a minimum 12-month follow-up of polysomnography. BAI was calculated by subtracting chronological age from the predicted brain age. To investigate BAI changes before and after CPAP treatment, we compared annual ΔBAI between CPAP-treated and untreated OSA patients. To identify individually varying CPAP effectiveness and factors influencing CPAP effectiveness, machine learning approaches were employed to predict which patient displayed positive outcomes (negative annual ΔBAI) based on their baseline clinical features. RESULTS CPAP-treated group showed lower annual ΔBAI than untreated (-0.6 ± 2.7 vs. 0.3 ± 2.6 years, p < 0.05). This BAI reduction with CPAP was reproduced independently in the Apnea, Bariatric surgery, and CPAP study cohort. Patients with more severe OSA at baseline displayed more positive annual ΔBAI (=accelerated brain aging) when untreated and displayed more negative annual ΔBAI (=decelerated brain aging) when CPAP-treated. Machine learning models achieved high accuracy (up to 86%) in predicting CPAP outcomes. INTERPRETATION CPAP treatment can alleviate brain aging in OSA, especially in severe cases. Sleep EEG-derived BAI has potential to assess CPAP's impact on brain health. The study provides insights into CPAP's effects and underscores BAI-based predictive modeling's utility in OSA management.
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Affiliation(s)
- Soonhyun Yook
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, 90033, USA
| | - Hea Ree Park
- Department of Neurology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, 10380, Korea
| | - Eun Yeon Joo
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, School of Medicine, Sungkyunkwan University, Seoul, 06351, Korea
| | - Hosung Kim
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, 90033, USA
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Ghaderi S, Mohammadi S, Mohammadi M. Obstructive sleep apnea and attention deficits: A systematic review of magnetic resonance imaging biomarkers and neuropsychological assessments. Brain Behav 2023; 13:e3262. [PMID: 37743582 PMCID: PMC10636416 DOI: 10.1002/brb3.3262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Obstructive sleep apnea (OSA) is a common sleep disorder that causes intermittent hypoxia and sleep fragmentation, leading to attention impairment and other cognitive deficits. Magnetic resonance imaging (MRI) is a powerful modality that can reveal the structural and functional brain alterations associated with attention impairment in OSA patients. The objective of this systematic review is to identify and synthesize the evidence on MRI biomarkers and neuropsychological assessments of attention deficits in OSA patients. METHODS We searched the Scopus and PubMed databases for studies that used MRI to measure biomarkers related to attention alteration in OSA patients and reported qualitative and quantitative data on the association between MRI biomarkers and attention outcomes. We also included studies that found an association between neuropsychological assessments and MRI findings in OSA patients with attention deficits. RESULTS We included 19 studies that met our inclusion criteria and extracted the relevant data from each study. We categorized the studies into three groups based on the MRI modality and the cognitive domain they used: structural and diffusion tensor imaging MRI findings, functional, perfusion, and metabolic MRI findings, and neuropsychological assessment findings. CONCLUSIONS We found that OSA is associated with structural, functional, and metabolic brain alterations in multiple regions and networks that are involved in attention processing. Treatment with continuous positive airway pressure can partially reverse some of the brain changes and improve cognitive function in some domains and in some studies. This review suggests that MRI techniques and neuropsychological assessments can be useful tools for monitoring the progression and response to treatment of OSA patients.
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Affiliation(s)
- Sadegh Ghaderi
- Department of Neuroscience and Addiction StudiesSchool of Advanced Technologies in MedicineTehran University of Medical SciencesTehranIran
| | - Sana Mohammadi
- Department of Medical SciencesSchool of MedicineIran University of Medical SciencesTehranIran
| | - Mahdi Mohammadi
- Department of Medical Physics and Biomedical Engineering, School of MedicineTehran University of Medical SciencesTehranIran
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Chai Y, Park HR, Jo H, Seo MY, Kim HY, Joo EY, Kim H. White matter microstructure and connectivity changes after surgery in male adults with obstructive sleep apnea: recovery or reorganization? Front Neurosci 2023; 17:1221290. [PMID: 37841681 PMCID: PMC10568132 DOI: 10.3389/fnins.2023.1221290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/06/2023] [Indexed: 10/17/2023] Open
Abstract
Study objectives Obstructive sleep apnea (OSA) is a prevalent clinical problem significantly affecting cognitive functions. Surgical treatment is recommended for those unable to use continuous positive airway pressure. We aimed to investigate the therapeutic effect of upper airway surgery on the white matter (WM) microstructure and brain connectivity in patients with OSA. Methods Twenty-one male patients with moderate-to-severe OSA were recruited for multi-level upper airway surgery. Overnight polysomnography (PSG), neuropsychiatric tests, and brain MRI scans were acquired before and 6.1 ± 0.8 months after surgery. Nineteen male patients with untreated OSA were also included as a reference group. We calculated the longitudinal changes of diffusion tensor imaging (DTI) parameters, including fractional anisotropy (ΔFA) and mean/axial/radial diffusivity (ΔMD/AD/RD). We also assessed changes in network properties based on graph theory. Results Surgically treated patients showed improvement in PSG parameters and verbal memory after surgery. Globally, ΔFA was significantly higher and ΔRD was lower in the surgery group than in the untreated group. Especially ΔFA of the tracts involved in the limbic system was higher after surgery. In network analysis, higher Δbetweenness and lower Δclustering coefficients were observed in the surgical group than in the untreated group. Finally, the improvement of verbal memory after surgery positively correlated with ΔFA in superior thalamic radiation (p = 0.021), fronto aslant tracts (p = 0.027), and forceps minor tracts (p = 0.032). Conclusion Surgical treatment of OSA can alleviate alterations in WM integrity and disruptions in local networks, particularly for the tracts involved in the limbic system. These findings may further explain the cognitive improvement observed after the treatment of OSA.
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Affiliation(s)
- Yaqiong Chai
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Hea Ree Park
- Department of Neurology, Inje University College of Medicine, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Hyunjin Jo
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Min Young Seo
- Department of Otorhinolaryngology—Head and Neck Surgery, Korea University College of Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology—Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Yeon Joo
- Department of Neurology, Neuroscience Center, Samsung Medical Center, Samsung Biomedical Research Institute, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Hosung Kim
- USC Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
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Marchena-Romero KJ, Ji X, Sommer R, Centen A, Ramirez J, Poulin JM, Mikulis D, Thrippleton M, Wardlaw J, Lim A, Black SE, MacIntosh BJ. Examining temporal features of BOLD-based cerebrovascular reactivity in clinical populations. Front Neurol 2023; 14:1199805. [PMID: 37396759 PMCID: PMC10310960 DOI: 10.3389/fneur.2023.1199805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/25/2023] [Indexed: 07/04/2023] Open
Abstract
Background Conventional cerebrovascular reactivity (CVR) estimation has demonstrated that many brain diseases and/or conditions are associated with altered CVR. Despite the clinical potential of CVR, characterization of temporal features of a CVR challenge remains uncommon. This work is motivated by the need to develop CVR parameters that characterize individual temporal features of a CVR challenge. Methods Data were collected from 54 adults and recruited based on these criteria: (1) Alzheimer's disease diagnosis or subcortical Vascular Cognitive Impairment, (2) sleep apnea, and (3) subjective cognitive impairment concerns. We investigated signal changes in blood oxygenation level dependent (BOLD) contrast images with respect to hypercapnic and normocapnic CVR transition periods during a gas manipulation paradigm. We developed a model-free, non-parametric CVR metric after considering a range of responses through simulations to characterize BOLD signal changes that occur when transitioning from normocapnia to hypercapnia. The non-parametric CVR measure was used to examine regional differences across the insula, hippocampus, thalamus, and centrum semiovale. We also examined the BOLD signal transition from hypercapnia back to normocapnia. Results We found a linear association between isolated temporal features of successive CO2 challenges. Our study concluded that the transition rate from hypercapnia to normocapnia was significantly associated with the second CVR response across all regions of interest (p < 0.001), and this association was highest in the hippocampus (R2 = 0.57, p < 0.0125). Conclusion This study demonstrates that it is feasible to examine individual responses associated with normocapnic and hypercapnic transition periods of a BOLD-based CVR experiment. Studying these features can provide insight on between-subject differences in CVR.
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Affiliation(s)
- Kayley-Jasmin Marchena-Romero
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Xiang Ji
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
| | - Rosa Sommer
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Andrew Centen
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Joel Ramirez
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
| | - Joshua M. Poulin
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
| | - David Mikulis
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Division of Neuroradiology, Joint Department of Medical Imaging, University Health Network, Toronto, ON, Canada
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Michael Thrippleton
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, The University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre, The University of Edinburgh, Edinburgh, United Kingdom
| | - Andrew Lim
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Sandra E. Black
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
| | - Bradley J. MacIntosh
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Dr. Sandra Black Centre for Brain Resilience and Recovery, Toronto, ON, Canada
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Wu PH, Rodríguez-Soto AE, Wiemken A, Englund EK, Rodgers ZB, Langham MC, Schwab RJ, Detre JA, Guo W, Wehrli FW. MRI evaluation of cerebral metabolic rate of oxygen (CMRO 2) in obstructive sleep apnea. J Cereb Blood Flow Metab 2022; 42:1049-1060. [PMID: 34994242 PMCID: PMC9125486 DOI: 10.1177/0271678x211071018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/15/2021] [Accepted: 12/10/2021] [Indexed: 01/09/2023]
Abstract
Patients with obstructive sleep apnea (OSA) are at elevated risk of developing systemic vascular disease and cognitive dysfunction. Here, cerebral oxygen metabolism was assessed in patients with OSA by means of a magnetic resonance-based method involving simultaneous measurements of cerebral blood flow rate and venous oxygen saturation in the superior sagittal sinus for a period of 10 minutes at an effective temporal resolution of 1.3 seconds before, during, and after repeated 24-second breath-holds mimicking spontaneous apneas, yielding, along with pulse oximetry-derived arterial saturation, whole-brain CMRO2 via Fick's Principle. Enrolled subjects were classified based on their apnea-hypopnea indices into OSA (N = 31) and non-sleep apnea reference subjects (NSA = 21), and further compared with young healthy subjects (YH, N = 10). OSA and NSA subjects were matched for age and body mass index. CMRO2 was lower in OSA than in the YH group during normal breathing (105.6 ± 14.1 versus 123.7 ± 22.8 μmol O2/min/100g, P = 0.01). Further, the fractional change in CMRO2 in response to a breath-hold challenge was larger in OSA than in the YH group (15.2 ± 9.2 versus 8.5 ± 3.4%, P = 0.04). However, there was no significant difference in CMRO2 between OSA and NSA subjects. The data suggest altered brain oxygen metabolism in OSA and possibly in NSA as well.
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Affiliation(s)
- Pei-Hsin Wu
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
- Department of Electrical Engineering, National Sun Yat-sen University, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Ana E Rodríguez-Soto
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew Wiemken
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Erin K Englund
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary B Rodgers
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Langham
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John A Detre
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Wensheng Guo
- Department of Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Felix W Wehrli
- Department of Radiology, University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA
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Song X, Roy B, Vacas S, Woo MA, Kang DW, Aysola RS, Kumar R. Brain regional homogeneity changes after short-term positive airway pressure treatment in patients with obstructive sleep apnea. Sleep Med 2022; 91:12-20. [PMID: 35245787 PMCID: PMC10498724 DOI: 10.1016/j.sleep.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 12/16/2022]
Abstract
Patients with obstructive sleep apnea (OSA) reveal functional changes in brain sites involved in autonomic, cognitive, and mood regulations. However, it is unclear whether these brain changes reverse with short-term positive airway pressure (PAP) treatment. Our aim was to examine brain functional changes in response to 3-months of PAP treatment using regional homogeneity (ReHo) measures, where increased and decreased ReHo value indicates hyper- and hypo-local neural activities, respectively, and considered as functional deficits. We collected brain magnetic resonance imaging data as well as mood, cognitive, and sleep variables from 17 treatment-naïve OSA at baseline and after 3-months of PAP treatment and 25 age- and gender-matched healthy controls. Whole-brain ReHo maps were calculated and compared between OSA and controls and OSA subjects before and after PAP treatment. At baseline, treatment-naïve OSA subjects showed higher ReHo in the bilateral thalamus, putamen, postcentral gyrus, paracentral lobule, supplementary motor area, and right insula, and lower ReHo in the frontal and parietal cortices, compared to controls. After 3-months of PAP treatment, abnormal sleep and mood scores decreased significantly to normal levels. ReHo decreased in the autonomic and somatosensory control areas, including the thalamus, putamen, postcentral gyrus, and insula, and increased in the cognitive and affective regulatory parietal regions. The normalized ReHo was correlated with improved sleep quality and reduced anxiety symptoms. These findings suggest that 3-months of PAP use can improve sleep, mood issues, and partly recover brain activities, however, longer PAP treatment may be required to fully and permanently reverse brain functional deficits.
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Affiliation(s)
- Xiaopeng Song
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Bhaswati Roy
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Susana Vacas
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Mary A Woo
- UCLA School of Nursing, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Daniel W Kang
- Department of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ravi S Aysola
- Department of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Rajesh Kumar
- Department of Anesthesiology, University of California Los Angeles, Los Angeles, CA 90095, USA; Brain Research Institute, University of California Los Angeles, Los Angeles, CA 90095, USA; Department of Radiological Sciences, University of California Los Angeles, Los Angeles, CA 90095, USA; Department of Bioengineering, University of California Los Angeles, Los Angeles, CA 90095, USA.
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Marillier M, Gruet M, Bernard AC, Verges S, Neder JA. The Exercising Brain: An Overlooked Factor Limiting the Tolerance to Physical Exertion in Major Cardiorespiratory Diseases? Front Hum Neurosci 2022; 15:789053. [PMID: 35126072 PMCID: PMC8813863 DOI: 10.3389/fnhum.2021.789053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/28/2021] [Indexed: 12/18/2022] Open
Abstract
“Exercise starts and ends in the brain”: this was the title of a review article authored by Dr. Bengt Kayser back in 2003. In this piece of work, the author highlights that pioneer studies have primarily focused on the cardiorespiratory-muscle axis to set the human limits to whole-body exercise tolerance. In some circumstances, however, exercise cessation may not be solely attributable to these players: the central nervous system is thought to hold a relevant role as the ultimate site of exercise termination. In fact, there has been a growing interest relative to the “brain” response to exercise in chronic cardiorespiratory diseases, and its potential implication in limiting the tolerance to physical exertion in patients. To reach these overarching goals, non-invasive techniques, such as near-infrared spectroscopy and transcranial magnetic stimulation, have been successfully applied to get insights into the underlying mechanisms of exercise limitation in clinical populations. This review provides an up-to-date outline of the rationale for the “brain” as the organ limiting the tolerance to physical exertion in patients with cardiorespiratory diseases. We first outline some key methodological aspects of neuromuscular function and cerebral hemodynamics assessment in response to different exercise paradigms. We then review the most prominent studies, which explored the influence of major cardiorespiratory diseases on these outcomes. After a balanced summary of existing evidence, we finalize by detailing the rationale for investigating the “brain” contribution to exercise limitation in hitherto unexplored cardiorespiratory diseases, an endeavor that might lead to innovative lines of applied physiological research.
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Affiliation(s)
- Mathieu Marillier
- Laboratory of Clinical Exercise Physiology, Queen's University and Kingston General Hospital, Kingston, ON, Canada
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University, Grenoble, France
| | - Mathieu Gruet
- IAPS Laboratory, University of Toulon, Toulon, France
| | - Anne-Catherine Bernard
- Laboratory of Clinical Exercise Physiology, Queen's University and Kingston General Hospital, Kingston, ON, Canada
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University, Grenoble, France
| | - Samuel Verges
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University, Grenoble, France
| | - J Alberto Neder
- Laboratory of Clinical Exercise Physiology, Queen's University and Kingston General Hospital, Kingston, ON, Canada
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Stickland RC, Zvolanek KM, Moia S, Ayyagari A, Caballero-Gaudes C, Bright MG. A practical modification to a resting state fMRI protocol for improved characterization of cerebrovascular function. Neuroimage 2021; 239:118306. [PMID: 34175427 PMCID: PMC8552969 DOI: 10.1016/j.neuroimage.2021.118306] [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: 02/16/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Cerebrovascular reactivity (CVR), defined here as the Blood Oxygenation Level Dependent (BOLD) response to a CO2 pressure change, is a useful metric of cerebrovascular function. Both the amplitude and the timing (hemodynamic lag) of the CVR response can bring insight into the nature of a cerebrovascular pathology and aid in understanding noise confounds when using functional Magnetic Resonance Imaging (fMRI) to study neural activity. This research assessed a practical modification to a typical resting-state fMRI protocol, to improve the characterization of cerebrovascular function. In 9 healthy subjects, we modelled CVR and lag in three resting-state data segments, and in data segments which added a 2–3 minute breathing task to the start of a resting-state segment. Two different breathing tasks were used to induce fluctuations in arterial CO2 pressure: a breath-hold task to induce hypercapnia (CO2 increase) and a cued deep breathing task to induce hypocapnia (CO2 decrease). Our analysis produced voxel-wise estimates of the amplitude (CVR) and timing (lag) of the BOLD-fMRI response to CO2 by systematically shifting the CO2 regressor in time to optimize the model fit. This optimization inherently increases gray matter CVR values and fit statistics. The inclusion of a simple breathing task, compared to a resting-state scan only, increases the number of voxels in the brain that have a significant relationship between CO2 and BOLD-fMRI signals, and improves our confidence in the plausibility of voxel-wise CVR and hemodynamic lag estimates. We demonstrate the clinical utility and feasibility of this protocol in an incidental finding of Moyamoya disease, and explore the possibilities and challenges of using this protocol in younger populations. This hybrid protocol has direct applications for CVR mapping in both research and clinical settings and wider applications for fMRI denoising and interpretation.
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Affiliation(s)
- Rachael C Stickland
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| | - Kristina M Zvolanek
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Stefano Moia
- Basque Center on Cognition, Brain and Language, Donostia, Gipuzkoa, Spain; University of the Basque Country EHU/UPV, Donostia, Gipuzkoa, Spain
| | - Apoorva Ayyagari
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | | | - Molly G Bright
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
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L'Heureux F, Baril AA, Gagnon K, Soucy JP, Lafond C, Montplaisir J, Gosselin N. Longitudinal changes in regional cerebral blood flow in late middle-aged and older adults with treated and untreated obstructive sleep apnea. Hum Brain Mapp 2021; 42:3429-3439. [PMID: 33939243 PMCID: PMC8249886 DOI: 10.1002/hbm.25443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/03/2021] [Accepted: 03/29/2021] [Indexed: 12/31/2022] Open
Abstract
Obstructive sleep apnea (OSA) is associated with abnormal cerebral perfusion at wakefulness, but whether these anomalies evolve over time is unknown. Here, we examined longitudinal changes in regional cerebral blood flow (rCBF) distribution in late middle‐aged and older adults with treated or untreated OSA. Twelve controls (64.8 ± 8.0 years) and 23 participants with newly diagnosed OSA (67.8 ± 6.2 years) were evaluated with polysomnography and cerebral 99mTc‐HMPAO single‐photon emission computed tomography during wakeful rest. OSA participants were referred to a sleep apnea clinic and 13 of them decided to start continuous positive airway pressure (CPAP). Participants were tested again after 18 months. Voxel‐based analysis and extracted relative rCBF values were used to assess longitudinal changes. Untreated OSA participants showed decreased relative rCBF in the left hippocampus and the right parahippocampal gyrus over time, while treated participants showed trends for increased relative rCBF in the left hippocampus and the right parahippocampal gyrus. No changes were found over time in controls. Untreated OSA is associated with worsening relative rCBF in specific brain areas over time, while treated OSA shows the opposite. Considering that OSA possibly accelerates cognitive decline in older adults, CPAP treatment could help reduce risk for cognitive impairment.
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Affiliation(s)
- Francis L'Heureux
- Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord de l'Île-de-Montréal, Montreal, Quebec, Canada.,Department of Neurosciences, Université de Montréal, Montreal, Quebec, Canada
| | - Andrée-Ann Baril
- The Framingham Heart Study, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Katia Gagnon
- Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord de l'Île-de-Montréal, Montreal, Quebec, Canada.,Department of Psychology, Université du Québec à Montreal, Montreal, Quebec, Canada
| | - Jean-Paul Soucy
- McConnel Brain Imaging Centre, McGill University, Montreal, Quebec, Canada
| | - Chantal Lafond
- Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord de l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Jacques Montplaisir
- Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord de l'Île-de-Montréal, Montreal, Quebec, Canada.,Department of Psychiatry, Université de Montréal, Montreal, Quebec, Canada
| | - Nadia Gosselin
- Center for Advanced Research in Sleep Medicine, Hôpital du Sacré-Coeur de Montréal, Centre Intégré Universitaire de Santé et de Services Sociaux du Nord de l'Île-de-Montréal, Montreal, Quebec, Canada.,Department of Psychology, Université de Montréal, Montreal, Quebec, Canada
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11
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A randomized sham-controlled trial on the effect of continuous positive airway pressure treatment on gait control in severe obstructive sleep apnea patients. Sci Rep 2021; 11:9329. [PMID: 33927278 PMCID: PMC8085224 DOI: 10.1038/s41598-021-88642-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 04/09/2021] [Indexed: 11/21/2022] Open
Abstract
To determine the effect of continuous positive airway pressure (CPAP), the gold standard treatment for obstructive sleep apnea syndrome (OSAS), on gait control in severe OSAS patients. We conducted a randomized, double-blind, parallel-group, sham-controlled monocentric study in Grenoble Alpes University Hospital, France. Gait parameters were recorded under single and dual-task conditions using a visuo-verbal cognitive task (Stroop test), before and after the 8-week intervention period. Stride-time variability, a marker of gait control, was the primary study endpoint. Changes in the determinants of gait control were the main secondary outcomes. ClinicalTrials.gov Identifier: (NCT02345694). 24 patients [median (Q1; Q3)]: age: 59.5 (46.3; 66.8) years, 87.5% male, body mass index: 28.2 (24.7; 29.8) kg. m−2, apnea–hypopnea index: 51.6 (35.0; 61.4) events/h were randomized to be treated by effective CPAP (n = 12) or by sham-CPAP (n = 12). A complete case analysis was performed, using a mixed linear regression model. CPAP elicited no significant improvement in stride-time variability compared to sham-CPAP. No difference was found regarding the determinants of gait control. This study is the first RCT to investigate the effects of CPAP on gait control. Eight weeks of CPAP treatment did not improve gait control in severe non-obese OSAS patients. These results substantiate the complex OSAS-neurocognitive function relationship.
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12
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Moia S, Termenon M, Uruñuela E, Chen G, Stickland RC, Bright MG, Caballero-Gaudes C. ICA-based denoising strategies in breath-hold induced cerebrovascular reactivity mapping with multi echo BOLD fMRI. Neuroimage 2021; 233:117914. [PMID: 33684602 PMCID: PMC8351526 DOI: 10.1016/j.neuroimage.2021.117914] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/25/2021] [Accepted: 02/22/2021] [Indexed: 12/19/2022] Open
Abstract
Performing a BOLD functional MRI (fMRI) acquisition during breath-hold (BH) tasks is a non-invasive, robust method to estimate cerebrovascular reactivity (CVR). However, movement and breathing-related artefacts caused by the BH can substantially hinder CVR estimates due to their high temporal collinearity with the effect of interest, and attention has to be paid when choosing which analysis model should be applied to the data. In this study, we evaluate the performance of multiple analysis strategies based on lagged general linear models applied on multi-echo BOLD fMRI data, acquired in ten subjects performing a BH task during ten sessions, to obtain subject-specific CVR and haemodynamic lag estimates. The evaluated approaches range from conventional regression models, i.e. including drifts and motion timecourses as nuisance regressors, applied on single-echo or optimally-combined data, to more complex models including regressors obtained from multi-echo independent component analysis with different grades of orthogonalization in order to preserve the effect of interest, i.e. the CVR. We compare these models in terms of their ability to make signal intensity changes independent from motion, as well as the reliability as measured by voxelwise intraclass correlation coefficients of both CVR and lag maps over time. Our results reveal that a conservative independent component analysis model applied on the optimally-combined multi-echo fMRI signal offers the largest reduction of motion-related effects in the signal, while yielding reliable CVR amplitude and lag estimates, although a conventional regression model applied on the optimally-combined data results in similar estimates. This work demonstrates the usefulness of multi-echo based fMRI acquisitions and independent component analysis denoising for precision mapping of CVR in single subjects based on BH paradigms, fostering its potential as a clinically-viable neuroimaging tool for individual patients. It also proves that the way in which data-driven regressors should be incorporated in the analysis model is not straight-forward due to their complex interaction with the BH-induced BOLD response.
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Affiliation(s)
- Stefano Moia
- Basque Center on Cognition, Brain and Language, Donostia, Spain; University of the Basque Country UPV/EHU, Donostia, Spain.
| | - Maite Termenon
- Basque Center on Cognition, Brain and Language, Donostia, Spain
| | - Eneko Uruñuela
- Basque Center on Cognition, Brain and Language, Donostia, Spain; University of the Basque Country UPV/EHU, Donostia, Spain
| | - Gang Chen
- Scientific and Statistical Computing Core, NIMH/NIH/HHS, Bethesda, MD, United States
| | - Rachael C Stickland
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Molly G Bright
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States; Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
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13
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Olaithe M, Pushpanathan M, Bucks RS. Time to regroup and redirect? Sleep fragmentation and hypoxia may not be where we should focus our efforts in looking for causal pathways to cognitive deficits in OSA. J Clin Sleep Med 2021; 17:339-340. [PMID: 33185184 DOI: 10.5664/jcsm.9000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Michelle Olaithe
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
| | - Maria Pushpanathan
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
| | - Romola S Bucks
- School of Psychological Science, University of Western Australia, Perth, Western Australia, Australia
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14
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Pinto J, Bright MG, Bulte DP, Figueiredo P. Cerebrovascular Reactivity Mapping Without Gas Challenges: A Methodological Guide. Front Physiol 2021; 11:608475. [PMID: 33536935 PMCID: PMC7848198 DOI: 10.3389/fphys.2020.608475] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Cerebrovascular reactivity (CVR) is defined as the ability of vessels to alter their caliber in response to vasoactive factors, by means of dilating or constricting, in order to increase or decrease regional cerebral blood flow (CBF). Importantly, CVR may provide a sensitive biomarker for pathologies where vasculature is compromised. Furthermore, the spatiotemporal dynamics of CVR observed in healthy subjects, reflecting regional differences in cerebral vascular tone and response, may also be important in functional MRI studies based on neurovascular coupling mechanisms. Assessment of CVR is usually based on the use of a vasoactive stimulus combined with a CBF measurement technique. Although transcranial Doppler ultrasound has been frequently used to obtain global flow velocity measurements, MRI techniques are being increasingly employed for obtaining CBF maps. For the vasoactive stimulus, vasodilatory hypercapnia is usually induced through the manipulation of respiratory gases, including the inhalation of increased concentrations of carbon dioxide. However, most of these methods require an additional apparatus and complex setups, which not only may not be well-tolerated by some populations but are also not widely available. For these reasons, strategies based on voluntary breathing fluctuations without the need for external gas challenges have been proposed. These include the task-based methodologies of breath holding and paced deep breathing, as well as a new generation of methods based on spontaneous breathing fluctuations during resting-state. Despite the multitude of alternatives to gas challenges, existing literature lacks definitive conclusions regarding the best practices for the vasoactive modulation and associated analysis protocols. In this work, we perform an extensive review of CVR mapping techniques based on MRI and CO2 variations without gas challenges, focusing on the methodological aspects of the breathing protocols and corresponding data analysis. Finally, we outline a set of practical guidelines based on generally accepted practices and available data, extending previous reports and encouraging the wider application of CVR mapping methodologies in both clinical and academic MRI settings.
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Affiliation(s)
- Joana Pinto
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
- Institute for Systems and Robotics - Lisboa and Department of Bioengineering, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Molly G. Bright
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Biomedical Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL, United States
| | - Daniel P. Bulte
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, United Kingdom
| | - Patrícia Figueiredo
- Institute for Systems and Robotics - Lisboa and Department of Bioengineering, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
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15
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Chang YT, Chen YC, Chen YL, Hsu SW, Yang FY, Lee CC, Hsu PY, Lin MC. Functional connectivity in default mode network correlates with severity of hypoxemia in obstructive sleep apnea. Brain Behav 2020; 10:e01889. [PMID: 33135393 PMCID: PMC7749584 DOI: 10.1002/brb3.1889] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/02/2020] [Accepted: 09/26/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Obstructive sleep apnea (OSA)-associated hypoxemia, sleep fragmentation, and cerebral vascular dysfunction are implicated in cognitive dysfunction. Functional connectivity within default mode network (DMN) is a possible mechanism underlying the cognitive impairment. The aim of this study was to investigate the impact of hypoxemia and sleep fragmentation on functional connectivity and on cognitive performance in patients with OSA. METHODS Twenty-eight patients with OSA were included (mean age = 58.0 ± 8.5 years). We correlated the functional connectivity in DMN with cognitive performances and further analyzed the relationship of functional connectivity in DMN with hypoxemia severity, as revealed by apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and nadir SaO2 (%), and with degree of sleep fragmentation, as shown by sleep efficiency and wake after sleep onset. RESULTS Functional connectivity in DMN was associated with AHI, ODI, and nadir SaO2 (%) (p < .05) and was not associated with sleep fragmentation measures (p > .05). Functional connectivity that was associated with AHI, ODI, and nadir SaO2 (%) was in the areas of bilateral middle temporal gyri, bilateral frontal pole, and bilateral hippocampus and was positively correlated with Cognitive Abilities Screening Instrument (CASI) total score (ρ = 0.484; p = .012), CASI-List-generating, CASI-Attention, and composite score of CASI-List-generating plus CASI-Attention (p < .05). CONCLUSION Functional connectivity in DMN is implicated in impairment of global cognitive function and of attention in OSA patients. The functional connectivity in the DMN is associated with hypoxemia rather than with sleep fragmentation.
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Affiliation(s)
- Ya-Ting Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Che Chen
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shih-Wei Hsu
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Feng-Yueh Yang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chen-Chang Lee
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Po-Yuan Hsu
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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16
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Objective and subjective long term outcome of maxillomandibular advancement in obstructive sleep apnea. Sleep Med 2020; 74:289-296. [DOI: 10.1016/j.sleep.2020.05.024] [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: 03/23/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 11/23/2022]
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17
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Li N, Liu Y, Zhao Y, Wu X, Tong J, Hua Y. Cerebrovascular reactivity in young and old patients with obstructive sleep apnea. Sleep Med 2020; 73:125-129. [PMID: 32827884 DOI: 10.1016/j.sleep.2020.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Impaired cerebrovascular reactivity (CVR) in patients with obstructive sleep apnea syndrome (OSAS) increases the risk of ischemic stroke. CVR also decreases with age in normal individuals. However, it is unclear whether OSAS affects CVR differently in young and old patients. The aim of this study was to compare CVR in old and young patients with OSAS via transcranial Doppler (TCD) measurements of changes in cerebral blood flow velocity in the middle cerebral artery (MCAmv) during breath holding and hyperventilation. METHODS A total of 20 old patients (≥65 y) and 40 young patients (<65 y) with similar distributions of sex and OSAS severity were recruited for this study. The breath-holding index (BHI) and the hyperventilation index (HVI) were calculated to measure CVR. RESULTS No differences were found in MCAmv at baseline, apnea or hyperventilation between the two groups with different OSAS severities. However, reduced BHI (P < 0.01) and HVI (P < 0.01) were found in the young group with increasing severity of OSAS. Notably, the decline in BHI and HVI associated with OSAS severity was steeper in young patients than in old patients (P < 0.01). CONCLUSIONS These findings suggest that CVR in young patients is more impacted by OSAS severity than that in old patients, suggesting the existence of age-related cerebrovascular susceptibility to OSAS.
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Affiliation(s)
- Na Li
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yumei Liu
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, 100053 China
| | - Ying Zhao
- Department of Stomatology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiaoguang Wu
- Evidence-based Medicine Center, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Junyao Tong
- Department of Stomatology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yang Hua
- Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China; Center of Vascular Ultrasonography, Beijing Institute of Brain Disorders, Beijing, 100053 China.
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18
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Mehta TR, Gurung P, Nene Y, Fayyaz M, Bollu PC. Sleep and ADHD: A review article. CURRENT DEVELOPMENTAL DISORDERS REPORTS 2019. [DOI: 10.1007/s40474-019-00178-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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Lau HL, Rundek T, Ramos AR. Sleep and Stroke: New Updates on Epidemiology, Pathophysiology, Assessment, and Treatment. CURRENT SLEEP MEDICINE REPORTS 2019; 5:71-82. [PMID: 31850157 PMCID: PMC6916645 DOI: 10.1007/s40675-019-00142-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review aims to discuss the most recent data on sleep disorders and stroke, highlighting relevant findings for the practicing neurologist or health providers who encounter patients with sleep disorders and stroke. RECENT FINDINGS Sleep apnea and abnormal sleep duration have the strongest association with stroke risk. Possible mechanisms include non-dipping of blood pressure during sleep, hypoxemia or reoxygenation leading to sympathetic activation, hypertension, atrial fibrillation and impaired cerebral hemodynamics. Treatment studies suggest that continuous positive airway pressure (CPAP) for sleep apnea could improve primary prevention of stroke, but data is equivocal for secondary prevention. However, CPAP could improve functional outcomes after stroke. SUMMARY Sleep disorders present an opportunity to improve stroke risk and functional outcomes. However, new strategies are needed to determine the patients at high-risk who would most likely benefit from targeted care. Novel methods for phenotyping sleep disorders could provide personalized stroke care to improve clinical outcomes and public health strategies.
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Affiliation(s)
- H Lee Lau
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Tanja Rundek
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
| | - Alberto R Ramos
- Departments of Neurology, Miller School of Medicine University of Miami, Miami, Florida, USA
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20
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Bain AR, Drvis I, Dujic Z, MacLeod DB, Ainslie PN. Physiology of static breath holding in elite apneists. Exp Physiol 2019; 103:635-651. [PMID: 29512224 DOI: 10.1113/ep086269] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 03/02/2018] [Indexed: 12/16/2022]
Abstract
NEW FINDINGS What is the topic of this review? This review provides an up-to-date assessment of the physiology involved with extreme static dry-land breath holding in trained apneists. What advances does it highlight? We specifically highlight the recent findings involved with the cardiovascular, cerebrovascular and metabolic function during a maximal breath hold in elite apneists. ABSTRACT Breath-hold-related activities have been performed for centuries, but only recently, within the last ∼30 years, has it emerged as an increasingly popular competitive sport. In apnoea sport, competition relates to underwater distances or simply maximal breath-hold duration, with the current (oxygen-unsupplemented) static breath-hold record at 11 min 35 s. Remarkably, many ultra-elite apneists are able to suppress respiratory urges to the point where consciousness fundamentally limits a breath-hold duration. Here, arterial oxygen saturations as low as ∼50% have been reported. In such cases, oxygen conservation to maintain cerebral functioning is critical, where responses ascribed to the mammalian dive reflex, e.g. sympathetically mediated peripheral vasoconstriction and vagally mediated bradycardia, are central. In defence of maintaining global cerebral oxygen delivery during prolonged breath holds, the cerebral blood flow may increase by ∼100% from resting values. Interestingly, near the termination of prolonged dry static breath holds, recent studies also indicate that reductions in the cerebral oxidative metabolism can occur, probably attributable to the extreme hypercapnia and irrespective of the hypoxaemia. In this review, we highlight and discuss the recent data on the cardiovascular, metabolic and, particularly, cerebrovascular function in competitive apneists performing maximal static breath holds. The physiological adaptation and maladaptation with regular breath-hold training are also summarized, and future research areas in this unique physiological field are highlighted; particularly, the need to determine the potential long-term health impacts of extreme breath holding.
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Affiliation(s)
- Anthony R Bain
- Center for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada.,Integrative Physiology, University of Colorado, Boulder, CO, USA
| | - Ivan Drvis
- Faculty of Kinesiology, University of Zagreb, Zagreb, Croatia
| | - Zeljko Dujic
- Department of Integrative Physiology, University of Split School of Medicine, Split, Croatia
| | - David B MacLeod
- Human Pharmacology and Physiology Laboratory, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Philip N Ainslie
- Center for Heart, Lung and Vascular Health, University of British Columbia, Kelowna, BC, Canada
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21
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Thiel S, Lettau F, Rejmer P, Rossi C, Haile S, Schwarz EI, Stöberl AS, Sievi NA, Boss A, Becker AS, Winklhofer S, Stradling JR, Kohler M. Effects of short-term continuous positive airway pressure withdrawal on cerebral vascular reactivity measured by blood oxygen level-dependent magnetic resonance imaging in obstructive sleep apnoea: a randomised controlled trial. Eur Respir J 2019; 53:13993003.01854-2018. [DOI: 10.1183/13993003.01854-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/20/2018] [Indexed: 12/20/2022]
Abstract
Impaired cerebral vascular reactivity (CVR) increases long-term stroke risk. Obstructive sleep apnoea (OSA) is associated with peripheral vascular dysfunction and vascular events. The aim of this trial was to evaluate the effect of continuous positive airway pressure (CPAP) withdrawal on CVR.41 OSA patients (88% male, mean age 57±10 years) were randomised to either subtherapeutic or continuation of therapeutic CPAP. At baseline and after 2 weeks, patients underwent a sleep study and magnetic resonance imaging (MRI). CVR was estimated by quantifying the blood oxygen level-dependent (BOLD) MRI response to breathing stimuli.OSA did recur in the subtherapeutic CPAP group (mean treatment effect apnoea–hypopnoea index +38.0 events·h−1, 95% CI 24.2–52.0; p<0.001) but remained controlled in the therapeutic group. Although there was a significant increase in blood pressure upon CPAP withdrawal (mean treatment effect +9.37 mmHg, 95% CI 1.36–17.39; p=0.023), there was no significant effect of CPAP withdrawal on CVR assessedviaBOLD MRI under either hyperoxic or hypercapnic conditions.Short-term CPAP withdrawal did not result in statistically significant changes in CVR as assessed by functional MRI, despite the recurrence of OSA. We thus conclude that, unlike peripheral endothelial function, CVR is not affected by short-term CPAP withdrawal.
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22
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Maresky HS, Shpirer I, Klar MM, Levitt M, Sasson E, Tal S. Continuous positive airway pressure alters brain microstructure and perfusion patterns in patients with obstructive sleep apnea. Sleep Med 2019; 57:61-69. [PMID: 30897457 DOI: 10.1016/j.sleep.2018.12.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/29/2018] [Accepted: 12/20/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To assess the effects of continuous positive airway pressure (CPAP) treatment on brain structure and function in patients with obstructive sleep apnea (OSA). METHODS A prospective study of seven OSA patients recruited from the sleep center at our institution was carried out. Patients were treated with six weeks of CPAP treatment. Pre-treatment and post-treatment magnetic resonance imaging (MRI) perfusion scans were obtained and compared to assess for treatment-induced changes. Microstructural changes were quantified using functional anistrophy (FA) and mean diffusivity (MD), and brain perfusion was quantified using cerebral blood flow (CBF) and cerebral blood volume (CBV). RESULTS Of the seven patients included the in study, six (85.7%) were male, and the mean age was 51 years (standard deviation = 13.14). Increased FA and decreased MD were found in the hippocampus, temporal lobes, fusiform gyrus, and occipital lobes. Decreased FA and increased MD were found in frontal regions for all patients (p < 0.05). Increased CBF and CBV were also observed following treatment (p < 0.05). CONCLUSION In addition to symptom resolution, CPAP treatment may allow for healing of OSA-induced brain damage as seen by restoration of brain structure and perfusion.
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Affiliation(s)
- Hillel S Maresky
- Department of Radiology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medical Imaging, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Isaac Shpirer
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Sleep and Snoring Clinic, Assaf Harofeh Medical Center, Zerifin, Israel
| | - Miriam M Klar
- Department of Radiology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Max Levitt
- Department of Radiology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Surgery, Division of Urology, Ottawa General Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Sigal Tal
- Department of Radiology, Assaf Harofeh Medical Center, Zerifin, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Jensen MLF, Vestergaard MB, Tønnesen P, Larsson HBW, Jennum PJ. Cerebral blood flow, oxygen metabolism, and lactate during hypoxia in patients with obstructive sleep apnea. Sleep 2019; 41:4788814. [PMID: 29309697 DOI: 10.1093/sleep/zsy001] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Study Objectives Obstructive sleep apnea (OSA) is associated with increased risk of stroke but the underlying mechanism is poorly understood. We suspect that the normal cerebrovascular response to hypoxia is disturbed in patients with OSA. Methods Global cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), and lactate concentration during hypoxia were measured in patients with OSA and matched controls. Twenty-eight patients (82.1% males, mean age 52.3 ± 10.0 years) with moderate-to-severe OSA assessed by partial polysomnography were examined and compared with 19 controls (73.7% males, mean age 51.8 ± 10.1 years). Patients and controls underwent magnetic resonance imaging (MRI) during 35 min of normoxia followed by 35 min inhaling hypoxic air (10%-12% O2). After 3 months of continuous positive airway pressure (CPAP) treatment, 22 patients were rescanned. Results During hypoxia, CBF significantly increased with decreasing arterial blood oxygen concentration (4.53 mL (blood)/100 g/min per -1 mmol(O2)/L, p < 0.001) in the control group, but was unchanged (0.89 mL (blood)/100 g/min per -1 mmol(O2)/L, p = 0.289) in the patient group before CPAP treatment. The CBF response to hypoxia was significantly weaker in patients than in controls (p = 0.003). After 3 months of CPAP treatment the CBF response normalized, showing a significant increase during hypoxia (5.15 mL (blood)/100 g/min per -1 mmol(O2)/L, p < 0.001). There was no difference in CMRO2 or cerebral lactate concentration between patients and controls, and no effect of CPAP treatment. Conclusions Patients with OSA exhibit reduced CBF in response to hypoxia. CPAP treatment normalized these patterns.
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Affiliation(s)
- M L F Jensen
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - M B Vestergaard
- Functional Imaging Unit, Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Glostrup, Denmark
| | - P Tønnesen
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
| | - H B W Larsson
- Functional Imaging Unit, Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, Glostrup, Denmark
| | - Poul J Jennum
- Danish Center for Sleep Medicine, Department of Clinical Neurophysiology, Rigshospitalet, University of Copenhagen, Glostrup, Denmark
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Impaired cerebral oxygenation and exercise tolerance in patients with severe obstructive sleep apnea syndrome. Sleep Med 2018; 51:37-46. [DOI: 10.1016/j.sleep.2018.06.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/19/2022]
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25
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MARILLIER MATHIEU, GRUET MATHIEU, BAILLIEUL SÉBASTIEN, LE ROUX MALLOUF THIBAULT, WUYAM BERNARD, TAMISIER RENAUD, LEVY PATRICK, PEPIN JEANLOUIS, VERGES SAMUEL. Neuromuscular Dysfunction and Cortical Impairment in Sleep Apnea Syndrome. Med Sci Sports Exerc 2018; 50:1529-1539. [DOI: 10.1249/mss.0000000000001625] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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26
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Song X, Roy B, Kang DW, Aysola RS, Macey PM, Woo MA, Yan-Go FL, Harper RM, Kumar R. Altered resting-state hippocampal and caudate functional networks in patients with obstructive sleep apnea. Brain Behav 2018; 8:e00994. [PMID: 29749715 PMCID: PMC5991585 DOI: 10.1002/brb3.994] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 03/29/2018] [Accepted: 04/06/2018] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Brain structural injury and metabolic deficits in the hippocampus and caudate nuclei may contribute to cognitive and emotional deficits found in obstructive sleep apnea (OSA) patients. If such contributions exist, resting-state interactions of these subcortical sites with cortical areas mediating affective symptoms and cognition should be disturbed. Our aim was to examine resting-state functional connectivity (FC) of the hippocampus and caudate to other brain areas in OSA relative to control subjects, and to relate these changes to mood and neuropsychological scores. METHODS We acquired resting-state functional magnetic resonance imaging (fMRI) data from 70 OSA and 89 healthy controls using a 3.0-Tesla magnetic resonance imaging scanner, and assessed psychological and behavioral functions, as well as sleep issues. After standard fMRI data preprocessing, FC maps were generated for bilateral hippocampi and caudate nuclei, and compared between groups (ANCOVA; covariates, age and gender). RESULTS Obstructive sleep apnea subjects showed significantly higher levels of anxiety and depressive symptoms over healthy controls. In OSA subjects, the hippocampus showed disrupted FC with the thalamus, para-hippocampal gyrus, medial and superior temporal gyrus, insula, and posterior cingulate cortex. Left and right caudate nuclei showed impaired FC with the bilateral inferior frontal gyrus and right angular gyrus. In addition, altered limbic-striatal-cortical FC in OSA showed relationships with behavioral and neuropsychological variables. CONCLUSIONS The compromised hippocampal-cortical FC in OSA may underlie depression and anxious mood levels in OSA, while impaired caudate-cortical FC may indicate deficits in reward processing and cognition. These findings provide insights into the neural mechanisms underlying the comorbidity of mood and cognitive deficits in OSA.
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Affiliation(s)
- Xiaopeng Song
- Department of Anesthesiology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Bhaswati Roy
- UCLA School of Nursing, University of California at Los Angeles, Los Angeles, CA, USA
| | - Daniel W Kang
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Ravi S Aysola
- Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Paul M Macey
- UCLA School of Nursing, University of California at Los Angeles, Los Angeles, CA, USA
| | - Mary A Woo
- UCLA School of Nursing, University of California at Los Angeles, Los Angeles, CA, USA
| | - Frisca L Yan-Go
- Department of Neurology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Ronald M Harper
- Department of Neurobiology, University of California at Los Angeles, Los Angeles, CA, USA.,Brain Research Institute, University of California at Los Angeles, Los Angeles, CA, USA
| | - Rajesh Kumar
- Department of Anesthesiology, University of California at Los Angeles, Los Angeles, CA, USA.,Brain Research Institute, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Radiological Sciences, University of California at Los Angeles, Los Angeles, CA, USA.,Department of Bioengineering, University of California at Los Angeles, Los Angeles, CA, USA
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27
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Wszedybyl-Winklewska M, Wolf J, Szarmach A, Winklewski PJ, Szurowska E, Narkiewicz K. Central sympathetic nervous system reinforcement in obstructive sleep apnoea. Sleep Med Rev 2018; 39:143-154. [DOI: 10.1016/j.smrv.2017.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/29/2017] [Accepted: 08/31/2017] [Indexed: 01/30/2023]
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Gregori-Pla C, Cotta G, Blanco I, Zirak P, Giovannella M, Mola A, Fortuna A, Durduran T, Mayos M. Cerebral vasoreactivity in response to a head-of-bed position change is altered in patients with moderate and severe obstructive sleep apnea. PLoS One 2018. [PMID: 29538409 PMCID: PMC5851619 DOI: 10.1371/journal.pone.0194204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Motivation Obstructive sleep apnea (OSA) can impair cerebral vasoreactivity and is associated with an increased risk of cerebrovascular disease. Unfortunately, an easy-to-use, non-invasive, portable monitor of cerebral vasoreactivity does not exist. Therefore, we have evaluated the use of near-infrared diffuse correlation spectroscopy to measure the microvascular cerebral blood flow (CBF) response to a mild head-of-bed position change as a biomarker for the evaluation of cerebral vasoreactivity alteration due to chronic OSA. Furthermore, we have monitored the effect of two years of continuous positive airway pressure (CPAP) treatment on the cerebral vasoreactivity. Methodology CBF was measured at different head-of-bed position changes (supine to 30° to supine) in sixty-eight patients with OSA grouped according to severity (forty moderate to severe, twenty-eight mild) and in fourteen control subjects without OSA. A subgroup (n = 13) with severe OSA was measured again after two years of CPAP treatment. Results All patients and controls showed a similar CBF response after changing position from supine to 30° (p = 0.819), with a median (confidence interval) change of -17.5 (-10.3, -22.9)%. However, when being tilted back to the supine position, while the control group (p = 0.091) and the mild patients with OSA (p = 0.227) recovered to the initial baseline, patients with moderate and severe OSA did not recover to the baseline (9.8 (0.8, 12.9)%, p < 0.001) suggesting altered cerebral vasoreactivity. This alteration was correlated with OSA severity defined by the apnea-hypopnea index, and with mean nocturnal arterial oxygen saturation. The CBF response was normalized after two years of CPAP treatment upon follow-up measurements. Conclusion In conclusion, microvascular CBF response to a head-of-bed challenge measured by diffuse correlation spectroscopy suggests that moderate and severe patients with OSA have altered cerebral vasoreactivity related to OSA severity. This may normalize after two years of CPAP treatment.
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Affiliation(s)
- Clara Gregori-Pla
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
- * E-mail:
| | - Gianluca Cotta
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Igor Blanco
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Peyman Zirak
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Martina Giovannella
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
| | - Anna Mola
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Ana Fortuna
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Turgut Durduran
- ICFO-Institut de Ciències Fotòniques, The Barcelona Institute of Science and Technology, Castelldefels (Barcelona), Spain
- Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain
| | - Mercedes Mayos
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- CIBER Enfermedades Respiratorias (CibeRes) (CB06/06), Madrid, Spain
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Baillieul S, Wuyam B, Pépin JL, Marillier M, Tamisier R, Pérennou D, Verges S. Continuous positive airway pressure improves gait control in severe obstructive sleep apnoea: A prospective study. PLoS One 2018; 13:e0192442. [PMID: 29474363 PMCID: PMC5825012 DOI: 10.1371/journal.pone.0192442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 01/11/2018] [Indexed: 01/10/2023] Open
Abstract
Study aim Severe obstructive sleep apnoea (OSA) can lead to neurocognitive alterations, including gait impairments. The beneficial effects of continuous positive airway pressure (CPAP) on improving excessive daytime sleepiness and daily functioning have been documented. However, a demonstration of CPAP treatment efficacy on gait control is still lacking. This study aims to test the hypothesis that CPAP improves gait control in severe OSA patients. Material and methods In this prospective controlled study, twelve severe OSA patients (age = 57.2±8.9 years, body mass index = 27.4±3.1 kg·m-2, apnoea-hypopnoea index = 46.3±11.7 events·h-1) and 10 healthy matched subjects were included. Overground gait parameters were recorded at spontaneous speed and stride time variability, a clinical marker of gait control, was calculated. To assess the role of executive functions in gait and postural control, a dual-task paradigm was applied using a Stroop test as secondary cognitive task. All assessments were performed before and after 8 weeks of CPAP treatment. Results Before CPAP treatment, OSA patients had significantly larger stride time variability (3.1±1.1% vs 2.1±0.5%) and lower cognitive performances under dual task compared to controls. After CPAP treatment, stride time variability was significantly improved and no longer different compared to controls. Cognitive performance under dual task also improved after CPAP treatment. Conclusion Eight weeks of CPAP treatment improves gait control of severe OSA patients, suggesting morphological and functional cerebral improvements. Our data provide a rationale for further mechanistic studies and the use of gait as a biomarker of OSA brain consequences.
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Affiliation(s)
- Sébastien Baillieul
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
- Pôle Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
- * E-mail:
| | - Bernard Wuyam
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
- Pôle Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Pépin
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
- Pôle Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
| | - Mathieu Marillier
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
| | - Renaud Tamisier
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
- Pôle Thorax et Vaisseaux, Grenoble Alpes University Hospital, Grenoble, France
| | - Dominic Pérennou
- LPNC laboratory (UMPR CNRS 5105), Grenoble Alpes University, Grenoble, France
- MPR Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Samuel Verges
- HP2 laboratory, Grenoble Alpes University, Grenoble, France
- U1042, INSERM, Grenoble, France
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Koo DL, Nam H, Thomas RJ, Yun CH. Sleep Disturbances as a Risk Factor for Stroke. J Stroke 2018; 20:12-32. [PMID: 29402071 PMCID: PMC5836576 DOI: 10.5853/jos.2017.02887] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 12/30/2022] Open
Abstract
Sleep, a vital process of human being, is carefully orchestrated by the brain and consists of cyclic transitions between rapid eye movement (REM) and non-REM (NREM) sleep. Autonomic tranquility during NREM sleep is characterized by vagal dominance and stable breathing, providing an opportunity for the cardiovascular-neural axis to restore homeostasis, in response to use, distress or fatigue inflicted during wakefulness. Abrupt irregular swings in sympathovagal balance during REM sleep act as phasic loads on the resting cardiovascular system. Any causes of sleep curtailment or fragmentation such as sleep restriction, sleep apnea, insomnia, periodic limb movements during sleep, and shift work, not only impair cardiovascular restoration but also impose a stress on the cardiovascular system. Sleep disturbances have been reported to play a role in the development of stroke and other cardiovascular disorders. This review aims to provide updated information on the role of abnormal sleep in the development of stroke, to discuss the implications of recent research findings, and to help both stroke clinicians and researchers understand the importance of identification and management of sleep pathology for stroke prevention and care.
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Affiliation(s)
- Dae Lim Koo
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunwoo Nam
- Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Robert J Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Chang-Ho Yun
- Department of Neurology, Bundang Clinical Neuroscience Institute, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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31
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Impaired cerebrovascular reactivity in obstructive sleep apnea: a case-control study. Sleep Med 2017; 43:7-13. [PMID: 29482816 DOI: 10.1016/j.sleep.2017.10.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/28/2017] [Accepted: 10/06/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Obstructive sleep apnea (OSA) is an independent risk factor for stroke. Little is known about the cerebrovascular hemodynamic changes during apnea. Hypercapnia occurs in apneas and hypopneas, and a reduced cerebral vasodilatory response to CO2 could compromise the cerebral blood flow (CBF). Therefore, we aimed to evaluate whether the apnea-hypopnea index (AHI) affected the cerebrovascular response to CO2. METHODS A total of 11 patients with OSA were compared to 16 controls. We assessed the cerebrovascular responses with arterial spin labeling (ASL) and blood oxygen level-dependent (BOLD) magnetic resonance imaging during hypercapnia or breath-holding tasks. RESULTS The CBF response to CO2 was impaired with increasing AHI (average CBF: p = 0.018; gray matter: p = 0.038; white matter: p = 0.045), that is, increased OSA severity. When comparing the OSA patients to the control subjects, the OSA patients had a significantly reduced CO2 response of the white matter CBF (p = 0.04). However, the BOLD response to CO2 and the breath-holding task did not show any significant differences between OSA patients and control subjects. CONCLUSION The cerebrovascular CO2 reactivity, measured by the CBF, was impaired with increasing AHI, that is, OSA severity. These findings may add to the understanding of the increased stroke risk found in OSA patients.
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32
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Beaudin AE, Hartmann SE, Pun M, Poulin MJ. Human cerebral blood flow control during hypoxia: focus on chronic pulmonary obstructive disease and obstructive sleep apnea. J Appl Physiol (1985) 2017; 123:1350-1361. [DOI: 10.1152/japplphysiol.00352.2017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/01/2017] [Accepted: 08/07/2017] [Indexed: 01/06/2023] Open
Abstract
The brain is a vital organ that relies on a constant and adequate blood flow to match oxygen and glucose delivery with the local metabolic demands of active neurons. Thus exquisite regulation of cerebral blood flow (CBF) is particularly important under hypoxic conditions to prevent a detrimental decrease in the partial pressure of oxygen within the brain tissues. Cerebrovascular sensitivity to hypoxia, assessed as the change in CBF during a hypoxic challenge, represents the capacity of cerebral vessels to respond to, and compensate for, a reduced oxygen supply, and has been shown to be impaired or blunted in a number of conditions. For instance, this is observed with aging, and in clinical conditions such as untreated obstructive sleep apnea (OSA) and in healthy humans exposed to intermittent hypoxia. This review will 1) provide a brief overview of cerebral blood flow regulation and results of pharmacological intervention studies which we have performed to better elucidate the basic mechanisms of cerebrovascular regulation in humans; and 2) present data from studies in clinical and healthy populations, using a translational physiology approach, to investigate human CBF control during hypoxia. Results from studies in patients with chronic obstructive pulmonary disease and OSA will be presented to identify the effects of the disease processes on cerebrovascular sensitivity to hypoxia. Data emerging from experimental human models of intermittent hypoxia during wakefulness will also be reviewed to highlight the effects of intermittent hypoxia on the brain.
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Affiliation(s)
- Andrew E. Beaudin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sara E. Hartmann
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Matiram Pun
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marc J. Poulin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; and
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Alex RM, Mousavi ND, Zhang R, Gatchel RJ, Behbehani K. Obstructive sleep apnea: Brain hemodynamics, structure, and function. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/jabr.12101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Raichel M. Alex
- Department of Bioengineering; University of Texas at Arlington; Arlington TX USA
| | | | - Rong Zhang
- Department of Neurology and Neurotherapeutics; University of Texas Southwestern Medical Center; Dallas TX USA
- Institute for Exercise and Environmental Medicine; Texas Health Hospital Dallas; Dallas TX USA
| | - Robert J. Gatchel
- Department of Psychology; University of Texas at Arlington; Arlington TX USA
| | - Khosrow Behbehani
- Department of Bioengineering; University of Texas at Arlington; Arlington TX USA
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Beaudin AE, Waltz X, Hanly PJ, Poulin MJ. Impact of obstructive sleep apnoea and intermittent hypoxia on cardiovascular and cerebrovascular regulation. Exp Physiol 2017; 102:743-763. [PMID: 28439921 DOI: 10.1113/ep086051] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/19/2017] [Indexed: 01/06/2023]
Abstract
NEW FINDINGS What is the topic of this review? This review examines the notion that obstructive sleep apnoea (OSA) and intermittent hypoxia (IH) have hormetic effects on vascular health. What advances does it highlight? Clinical (OSA patient) and experimental animal and human models report that IH is detrimental to vascular regulation. However, mild IH and, by extension, mild OSA also have physiological and clinical benefits. This review highlights clinical and experimental animal and human data linking OSA and IH to vascular disease and discusses how hormetic effects of OSA and IH relate to OSA severity, IH intensity and duration, and patient/subject age. Obstructive sleep apnoea (OSA) is associated with increased risk of cardiovascular and cerebrovascular disease, a consequence attributed in part to chronic intermittent hypoxia (IH) resulting from repetitive apnoeas during sleep. Although findings from experimental animal, and human, models have shown that IH is detrimental to vascular regulation, the severity of IH used in many of these animal studies [e.g. inspired fraction of oxygen (FI,O2) = 2-3%; oxygen desaturation index = 120 events h-1 ] is considerably greater than that observed in the majority of patients with OSA. This may also explain disparities between animal and recently developed human models of IH, where IH severity is, by necessity, less severe (e.g. FI,O2 = 10-12%; oxygen desaturation index = 15-30 events h-1 ). In this review, we highlight the current knowledge regarding the impact of OSA and IH on cardiovascular and cerebrovascular regulation. In addition, we critically discuss the recent notion that OSA and IH may have hormetic effects on vascular health depending on conditions such as OSA severity, IH intensity and duration, and age. In general, data support an independent causal link between OSA and vascular disease, particularly for patients with severe OSA. However, the data are equivocal for older OSA patients and patients with mild OSA, because advanced age and short-duration, low-intensity IH have been reported to provide a degree of protection against IH and ischaemic events such as myocardial infarction and stroke, respectively. Overall, additional studies are needed to investigate the beneficial/detrimental effects of mild OSA on the various vascular beds.
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Affiliation(s)
- Andrew E Beaudin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Xavier Waltz
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Laboratoire HP2, U1042, INSERM, Université Grenoble Alpes, Grenoble, France
| | - Patrick J Hanly
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Sleep Centre, Foothills Medical Centre, Calgary, AB, Canada
| | - Marc J Poulin
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
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Abstract
Patients with wake-up strokes account for approximately 1 in 5 individuals presenting with an acute ischemic stroke. However, they are commonly excluded from acute stroke treatment. This article reviews the current understanding of wake-up strokes. A comparison of wake-up and awake-onset strokes demonstrated that they are physiologically, clinically, and radiologically similar. Use of advanced CT and MRI techniques may help extend acute stroke treatment options to patients with wake-up stroke.
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Affiliation(s)
- Jenny P Tsai
- Department of Neurology and Neurological Sciences, Stanford University Medical Centre, Stanford, CA
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36
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Leite Filho CA, Silva FFD, Pradella-Hallinan M, Xavier SD, Miranda MC, Pereira LD. Auditory behavior and auditory temporal resolution in children with sleep-disordered breathing. Sleep Med 2017; 34:90-95. [PMID: 28522104 DOI: 10.1016/j.sleep.2017.03.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 02/26/2017] [Accepted: 03/04/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Intermittent hypoxia caused by obstructive sleep apnea syndrome (OSAS) may lead to damage in brain areas associated to auditory processing. The aim of this study was to compare children with OSAS or primary snoring (PS) to children without sleep-disordered breathing with regard to their performance on the Gaps-in-Noise (GIN) test and the Scale of Auditory Behaviors (SAB) questionnaire. METHODS Thirty-seven children (6-12 years old) were submitted to sleep anamnesis and in-lab night-long polysomnography. Three groups were organized according to clinical criteria: OSAS group (13 children), PS group (13 children), and control group (11 children). They were submitted to the GIN test and parents answered SAB questionnaire. The Kruskal-Wallis statistical test was used to compare the groups; p < 0.05 was considered statistically significant. RESULTS The OSAS group performed significantly worse than PS (p = 0.011) and Control (p = 0.029) groups on gap detection percentage, while PS and Control groups showed no significant differences. The three groups showed similar gap detection thresholds. Regarding SAB questionnaire, PS group had significantly worse scores when compared to Control (p = 0.011), but not to OSAS (p = 0.101) groups. No statistical difference between OSAS and Control groups were found. CONCLUSION Children with OSAS showed worse performance on GIN test in comparison to children with PS and children without sleep-disordered breathing. PS negatively affected auditory behavior in children. These findings suggest that sleep-disordered breathing may lead to auditory behavior impairment.
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Affiliation(s)
- Carlos Alberto Leite Filho
- Department of Speech, Language and Hearing Sciences, Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil.
| | | | | | - Sandra Doria Xavier
- Department of Otorhinolaryngology, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, Brazil
| | | | - Liliane Desgualdo Pereira
- Department of Speech, Language and Hearing Sciences, Universidade Federal de São Paulo (Unifesp), São Paulo, Brazil
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Wong E, Yang B, Du L, Ho WH, Lau C, Ke Y, Chan YS, Yung WH, Wu EX. The multi-level impact of chronic intermittent hypoxia on central auditory processing. Neuroimage 2017; 156:232-239. [PMID: 28528846 DOI: 10.1016/j.neuroimage.2017.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 04/07/2017] [Accepted: 05/16/2017] [Indexed: 12/21/2022] Open
Abstract
During hypoxia, the tissues do not obtain adequate oxygen. Chronic hypoxia can lead to many health problems. A relatively common cause of chronic hypoxia is sleep apnea. Sleep apnea is a sleep breathing disorder that affects 3-7% of the population. During sleep, the patient's breathing starts and stops. This can lead to hypertension, attention deficits, and hearing disorders. In this study, we apply an established chronic intermittent hypoxemia (CIH) model of sleep apnea to study its impact on auditory processing. Adult rats were reared for seven days during sleeping hours in a gas chamber with oxygen level cycled between 10% and 21% (normal atmosphere) every 90s. During awake hours, the subjects were housed in standard conditions with normal atmosphere. CIH treatment significantly reduces arterial oxygen partial pressure and oxygen saturation during sleeping hours (relative to controls). After treatment, subjects underwent functional magnetic resonance imaging (fMRI) with broadband sound stimulation. Responses are observed in major auditory centers in all subjects, including the auditory cortex (AC) and auditory midbrain. fMRI signals from the AC are statistically significantly increased after CIH by 0.13% in the contralateral hemisphere and 0.10% in the ipsilateral hemisphere. In contrast, signals from the lateral lemniscus of the midbrain are significantly reduced by 0.39%. Signals from the neighboring inferior colliculus of the midbrain are relatively unaffected. Chronic hypoxia affects multiple levels of the auditory system and these changes are likely related to hearing disorders associated with sleep apnea.
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Affiliation(s)
- Eddie Wong
- Department of Physics and Materials Science, The City University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Laboratory of Biomedical Imaging and Signal Processing, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Department of Electrical and Electronic Engineering, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Bin Yang
- Department of Physics and Materials Science, The City University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Department of Radiology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
| | - Lida Du
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Gerald Choa Neuroscience Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Wai Hong Ho
- Department of Physics and Materials Science, The City University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Condon Lau
- Department of Physics and Materials Science, The City University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China.
| | - Ya Ke
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Gerald Choa Neuroscience Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Ying Shing Chan
- School of Biomedical Sciences, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Wing Ho Yung
- School of Biomedical Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Gerald Choa Neuroscience Centre, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
| | - Ed X Wu
- Laboratory of Biomedical Imaging and Signal Processing, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China; Department of Electrical and Electronic Engineering, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China
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Urback AL, MacIntosh BJ, Goldstein BI. Cerebrovascular reactivity measured by functional magnetic resonance imaging during breath-hold challenge: A systematic review. Neurosci Biobehav Rev 2017; 79:27-47. [PMID: 28487157 DOI: 10.1016/j.neubiorev.2017.05.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 04/05/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
Cerebrovascular reactivity (CVR) is the cerebral hemodynamic response to a vasoactive substance. Breath-hold (BH) induced CVR has the advantage of being non-invasive and easy to implement during magnetic resonance imaging (MRI). We systematically reviewed the literature regarding MRI measurement of BH induced CVR. The literature was searched using MEDLINE with the search terms breath-hold; and MRI or cerebrovascular reactivity. The search yielded 2244 results and 54 articles were included. Between-group comparisons have found that CVR was higher among healthy controls than patients with various pathologies (e.g. sleep apnea, diabetes, hypertension etc.). However, counter-intuitive findings have also been reported, including higher CVR among smokers, sedentary individuals, and patients with schizophrenia vs. CONTROLS Methodological studies have highlighted important measurement characteristics (e.g. normalizing signal to end-tidal CO2), and comparisons of BH induced CVR to non-BH methods. Future studies are warranted to address questions about group differences, treatment response, disease progression, and other salient clinical themes. Standardization of CVR and BH designs is needed to fully exploit the potential of this practical non-invasive method.
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Affiliation(s)
- Adam L Urback
- Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre 2075 Bayview Ave., FG-53, Toronto, ON, M4N 3M5, Canada; Department of Pharmacology, University of Toronto, Medicine, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
| | - Bradley J MacIntosh
- University of Toronto, Department of Medical Biophysics, 101 College Street Suite 15-701, Toronto, ON, M5G 1L7, Canada; Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room M6 180, Toronto, ON, M4N 3M5, Canada.
| | - Benjamin I Goldstein
- Centre for Youth Bipolar Disorder, Sunnybrook Health Sciences Centre 2075 Bayview Ave., FG-53, Toronto, ON, M4N 3M5, Canada; Department of Pharmacology, University of Toronto, Medicine, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada; Department of Psychiatry, University of Toronto, Medicine,250 College Street, Room 835, Toronto, ON, M5T 1R8, Canada.
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Cao MT, Sternbach JM, Guilleminault C. Continuous positive airway pressure therapy in obstuctive sleep apnea: benefits and alternatives. Expert Rev Respir Med 2017; 11:259-272. [PMID: 28287009 DOI: 10.1080/17476348.2017.1305893] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a highly prevalent condition affecting persons of all age with an increasing public health burden. It is implicated in cardiovascular disease, metabolic syndrome, neurocognitive impairment, reductions in quality of life, and increased motor vehicle accidents. The goals of OSA treatment are to improve sleep and daytime symptoms, and minimize cardiovascular risks.Areas covered: Continuous positive airway pressure (CPAP) is considered the gold standard therapy that delivers pressurized air into the upper airway to relieve obstruction during sleep. Although CPAP is an effective modality of treatment for OSA, adherence to therapy is highly variable. This article highlights the benefits of CPAP therapy, along with alternative treatment options including oral appliance, implantable and wearable devices, and surgery. Expert commentary: CPAP therapy is the gold standard treatment option and should continue to be offered to those who suffer from OSA. Alternative options are available for those who are unable to adhere to CPAP or choose an alternative treatment modality. The most interesting advances have been incorporating orthodontic procedures in conjunction with myofunctional therapy in prepubertal children, raising the possibility of OSA prevention by initiating treatment early in life.
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Affiliation(s)
- Michelle T Cao
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - Joshua M Sternbach
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
| | - C Guilleminault
- a Division of Sleep Medicine , Stanford University , Redwood City , CA , USA
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Um YH, Hong SC, Jeong JH. Sleep Problems as Predictors in Attention-Deficit Hyperactivity Disorder: Causal Mechanisms, Consequences and Treatment. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2017; 15:9-18. [PMID: 28138105 PMCID: PMC5290714 DOI: 10.9758/cpn.2017.15.1.9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/06/2016] [Accepted: 09/11/2016] [Indexed: 01/11/2023]
Abstract
Attention-deficit hyperactivity disorder (ADHD) is notorious for its debilitating consequences and early age of onset. The need for early diagnosis and intervention has frequently been underscored. Previous studies have attempted to clarify the bidirectional relationship between ADHD and sleep problems, proposing a potential role for sleep problems as early predictors of ADHD. Sleep deprivation, sleep-disordered breathing, and circadian rhythm disturbances have been extensively studied, yielding evidence with regard to their induction of ADHD-like symptoms. Genetic-phenotypic differences across individuals regarding the aforementioned sleep problems have been elucidated along with the possible use of these characteristics for early prediction of ADHD. The long-term consequences of sleep problems in individuals with ADHD include obesity, poor academic performance, and disrupted parent-child interactions. Early intervention has been proposed as an approach to preventing these debilitating outcomes of ADHD, with novel treatment approaches ranging from melatonin and light therapy to myofunctional therapy and adjustments of the time point at which school starts.
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Affiliation(s)
- Yoo Hyun Um
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Chul Hong
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lawley JS, Macdonald JH, Oliver SJ, Mullins PG. Unexpected reductions in regional cerebral perfusion during prolonged hypoxia. J Physiol 2016; 595:935-947. [PMID: 27506309 DOI: 10.1113/jp272557] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/04/2016] [Indexed: 01/06/2023] Open
Abstract
KEY POINTS Cognitive performance is impaired by hypoxia despite global cerebral oxygen delivery and metabolism being maintained. Using arterial spin labelled (ASL) magnetic resonance imaging, this is the first study to show regional reductions in cerebral blood flow (CBF) in response to decreased oxygen supply (hypoxia) at 2 h that increased in area and became more pronounced at 10 h. Reductions in CBF were seen in brain regions typically associated with the 'default mode' or 'task negative' network. Regional reductions in CBF, and associated vasoconstriction, within the default mode network in hypoxia is supported by increased vasodilatation in these regions to a subsequent hypercapnic (5% CO2 ) challenge. These results suggest an anatomical mechanism through which hypoxia may cause previously reported deficits in cognitive performance. ABSTRACT Hypoxia causes an increase in global cerebral blood flow, which maintains global cerebral oxygen delivery and metabolism. However, neurological deficits are abundant under hypoxic conditions. We investigated regional cerebral microvascular responses to acute (2 h) and prolonged (10 h) poikilocapnic normobaric hypoxia. We found that 2 h of hypoxia caused an expected increase in frontal cortical grey matter perfusion but unexpected perfusion decreases in regions of the brain normally associated with the 'default mode' or 'task negative' network. After 10 h in hypoxia, decreased blood flow to the major nodes of the default mode network became more pronounced and widespread. The use of a hypercapnic challenge (5% CO2 ) confirmed that these reductions in cerebral blood flow from hypoxia were related to vasoconstriction. Our findings demonstrate steady-state deactivation of the default network under acute hypoxia, which become more pronounced over time. Moreover, these data provide a unique insight into the nuanced localized cerebrovascular response to hypoxia that is not attainable through traditional methods. The observation of reduced perfusion in the posterior cingulate and cuneal cortex, which are regions assumed to play a role in declarative and procedural memory, provides an anatomical mechanism through which hypoxia may cause deficits in working memory.
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Affiliation(s)
- Justin S Lawley
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Gwynedd, UK.,Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Dallas, TX, USA
| | - Jamie H Macdonald
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Gwynedd, UK
| | - Samuel J Oliver
- Extremes Research Group, School of Sport, Health and Exercise Sciences, Bangor University, Gwynedd, UK
| | - Paul G Mullins
- Bangor Imaging Centre, School of Psychology, Bangor University, Gwynedd, UK
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Rodgers ZB, Leinwand SE, Keenan BT, Kini LG, Schwab RJ, Wehrli FW. Cerebral metabolic rate of oxygen in obstructive sleep apnea at rest and in response to breath-hold challenge. J Cereb Blood Flow Metab 2016; 36:755-67. [PMID: 26661146 PMCID: PMC4821016 DOI: 10.1177/0271678x15605855] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/15/2015] [Indexed: 01/06/2023]
Abstract
Obstructive sleep apnea (OSA) is associated with extensive neurologic comorbidities. It is hypothesized that the repeated nocturnal apneas experienced in patients with OSA may inhibit the normal apneic response, resulting in hypoxic brain injury and subsequent neurologic dysfunction. In this study, we applied the recently developedOxFlowMRI method for rapid quantification of cerebral metabolic rate of oxygen (CMRO2) during a volitional apnea paradigm. MRI data were analyzed in 11 OSA subjects and 10 controls (mean ± SD apnea-hypopnea index (AHI): 43.9 ± 18.1 vs. 2.9 ± 1.6 events/hour,P < 0.0001; age: 53.8 ± 8.2 vs. 45.3 ± 8.5 years,P = 0.027; BMI: 36.6 ± 4.4 vs. 31.9 ± 2.2 kg/m(2),P = 0.0064). Although total cerebral blood flow and arteriovenous oxygen difference were not significantly different between apneics and controls (P > 0.05), apneics displayed reduced baseline CMRO2(117.4 ± 37.5 vs. 151.6 ± 29.4 µmol/100 g/min,P = 0.013). In response to apnea, CMRO2decreased more in apneics than controls (-10.9 ± 8.8 % vs. -4.0 ± 6.7 %,P = 0.036). In contrast, group differences in flow-based cerebrovascular reactivity were not significant. Results should be interpreted with caution given the small sample size, and future studies with larger independent samples should examine the observed associations, including potential independent effects of age or BMI. Overall, these data suggest that dysregulation of the apneic response may be a mechanism for OSA-associated neuropathology.
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Affiliation(s)
- Zachary B Rodgers
- Laboratory for Structural NMR Imaging, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Sarah E Leinwand
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Brendan T Keenan
- Center for Sleep and Circadian Neurobiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lohith G Kini
- Center for Neuroengineering and Therapeutics, Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard J Schwab
- Division of Sleep Medicine, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA, USA
| | - Felix W Wehrli
- Laboratory for Structural NMR Imaging, Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PA, USA
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Li HJ, Nie X, Gong HH, Zhang W, Nie S, Peng DC. Abnormal resting-state functional connectivity within the default mode network subregions in male patients with obstructive sleep apnea. Neuropsychiatr Dis Treat 2016; 12:203-12. [PMID: 26855576 PMCID: PMC4725694 DOI: 10.2147/ndt.s97449] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Abnormal resting-state functional connectivity (rs-FC) between the central executive network and the default mode network (DMN) in patients with obstructive sleep apnea (OSA) has been reported. However, the effect of OSA on rs-FC within the DMN subregions remains uncertain. This study was designed to investigate whether the rs-FC within the DMN subregions was disrupted and determine its relationship with clinical symptoms in patients with OSA. METHODS Forty male patients newly diagnosed with severe OSA and 40 male education- and age-matched good sleepers (GSs) underwent functional magnetic resonance imaging (fMRI) examinations and clinical and neuropsychologic assessments. Seed-based region of interest rs-FC method was used to analyze the connectivity between each pair of subregions within the DMN, including the medial prefrontal cortex (MPFC), posterior cingulate cortex (PCC), hippocampus formation (HF), inferior parietal cortices (IPC), and medial temporal lobe (MTL). The abnormal rs-FC strength within the DMN subregions was correlated with clinical and neuropsychologic assessments using Pearson correlation analysis in patients with OSA. RESULTS Compared with GSs, patients with OSA had significantly decreased rs-FC between the right HF and the PCC, MPFC, and left MTL. However, patients with OSA had significantly increased rs-FC between the MPFC and left and right IPC, and between the left IPC and right IPC. The rs-FC between the right HF and left MTL was positively correlated with rapid eye movement (r=0.335, P=0.035). The rs-FC between the PCC and right HF was negatively correlated with delayed memory (r=-0.338, P=0.033). CONCLUSION OSA selectively impairs the rs-FC between right HF and PCC, MPFC, and left MTL within the DMN subregions, and provides an imaging indicator for assessment of cognitive dysfunction in OSA patients.
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Affiliation(s)
- Hai-Jun Li
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Xiao Nie
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Hong-Han Gong
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Wei Zhang
- Department of Pneumology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Si Nie
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - De-Chang Peng
- Department of Radiology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
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44
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Baril AA, Gagnon K, Arbour C, Soucy JP, Montplaisir J, Gagnon JF, Gosselin N. Regional Cerebral Blood Flow during Wakeful Rest in Older Subjects with Mild to Severe Obstructive Sleep Apnea. Sleep 2015; 38:1439-49. [PMID: 25761981 DOI: 10.5665/sleep.4986] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 01/31/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To evaluate changes in regional cerebral blood flow (rCBF) during wakeful rest in older subjects with mild to severe obstructive sleep apnea (OSA) and healthy controls, and to identify markers of OSA severity that predict altered rCBF. DESIGN High-resolution (99m)Tc-HMPAO SPECT imaging during wakeful rest. SETTING Research sleep laboratory affiliated with a University hospital. PARTICIPANTS Fifty untreated OSA patients aged between 55 and 85 years, divided into mild, moderate, and severe OSA, and 20 age-matched healthy controls. INTERVENTIONS N/A. MEASUREMENTS Using statistical parametric mapping, rCBF was compared between groups and correlated with clinical, respiratory, and sleep variables. RESULTS Whereas no rCBF change was observed in mild and moderate groups, participants with severe OSA had reduced rCBF compared to controls in the left parietal lobules, left precentral gyrus, bilateral postcentral gyri, and right precuneus. Reduced rCBF in these regions and in areas of the bilateral frontal and left temporal cortex was associated with more hypopneas, snoring, hypoxemia, and sleepiness. Higher apnea, microarousal, and body mass indexes were correlated to increased rCBF in the basal ganglia, insula, and limbic system. CONCLUSIONS While older individuals with severe obstructive sleep apnea (OSA) had hypoperfusion in the sensorimotor and parietal areas, respiratory variables and subjective sleepiness were correlated with extended regions of hypoperfusion in the lateral cortex. Interestingly, OSA severity, sleep fragmentation, and obesity correlated with increased perfusion in subcortical and medial cortical regions. Anomalies with such a distribution could result in cognitive deficits and reflect impaired vascular regulation, altered neuronal integrity, and/or undergoing neurodegenerative processes.
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Affiliation(s)
- Andrée-Ann Baril
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Department of Psychiatry, Montreal, Quebec, Canada
| | - Katia Gagnon
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université du Québec à Montréal, Department of Psychology, Montreal, Quebec, Canada
| | - Caroline Arbour
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Department of Psychology, Montreal, Quebec, Canada
| | - Jean-Paul Soucy
- McGill University, McConnell Brain Imaging Centre, Montreal, Quebec, Canada
| | - Jacques Montplaisir
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Department of Psychiatry, Montreal, Quebec, Canada
| | - Jean-François Gagnon
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université du Québec à Montréal, Department of Psychology, Montreal, Quebec, Canada
| | - Nadia Gosselin
- Center for Advanced Research in Sleep Medicine (CARSM), Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada.,Université de Montréal, Department of Psychology, Montreal, Quebec, Canada
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45
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Torabi-Nami M, Mehrabi S, Borhani-Haghighi A, Derman S. Withstanding the obstructive sleep apnea syndrome at the expense of arousal instability, altered cerebral autoregulation and neurocognitive decline. J Integr Neurosci 2015; 14:169-93. [DOI: 10.1142/s0219635215500144] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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46
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Innes CRH, Kelly PT, Hlavac M, Melzer TR, Jones RD. Decreased Regional Cerebral Perfusion in Moderate-Severe Obstructive Sleep Apnoea during Wakefulness. Sleep 2015; 38:699-706. [PMID: 25669185 DOI: 10.5665/sleep.4658] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/14/2015] [Indexed: 12/21/2022] Open
Abstract
STUDY OBJECTIVES To investigate gray matter volume and concentration and cerebral perfusion in people with untreated obstructive sleep apnea (OSA) while awake. DESIGN Voxel-based morphometry to quantify gray matter concentration and volume. Arterial spin labeling perfusion imaging to quantify cerebral perfusion. SETTING Lying supine in a 3-T magnetic resonance imaging scanner in the early afternoon. PARTICIPANTS 19 people with OSA (6 females, 13 males; mean age 56.7 y, range 41-70; mean AHI 18.5, range 5.2-52.8) and 19 controls (13 females, 6 males; mean age: 50.0 y, range 41-81). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS There were no differences in regional gray matter concentration or volume between participants with OSA and controls. Neither was there any difference in regional perfusion between controls and people with mild OSA (n = 11). However, compared to controls, participants with moderate-severe OSA (n = 8) had decreased perfusion (while awake) in three clusters. The largest cluster incorporated, bilaterally, the paracingulate gyrus, anterior cingulate gyrus, and subcallosal cortex, and the left putamen and left frontal orbital cortex. The second cluster was right-lateralized, incorporating the posterior temporal fusiform cortex, parahippocampal gyrus, and hippocampus. The third cluster was located in the right thalamus. CONCLUSIONS There is decreased regional perfusion during wakefulness in participants with moderate-severe obstructive sleep apnea, and these are in brain regions which have shown decreased regional gray matter volume in previous studies in people with severe OSA. Thus, we hypothesize that cerebral perfusion changes are evident before (and possibly underlie) future structural changes.
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Affiliation(s)
- Carrie R H Innes
- New Zealand Brain Research Institute, Christchurch, New Zealand.,Medical Physics & Bioengineering, Christchurch Hospital, Christchurch, New Zealand.,Electrical and Computer Engineering, University of Canterbury, Christchurch, New Zealand
| | - Paul T Kelly
- Sleep Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Michael Hlavac
- Sleep Unit, Christchurch Hospital, Christchurch, New Zealand
| | - Tracy R Melzer
- New Zealand Brain Research Institute, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard D Jones
- New Zealand Brain Research Institute, Christchurch, New Zealand.,Medical Physics & Bioengineering, Christchurch Hospital, Christchurch, New Zealand.,Electrical and Computer Engineering, University of Canterbury, Christchurch, New Zealand.,Department of Medicine, University of Otago, Christchurch, New Zealand.,Department of Psychology, University of Canterbury, Christchurch, New Zealand
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47
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Abad VC, Guilleminault C. Pharmacological treatment of sleep disorders and its relationship with neuroplasticity. Curr Top Behav Neurosci 2015; 25:503-53. [PMID: 25585962 DOI: 10.1007/7854_2014_365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Sleep and wakefulness are regulated by complex brain circuits located in the brain stem, thalamus, subthalamus, hypothalamus, basal forebrain, and cerebral cortex. Wakefulness and NREM and REM sleep are modulated by the interactions between neurotransmitters that promote arousal and neurotransmitters that promote sleep. Various lines of evidence suggest that sleep disorders may negatively affect neuronal plasticity and cognitive function. Pharmacological treatments may alleviate these effects but may also have adverse side effects by themselves. This chapter discusses the relationship between sleep disorders, pharmacological treatments, and brain plasticity, including the treatment of insomnia, hypersomnias such as narcolepsy, restless legs syndrome (RLS), obstructive sleep apnea (OSA), and parasomnias.
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Affiliation(s)
- Vivien C Abad
- Psychiatry and Behavioral Science-Division of Sleep Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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