ABSTRACT
Obstructive sleep apnea (OSA) is a very common condition in patients with stroke and
is found in over half of stroke patients. There is a complex relationship between
OSA and stroke, attributable to shared risk factors. There are numerous mechanisms
by which OSA may contribute to increased stroke risk, including promotion of atherosclerosis,
hypercoagulability, and adverse effects on cerebral hemodynamics. Obstructive sleep
apnea is also a risk factor for hypertension, and likely for atrial fibrillation and
diabetes, conditions that in turn are risk factors for stroke. OSA is also associated
with poor outcomes following stroke. Further epidemiological studies are needed to
assess the relationship between OSA and stroke better. Clinical trials using continuous
positive airway pressure as a treatment for OSA in stroke patients are needed to determine
whether treatment of this condition alters outcome following stroke.
KEYWORDS
Obstructive sleep apnea - sleep-disordered breathing - stroke - continuous positive
airway pressure
REFERENCES
- 1
Dyken M, Somers V, Yamada T, Ren Z, Zimmerman M B.
Investigating the relationship between stroke and obstructive sleep apnea.
Stroke.
1996;
27
401-407
- 2
Iranzo A, Santamaria J, Berenguer J.
Prevalence and clinical importance of sleep apnea in the first night after cerebral
infarction.
Neurology.
2002;
58
911-916
- 3
Turkington P, Bamford J, Wanklyn P, Elliott M.
Prevalence and predictors of upper airway obstruction in the first 24 hours after
acute stroke.
Stroke.
2002;
33
2037-2042
- 4
Shahar E, Whitney C W, Redline S et al..
Sleep-disordered breathing and cardiovascular disease: cross-sectional results of
the Sleep Heart Health Study.
Am J Respir Crit Care Med.
2001;
163
19-25
- 5
Chin K, Nakamura T, Kouichi S et al..
Effects of nasal continuous positive airway pressure on soluble cell adhesion molecules
in patients with obstructive sleep apnea syndrome.
Am J Med.
2000;
109
562-567
- 6
Bokinsky G, Miller M, Ault K, Husband P, Mitchell J.
Spontaneous platelet activation and aggregation during obstructive sleep apnea and
its response to therapy with nasal continuous positive airway pressure: a preliminary
investigation.
Chest.
1995;
108
625-630
- 7
Good D, Henkle J, Gelber D, Welsh J, Verhulst S.
Sleep-disordered breathing and poor functional outcome after stroke.
Stroke.
1996;
27
252-259
- 8
American Academy of Sleep Medicine Task Force .
Sleep-related breathing disorders in adults: recommendations for syndrome definition
and measurement techniques in clinical research.
Sleep.
1999;
22
667-689
- 9
Young T, Peppard P, Palta M et al..
Population-based study of sleep-disordered breathing as a risk factor for hypertension.
Arch Intern Med.
1997;
157
1746-1752
- 10
Pepperell J, Ramdassingh-Dow S, Crosthwaite N et al..
Ambulatory blood pressure after therapeutic and subtherapeutic nasal continuous positive
airway pressure for obstructive sleep apnoea: a randomized parallel trial.
Lancet.
2002;
359
204-210
- 11
Kanagala R, Murali N S, Friedman P A et al..
Obstructive sleep apnea and the recurrence of atrial fibrillation.
Circulation.
2003;
107
2589-2594
- 12
Javaheri S, Parker T J, Liming J D et al..
Sleep apnea in 81 ambulatory male patients with stable heart failure: types and their
prevalences, consequences, and presentations.
Circulation.
1998;
97
2154-2159
- 13
Elmasry A, Lindberg E, Berne C et al..
Sleep-disordered breathing and glucose metabolism in hypertensive men: a population-based
study.
J Intern Med.
2001;
249
153-161
- 14
Vgontzas A N, Papanicolaou D A, Bixler E O et al..
Sleep apnea and daytime sleepiness and fatigue: relation to visceral obesity, insulin
resistance, and hypercytokinemia.
J Clin Endocrinol Metab.
2000;
85
1151-1158
- 15
Thomas C E.
Patent foramen ovale and stroke risk: incidental finding or causal culprit?.
Semin Neurol.
2005;
25
371-375
- 16
Homma S, Sacco R L, Di Tullio M R, Sciacca R R, Mohr J P. for the PFO in Cryptogenic
Stroke Study (PICSS) Investigators .
Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen
ovale in cryptogenic stroke study.
Circulation.
2002;
105
2625-2631
- 17
Beelke M, Angeli S, Del Sette M et al..
Obstructive sleep apnea can be provocative for right-to-left shunting through a patent
foramen ovale.
Sleep.
2002;
25
856-862
- 18
Schulz R, Mahmoudi S, Hattar K et al..
Enhanced release of superoxide from polymorphonuclear neutrophils in obstructive sleep
apnea: impact of continuous positive airway pressure therapy.
Am J Respir Crit Care Med.
2000;
162
566-570
- 19
Hui D S, Ko F W, Fok J P et al..
The effects of nasal continuous positive airway pressure on platelet activation in
obstructive sleep apnea syndrome.
Chest.
2004;
125
1768-1775
- 20
Wessendorf T E, Thilmann A F, Wang Y M, Schreiber A, Konietzko N, Teschler H.
Fibrinogen levels and obstructive sleep apnea in ischemic stroke.
Am J Respir Crit Care Med.
2000;
162
2039-2042
- 21
Winnicki M, Shamsuzzaman A, Lanfranchi P et al..
Erythropoietin and obstructive sleep apnea.
Am J Hypertens.
2004;
17
783-786
- 22
Somers V, Dyken M, Clary M, Abboud F M.
Sympathetic neural mechanisms in obstructive sleep apnea.
J Clin Invest.
1995;
96
1897-1904
- 23
Balfors E M, Franklin K A.
Impairment of cerebral perfusion during obstructive sleep apneas.
Am J Respir Crit Care Med.
1994;
150
1587-1591
- 24
Netzer N, Werner P, Jochums I, Lehmann M, Strohl K.
Blood flow of the middle cerebral artery with sleep-disordered breathing: correlation
with obstructive hypopneas.
Stroke.
1998;
29
87-93
- 25
Ross R.
Atherosclerosis: an inflammatory disease.
N Engl J Med.
1999;
340
115-126
- 26
Yokoe T, Minoguchi K, Matsuo H et al..
Elevated levels of C-reactive protein and interleukin-6 in patients with obstructive
sleep apnea syndrome are decreased by nasal continuous positive airway pressure.
Circulation.
2003;
107
1129-1134
- 27
Dyugovskaya L, Lavie P, Lavie L.
Increased adhesion molecules expression and production of reactive oxygen species
in leukocytes of sleep apnea patients.
Am J Respir Crit Care Med.
2002;
165
934-939
- 28
Barcelo A, Miralles C, Barbe F, Vila M, Pons S, Agusti A G.
Abnormal lipid peroxidation in patients with sleep apnoea.
Eur Respir J.
2000;
16
644-647
- 29
Ip M S, Lam B, Chan L Y et al..
Circulating nitric oxide is suppressed in obstructive sleep apnea and is reversed
by nasal continuous positive airway pressure.
Am J Respir Crit Care Med.
2000;
162
2166-2171
- 30
Parra O, Abroix A, Bechich S et al..
Time course of sleep-related breathing disorders in first-ever stroke or transient
ischemic attack.
Am J Respir Crit Care Med.
2000;
161
375-380
- 31
Bassetti C, Aldrich M, Quint D.
Sleep-disordered breathing in patients with acute supra- and infratentorial strokes:
a prospective study of 39 patients.
Stroke.
1997;
28
1765-1772
- 32
Bassetti C, Aldrich M S.
Night time versus daytime transient ischaemic attack and ischaemic stroke: a prospective
study of 110 patients.
J Neurol Neurosurg Psychiatry.
1999;
67
463-467
- 33
Bassetti C, Aldrich M.
Sleep apnea in acute cerebrovascular diseases: final report on 128 patients.
Sleep.
1999;
22
217-223
- 34
Bassetti C, Aldrich M, Chervin R, Quint D.
Sleep apnea in patients with transient ischemic attack and stroke: a prospective study
of 59 patients.
Neurology.
1996;
47
1167-1173
- 35
Hui D, Choy D, Wong L et al..
Prevalence of sleep-disordered breathing and continuous positive airway pressure compliance:
results in Chinese patients with first-ever ischemic stroke.
Chest.
2002;
122
852-860
- 36
Kaneko Y, Hajek V, Zivanovic V, Raboud J, Bradley T.
Relationship of sleep apnea to functional capacity and length of hospitalization following
stroke.
Sleep.
2003;
26
293-297
- 37
Cherkassky T, Oksenberg A, Froom P, Ring H.
Sleep-related breathing disorders and rehabilitation outcome of stroke patients: a
prospective study.
Am J Phys Med Rehabil.
2003;
82
452-455
- 38
Turkington P M, Allgar V, Bamford J, Wanklyn P, Elliott M W.
Effect of upper airway obstruction in acute stroke on functional outcome at 6 months.
Thorax.
2004;
59
367-371
- 39
Wei L, Erinjeri J, Rovainen C, Woolsey T.
Collateral growth and angiogenesis around cortical stroke.
Stroke.
2001;
32
2179-2184
- 40
Aoyagi A, Saito H, Abe K, Nishiyama N.
Early impairment and late recovery of synaptic transmission in the rat dentate gyrus
following transient forebrain ischemia in vivo.
Brain Res.
1998;
799
130-137
- 41
Frost S, Barbay S, Friel K, Plautz E, Nudo R.
Reorganization of remote cortical regions after ischemic brain injury: a potential
substrate for stroke recovery.
J Neurophysiol.
2003;
89
3205-3214
- 42
Stroemer R, Kent T A, Hulsebosch C E.
Neocortical neural sprouting, synaptogenesis, and behavioral recovery after neocortical
infarction in rats.
Stroke.
1995;
26
2135-2144
- 43
Dereski M, Chopp M, Knight R, Rodolosi L, Garcia J.
The heterogeneous temporal evolution of focal ischemic neuronal damage in the rat.
Acta Neuropathol (Berl).
1993;
85
327-333
- 44
Baird A, Benfield A, Schlaug G et al..
Enlargement of human cerebral ischemic lesion volumes measured by diffusion-weighted
magnetic resonance imaging.
Ann Neurol.
1997;
41
581-589
- 45
Chopp M, Li Y, Jiang N, Zhang R, Prostak J.
Antibodies against adhesion molecules reduce apoptosis after transient middle cerebral
artery occlusion in rat brain.
J Cereb Blood Flow Metab.
1996;
16
578-584
- 46
Sandberg O, Franklin K, Bucht G, Eriksson S, Gustafson Y.
Nasal continuous positive airway pressure in stroke patients with sleep apnoea: a
randomized treatment study.
Eur Respir J.
2001;
18
630-634
- 47
Wessendorf T E, Wang Y M, Thilmann A F, Sorgenfrei U, Konietzko N, Teschler H.
Treatment of obstructive sleep apnoea with nasal continuous positive airway pressure
in stroke.
Eur Respir J.
2001;
18
623-629
- 48
Disler P, Hansford A, Skelton J et al..
Diagnosis and treatment of obstructive sleep apnea in a stroke rehabilitation unit:
a feasibility study.
Am J Phys Med Rehabil.
2002;
81
622-625
Devin L BrownM.D.
Assistant Professor, Stroke Program, University of Michigan, TC 1920/0316, 1500 East
Medical Center Drive, Ann Arbor, MI 48109