SAS Care 1: sleep-disordered breathing in acute stroke an transient ischaemic attack - prevalence, evolution and association with functional outcome at 3 months, a prospective observational polysomnography study

A multidisciplinary approach to the home management of continuous positive airway pressure therapy for obstructive sleep apnea: beyond usual care pathways (a narrative review)

Obstructive sleep apnea (OSA) is a common chronic condition that is growing in prevalence, associated with important comorbidities, and has several different phenotypes. Continuous positive airway pressure (CPAP) is the gold standard OSA treatment, but its effectiveness relies on consistent adherence, which can often be difficult to maintain. This narrative review discusses current challenges in the care pathways for CPAP therapy management in OSA, including fragmented care/lack of continuity, inadequate management of comorbidities, suboptimal implementation of digital medicine solutions, and existing reimbursement paradigms. Key tasks to be shared between the appropriate healthcare professionals and providers include technical CPAP follow-up (adherence, effectiveness, alert management), management of comorbidities, and multimodal non-invasive monitoring. What this looks like and who provides the different aspects of care should vary by OSA phenotype, ranging from simple follow-up in primary care (uncomplicated OSA with good CPAP adherence) to multidisciplinary specialist management (high-risk OSA with comorbidities), with regular reassessment to ensure continued alignment with the chosen care plan. In addition to better defining these pathways, how they are reimbursed also needs to be addressed. We suggest that there should be a multidisciplinary approach to symptom reduction and adherence, longitudinal assessment of patient-reported outcomes, and a focus on long-term cardiometabolic health as part of managing CPAP-treated patients with OSA. Facilitated by the appropriate use of digital technologies, these approaches should lead to more personalized care and greater patient engagement, resulting in better long-term adherence and treatment effectiveness. The ultimate goal should be to do better for less.

The expression changes endothelial and fibrinolytic biomarkers in acute ischemic stroke patients with OSA

OBJECTIVE

To assess the expression changes of serum fibrinogen, E-selectin, and tissue-type plasminogen activator (t-PA) in acute ischemic stroke (AIS) patients with varying degrees of obstructive sleep apnea syndrome (OSA), and evaluate their value in diagnosing AIS with OSA.

METHODS

Data were gathered from 80 patients with AIS who were admitted to the First Hospital of Jilin University between January 2023 and December 2023. Out of these, 60 patients completed the NIHSS Scale, ESS Scale, STOP-Bang Scale, and underwent polysomnography within a week of symptom onset. Based on the apnea-hypopnea index (AHI) score, patients were categorized into three groups: 15 in the non-exposed group (AHI < 5), 15 in the mildly exposed group (5 ≤ AHI ≤ 15), and 30 in the moderately to severely exposed group (AHI > 15). Serum levels of fibrinogen, E-selectin, and t-PA were determined using enzyme-linked immunosorbent assay.

RESULTS

Polysomnography results indicated AIS with OSA had an increased arousal index and oxygen desaturation index (P < 0.001). Additionally, serum levels of fibrinogen, E-selectin, and t-PA were markedly elevated in the moderately-severely exposed group compared to the non-exposed group (P < 0.001), and these levels positively correlated with the severity of OSA. ROC curves showed the sensitivities of serum of fibrinogen, E-selection, and t-PA was 84.4%, 80%, and 82.2%, respectively, and the specificities of 60%, 66.7%, and 66.7%, compared with that of PSG respectively.

CONCLUSION

The expression of serum fibrinogen, E-selectin, and t-PA is elevated in AIS with OSA and correlates with the severity of OSA.

Changes in sleep-disordered breathing severity and post-stroke outcomes in the first year after stroke

BACKGROUND

Sleep-disordered breathing (SDB) is common among stroke survivors and is associated with worse functional, cognitive, and neurologic outcomes after stroke. Little is known about the association between changes in SDB and changes in these outcomes over time.

METHODS

Ischemic stroke (IS) patients identified through the Brain Attack Surveillance in Corpus Christi project were offered SDB testing with a portable respiratory monitor (ApneaLink Plus) shortly after stroke, and at 3-, 6-, and 12-months post-stroke. SDB was quantified using the respiratory event index (REI; apneas plus hypopneas per hour of recording). At 3-, 6-, and 12-months post-stroke, functional outcomes, cognitive outcomes, and neurologic outcomes were measured. Linear mixed models were fitted to obtain random slopes reflecting individual changes in REI and each of outcome over time, adjusted for multiple covariates. Associations between the resulting individual slopes for REI and each outcome were then evaluated using linear regression models.

RESULTS

Of 482 IS patients with at least one REI measurement, in fully adjusted models, faster reduction in REI was not associated with faster improvement in functional (β = -0.06; 95 % CI: -0.15, 0.03, p = 0.16), cognitive (β = -0.03; 95 % CI: -0.12, 0.06, p = 0.51), or neurologic outcomes (β = -0.04; 95 % CI: -0.13, 0.05, p = 0.41).

CONCLUSIONS

In this observational study of stroke survivors, there was no clear association between the rate of improvement in SDB and improvement in functional, cognitive, or neurologic outcomes. It remains to be seen whether treatment of SDB might lead to improved outcomes among stroke survivors.

Sleep apnea is a common and dangerous cardiovascular risk factor

Sleep apnea involves almost one billion individuals throughout the world, including 40 million Americans. Of major medical concern is the fact that the prevalence of sleep apnea is significantly increasing due to the epidemic of obesity, physical inactivity, and diabetes mellitus which are important risk factors for the development and persistence of sleep apnea in individuals. Sleep apnea is characterized by multiple episodes of apnea or hypopnea during sleep, which cause nocturnal arousals, gasping for breath during the night, daytime sleepiness, irritability, forgetfulness, fatigue and recurrent headaches. Obstructive sleep apnea occurs when upper airway obstruction occurs in an individual during sleep with absent or markedly reduced airflow in the presence of continued activity of inspiratory thoracic and diaphragmatic muscles. Central sleep apnea is defined as the absence or the significant reduction of naso-oral airflow due to the withdrawal during sleep of ponto-medullary respiratory center stimulation of the nerves of the inspiratory thoracic and diaphragmatic muscles and absence of contraction of these muscles during apnea. Complex sleep apnea occurs when an individual exhibits characteristics of both obstructive and central sleep apnea. The severity of sleep apnea is measured by polysomnography and the apnea hypopnea index (AHI), which is the average number of apneas and hypopneas per hour of sleep measured by polysomnography. Sleep apnea is mild if the AHI is 5-14/h with no or mild symptoms, moderate if the AHI is 15 to 30/h with occasional daytime sleepiness, and severe if the AHI is >30/h with frequent daytime sleepiness that interferes with the normal activities of daily life. Chronic sleep apneas and hypopneas followed by compensatory hyperpneas are associated with significant adverse cardiovascular consequences including: 1) recurrent hypoxemia and hypercarbia; 2) Increased sympathetic nerve activity and decreased parasympathetic nerve activity; 3) oxidative stress and vascular endothelial dysfunction; and 4) cardiac remodeling and cardiovascular disease. Moderate or severe sleep apnea significantly increases the risk of coronary artery disease, congestive heart failure, cerebral vascular events (strokes), and cardiac dysrhythmias, and also increase the morbidity and mortality of these diseases. Nevertheless, sleep apnea is currently underdiagnosed and untreated in many individuals due to the challenges in the prediction and detection of sleep apnea and a lack of well-defined optimal treatment guidelines. Chronic continuous positive airway pressure for ≥4 h/night for >70% of nights is beneficial in the treatment of patients with sleep apnea. CPAP Improves sleep quality, reduces the AHI, augments cardiac output and increases oxygen delivery to brain and heart, reduces resistant hypertension, decreases cardiac dysrhythmias, and reduces daytime sleepiness. The present article discusses the diagnosis of obstructive sleep apnea, central sleep apnea, and complex apnea. Thereafter the important pathophysiologic mechanisms in sleep apnea and the relationship of these pathophysiologic mechanics to atherosclerotic vascular disease are reviewed. Guidelines are then provided for the treatment of mild, moderate and severe sleep apnea. In order to reduce the cardiovascular morbidity and mortality caused by sleep apnea and facilitate the diagnosis and the long-term, effective treatment of sleep apnea in patients, the close cooperation is necessary of cardiovascular specialists, pulmonary specialists, and respiratory therapy/rehabilitation specialists.

Performance of questionnaires to predict sleep-disordered breathing in acute stroke patients

Sleep-disordered breathing is common in stroke and may negatively affect its outcome. Screening for sleep-disordered breathing in this setting is of interest but poorly studied. We aimed to evaluate the performance of eight obstructive sleep apnea screening questionnaires to predict sleep-disordered breathing in acute stroke or transient ischaemic attack patients, and to assess the impact of stroke/transient ischaemic attack-specific factors on sleep-disordered breathing prediction. We analysed acute stroke/transient ischaemic attack patients (N = 195) from a prospective cohort ("Sleep Deficiency and Stroke Outcome study"). Assessments included anthropometrics, stroke-specific parameters, sleep history, an in-hospital respiratory polygraphy within the first week after stroke, and obstructive sleep apnea screening questionnaires (Berlin Questionnaire, Epworth Sleepiness Scale, STOP-BANG, NoSAS, Sleep Apnea Clinical Score, No-Apnea, Sleep Obstructive apnea score optimized for Stroke, SLEEP-IN). In a binary classification task for respiratory event index ≥ 15 per hr, we evaluated the performance of the above-mentioned questionnaires. We used logistic regression to identify predictors for sleep-disordered breathing in this cohort. The areas under the curve for respiratory event index ≥ 15 per hr were: Berlin Questionnaire 0.60; STOP-BANG 0.72; NoSAS 0.69; No-Apnea 0.69; Sleep Apnea Clinical Score 0.75; Epworth Sleepiness Scale 0.50; Sleep Obstructive apnea score optimized for Stroke 0.58; and SLEEP-IN 0.67. The No-Apnea had the lowest false omission rate (0.13), a sensitivity of 0.97 and a specificity of 0.12. In multiple logistic regression analysis (respiratory event index ≥ 15 per hr), age, neck circumference, National Institutes of Health Stroke Scale at admission, prior stroke, cardioembolic stroke aetiology and observed apneas were associated with sleep-disordered breathing. The logistic regression model performed similar (area under the curve 0.80) to Sleep Apnea Clinical Score (p = 0.402) and STOP-BANG (p = 0.127), but outperformed the other questionnaires. Neither existing questionnaires nor our statistical model are sufficient to accurately diagnose sleep-disordered breathing after stroke, thus requiring sleep study evaluation. The No-Apnea questionnaire may help to identify patients amenable to sleep testing.

Prevalence, incidence, and the time trends of sleep-disordered breathing among patients with stroke: a systematic review and meta-analysis

BACKGROUND

Recent studies have investigated the epidemiological burden of sleep-disordered breathing (SDB) in patients with stroke; however, the results have been inconsistent, and the temporal trends of SDB after stroke remain unclear.

OBJECTIVE

To perform a systematic review and meta-analysis of the prevalence and incidence of post-stroke SDB, evaluate demographic and clinical characteristic predictors of post-stroke SDB, and examine temporal trends in the overall burden of post-stroke SDB.

METHODS

We searched PubMed, MEDLINE, Embase, Web of Science, CINAHL, and the Cochrane Library for studies reporting the burden of SDB in stroke patients published between 1 January 2010 and 30 December 2023. Two researchers independently screened the records for eligibility, extracted the data, and assessed the quality of the studies. Data were analyzed using random effects meta-analyses, and sources of heterogeneity were explored using subgroup analyses and meta-regression analyses.

RESULTS

Out of the 8,799 references retrieved, none examined the incidence of SDB after stroke. However, 85 studies from 26 countries examined the prevalence of SDB and were included. The overall prevalence of SDB, mild SDB, and moderate to severe SDB were 60.0% (95% CI, 60.0-70.0%), 30.0% (95% CI, 23.0-37.0%), and 45.0% (95% CI, 33.0-57.0%), respectively. Meta-regression revealed that sex (p < 0.0001) and sample size (p < 0.01) were sources of heterogeneity among the studies. The pooled overall prevalence of SDB remained stable over time.

CONCLUSION

SDB is common in patients with stroke, and no reduction in the high prevalence of SDB has been observed over time, suggesting that early screening and prevention of post-stroke SDB still have not received sufficient attention. Moreover, additional studies investigating the incidence of this disease are needed to inform clinical practice.

Increasing and high prevalence of moderate to severe obstructive sleep apnea in acute ischemic stroke in Taiwan

STUDY OBJECTIVES

The prevalence of obstructive sleep apnea (OSA) after stroke is variable, likely due to the time of examination and patient population. Although risk factors for OSA are well established, those for OSA in patients with ischemic stroke have not yet been fully identified. Therefore, we examined the prevalence of OSA and identified risk factors for OSA in the acute stage of ischemic stroke in the Taiwanese population.

METHODS

A total of 103 patients with acute ischemic stroke were screened for OSA by performing polysomnography. The demographic and clinical data, Epworth Sleepiness Scale score, and other stroke risk factors were recorded. Sleep parameters, namely sleep efficiency, sleep stages, apnea-hypopnea index, and oxygen desaturation index were recorded. Logistic regression analysis was conducted to determine clinical and demographic risk factors for moderate to severe OSA in patients with stroke.

RESULTS

We determined that 91.2% of the patients had OSA in the acute stage of ischemic stroke, and 70% of the patients had moderate to severe OSA. Multivariate logistic regression analysis revealed that patients aged ≥65 years had a significantly higher risk of moderate to severe OSA (adjusted OR: 3.04, 95% CI: 1.20-7.69, p < 0.05) compared with patients with ischemic stroke aged <50 years.

CONCLUSION

OSA is highly prevalent among patients with ischemic stroke in the acute stage, and those aged ≥65 years had a significantly increased risk of moderate to severe OSA. In clinical practice, routine PSG screening of OSA may be necessary among older patients with stroke.

The multifaceted aspects of sleep and sleep-wake disorders following stroke

Sleep-wake disorders (SWD) are acknowledged risk factors for both ischemic stroke and poor cardiovascular and functional outcome after stroke. SWD are frequent following stroke, with sleep apnea (SA) being the most frequent SWD affecting more than half of stroke survivors. While sleep disturbances and SWD are frequently reported in the acute phase, they may persist in the chronic phase after an ischemic stroke. Despite the frequency and risk associated with SWD following stroke, screening for SWD remains rare in the clinical setting, due to challenges in the assessment of post-stroke SWD, uncertainty regarding the optimal timing for their diagnosis, and a lack of clear treatment guidelines (i.e., when to treat and the optimal treatment strategy). However, little evidence support the feasibility of SWD treatment even in the acute phase of stroke and its favorable effect on long-term cardiovascular and functional outcomes. Thus, sleep health recommendations and SWD treatment should be systematically embedded in secondary stroke prevention strategy. We therefore propose that the management of SWD associated with stroke should rely on a multidisciplinary approach, with an integrated diagnostic, treatment, and follow-up strategy. The challenges in the field are to improve post-stroke SWD diagnosis, prognosis and treatment, through a better appraisal of their pathophysiology and temporal evolution.

Longitudinal Assessment of Sleep Apnea in the Year After Stroke in a Population-Based Study

BACKGROUND

The aim of this study was to characterize change in sleep-disordered breathing severity in the year following stroke, overall, and by ethnicity, within the population-based Brain Attack Surveillance in Corpus Christi Project.

METHODS

First-ever ischemic strokes (n=414) were ascertained by active and passive surveillance and validated by stroke-trained physicians. Patients with stroke were invited to participate in portable sleep apnea testing (ApneaLink Plus) at baseline and 3, 6, and 12 months poststroke. Sleep-disordered breathing severity was assessed by the respiratory event index (apneas and hypopneas/hour of recording). The component obstructive apnea index and central apnea index were also assessed. Time and ethnicity effects on outcomes, as well as ethnic differences in time effects, were analyzed using generalized estimating equations with multivariable adjustment for confounding factors.

RESULTS

Mean age (n=414) was 63.9 years (SD=10.9); 68.4% were Mexican American. Baseline mean respiratory event index, obstructive apnea index, and central apnea index were 21.3 (SD=16.6), 8.6 (SD=11.5), and 1.5 (SD=3.2), respectively. There was no time effect on respiratory event index (P=0.35) but obstructive apnea index increased over time (P<0.01). Averaged over follow-up, respiratory event index and obstructive apnea index were significantly higher in Mexican American than non-Hispanic White persons. No ethnic difference in the time effect was found for either outcome. For central apnea index, there was an ethnicity-time interaction (P=0.01) such that central apnea index increased in non-Hispanic White but did not change in Mexican American persons.

CONCLUSIONS

Sleep-disordered breathing severity was significant and stable for most individuals in the year after stroke. These results do not confirm previous reports of diminishing sleep-disordered breathing severity over time after stroke and would support early assessment and treatment where indicated.

Effect of different ventilation modalities on the early prognosis of patients with sleep apnea after acute ischemic stroke---protocol for a prospective, open-label and randomised controlled trial

BACKGROUND

Sleep apnea is highly prevalent after acute ischemic stroke (AIS) and has increased stroke-related mortality and morbidity. The conventional sleep apnea treatment is continuous positive airway pressure (CPAP) ventilation. However, it is poorly tolerated by patients and is not used in all stroke patients. This protocol describes the impact of high-flow nasal cannula (HFNC) oxygen therapy compared to nasal continuous positive airway pressure (nCPAP) ventilation or usual care on the early prognosis of patients with sleep apnea after AIS.

METHODS

This randomised controlled study will be conducted in the intensive care unit of the Department of Neurology at the Wuhan Union Hospital. According to the study plan, 150 patients with sleep apnea after AIS will be recruited. All patients are randomly allocated in a 1:1:1 ratio to one of three groups: the nasal catheter group (standard oxygen group), the HFNC group, and the nCPAP group. Patients receive different types of ventilation after admission to the group, and their tolerance while using the different ventilation is recorded. Patients will be followed up by telephone three months after discharge, and stroke recovery is recorded. The primary outcomes were 28-day mortality, the incidence of pulmonary infection and endotracheal intubation.

DISCUSSION

This study analyses different ventilation modalities for early interventions in patients with sleep apnea after AIS. We will investigate whether nCPAP and HFNC reduce early mortality and endotracheal intubation rates and improve distant neurological recovery in patients.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT05323266; 25 March 2022).

Association of Obstructive Sleep Apnea and Atrial Fibrillation in Acute Ischemic Stroke: A Cross-Sectional Study

Background: There is a growing body of evidence suggesting a link between obstructive sleep apnea (OSA) and atrial fibrillation (AF). The primary objective of this study is to evaluate the association between OSA and AF in acute ischemic stroke. The secondary objective is to describe the clinical features of patients with acute ischemic stroke and concomitant OSA. Methods: We enrolled consecutive patients with acute ischemic stroke. All patients underwent full-night cardiorespiratory polygraphy. To determine if there is an association between AF and OSA, we compared the observed frequency of this association with the expected frequency from a random co-occurrence of the two conditions. Subsequently, patients with and without OSA were compared. Results: A total of 174 patients were enrolled (mean age 67.3 ± 11.6 years; 95 males). OSA and AF were present in 89 and 55 patients, respectively. The association OSA + AF was observed in 33/174 cases, which was not statistically different compared to the expected co-occurrence of the two conditions. Patients with OSA showed a higher neck circumference and body mass index, a higher prevalence of hypertension and dysphagia, and a higher number of central apneas/hypoapneas. In the multivariate analysis, dysphagia and hypertension were independent predictors of OSA. A positive correlation was observed between OSA severity, BMI, and neck circumference. The number of central apneas/hypoapneas was positively correlated with stroke severity. Conclusions: Our data suggest that OSA and AF are highly prevalent but not associated in acute stroke. Our findings support the hypothesis that OSA acts as an independent risk factor for stroke.

Sleep-Disordered Breathing in Acute Stroke: A Single-Center, Prospective, Longitudinal Study

BACKGROUND

Sleep-disordered breathing (SDB) is common among acute stroke patients. We sought to investigate the prevalence, severity and type of SDB in consecutive acute stroke patients. Moreover, we aimed to identify independent predictors of SDB in the acute stroke setting and investigate potential associations between SDB and functional outcomes at three months.

METHODS

We prospectively studied consecutive acute stroke patients, who underwent overnight polysomnography within 72 h from symptom onset. Demographics, clinical and imaging characteristics were documented. Daytime sleepiness preceding the stroke, stroke severity on admission and functional outcome at three months were evaluated using the Epworth-Sleepiness Scale (ESS), National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS), respectively. SDB was documented using standard polysomnography criteria.

RESULTS

A total of 130 consecutive acute stroke patients were prospectively evaluated [110 with ischemic stroke and 20 with intracerebral hemorrhage, mean age 60.5 ± 10.9 years, 77% men, median NIHSS score on admission: 3 (IQR: 2-17)]. The rate of SDB detection on polysomnography recordings was 79% (95% CI: 71-86). Three variables were independently associated with the likelihood of SDB detection in multivariable analyses adjusting for potential confounders: age (OR per 10-year-increase: 2.318, 95% CI: 1.327-4.391, p = 0.005), male sex (OR: 7.901, 95% CI: 2.349-30.855, p = 0.001) and abnormal ESS-score (OR: 6.064, 95% CI: 1.560-32.283, p = 0.017). Among patients with SDB, congestive heart failure was independently associated with the likelihood of central apnea detection (OR: 18.295, 95% CI: 4.464-19.105, p < 0.001). Among all patients, increasing NIHSS score on admission (OR: 0.817, 95% CI: 0.737-0.891, p < 0.001) and Apnea-Hypopnea Index (OR: 0.979, 95% CI: 0.962-0.996, p = 0.020) emerged as independent predictors of excellent functional outcome at 3 months (mRS-scores 0-1).

CONCLUSION

The high prevalence and severity of SDB in acute stroke patients and its negative impact on functional outcome indicate the importance of polysomnography implementation in everyday clinical practice of acute stroke work-up and management.

Sleep and Stroke: Opening Our Eyes to Current Knowledge of a Key Relationship

PURPOSE OF REVIEW

To elucidate the interconnection between sleep and stroke.

RECENT FINDINGS

Growing data support a bidirectional relationship between stroke and sleep. In particular, there is strong evidence that sleep-disordered breathing plays a pivotal role as risk factor and concur to worsening functional outcome. Conversely, for others sleep disorders (e.g., insomnia, restless legs syndrome, periodic limb movements of sleep, REM sleep behavior disorder), the evidence is weak. Moreover, sleep disturbances are highly prevalent also in chronic stroke and concur to worsening quality of life of patients. Promising novel technologies will probably allow, in a near future, to guarantee a screening of commonest sleep disturbances in a larger proportion of patients with stroke. Sleep assessment and management should enter in the routinary evaluation of stroke patients, of both acute and chronic phase. Future research should focus on the efficacy of specific sleep intervention as a therapeutic option for stroke patients.

Sleep apnoea and ischaemic stroke: current knowledge and future directions

Sleep apnoea, one of the most common chronic diseases, is a risk factor for ischaemic stroke, stroke recurrence, and poor functional recovery after stroke. More than half of stroke survivors present with sleep apnoea during the acute phase after stroke, with obstructive sleep apnoea being the most common subtype. Following a stroke, sleep apnoea frequency and severity might decrease over time, but moderate to severe sleep apnoea is nevertheless present in up to a third of patients in the chronic phase after an ischaemic stroke. Over the past few decades evidence suggests that treatment for sleep apnoea is feasible during the acute phase of stroke and might favourably affect recovery and long-term outcomes. Nevertheless, sleep apnoea still remains underdiagnosed and untreated in many cases, due to challenges in the detection and prediction of post-stroke sleep apnoea, uncertainty as to the optimal timing for its diagnosis, and a scarcity of clear treatment guidelines (ie, uncertainty on when to treat and the optimal treatment strategy). Moreover, the pathophysiology of sleep apnoea associated with stroke, the proportion of stroke survivors with obstructive and central sleep apnoea, and the temporal evolution of sleep apnoea subtypes following stroke remain to be clarified. To address these shortcomings, the management of sleep apnoea associated with stroke should be integrated into a multidisciplinary diagnostic, treatment, and follow-up strategy.

Sleep-disordered breathing and ventilatory chemosensitivity in first ischaemic stroke patients: a prospective cohort study

RATIONALE

Sleep-disordered breathing (SDB) is highly prevalent after stroke. The clinical and ventilatory chemosensitivity characteristics of SDB, namely obstructive, central and coexisting obstructive and central sleep apnoea (coexisting sleep apnoea) following stroke are poorly described.

OBJECTIVE

To determine the respective clinical and ventilatory chemosensitivity characteristics of SDB at least 3 months after a first ischaemic stroke.

METHODS

Cross-sectional analysis of a prospective, monocentric cohort conducted in a university hospital. 380 consecutive stroke or transient ischaemic attack patients were screened between December 2016 and December 2019.

MEASUREMENTS AND MAIN RESULTS

Full-night polysomnography, and hypercapnic ventilatory response were performed at a median (Q1; Q3) time from stroke onset of 134.5 (97.0; 227.3) days. 185 first-time stroke patients were included in the analysis. 94 (50.8%) patients presented no or mild SDB (Apnoea-Hypopnoea Index <15 events/hour of sleep) and 91 (49.2%) moderate to severe SDB, of which 52 (57.1%) presented obstructive sleep apnoea and 39 (42.9%) coexisting or central sleep apnoea. Obstructive sleep apnoea patients significantly differed regarding their clinical presentation from patients with no or mild SDB, whereas there was no difference with coexisting and central sleep apnoea patients. The latter presented a higher frequency of cerebellar lesions along with a heightened hypercapnic ventilatory response compared with no or mild SDB patients.

CONCLUSION

SDB in first-time stroke patients differ in their presentation by their respective clinical traits and ventilatory chemosensitivity characteristics. The heightened hypercapnic ventilatory response in coexisting and central sleep apnoea stroke patients may orientate them to specific ventilatory support.

Effect of early sleep apnoea treatment with adaptive servo-ventilation in acute stroke patients on cerebral lesion evolution and neurological outcomes: study protocol for a multicentre, randomized controlled, rater-blinded, clinical trial (eSATIS: early Sleep Apnoea Treatment in Stroke)

BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent in acute ischaemic stroke and is associated with worse functional outcome and increased risk of recurrence. Recent meta-analyses suggest the possibility of beneficial effects of nocturnal ventilatory treatments (continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV)) in stroke patients with SDB. The evidence for a favourable effect of early SDB treatment in acute stroke patients remains, however, uncertain.

METHODS

eSATIS is an open-label, multicentre (6 centres in 4 countries), interventional, randomized controlled trial in patients with acute ischaemic stroke and significant SDB. Primary outcome of the study is the impact of immediate SDB treatment with non-invasive ASV on infarct progression measured with magnetic resonance imaging in the first 3 months after stroke. Secondary outcomes are the effects of immediate SDB treatment vs non-treatment on clinical outcome (independence in daily functioning, new cardio-/cerebrovascular events including death, cognition) and physiological parameters (blood pressure, endothelial functioning/arterial stiffness). After respiratory polygraphy in the first night after stroke, patients are classified as having significant SDB (apnoea-hypopnoea index (AHI) > 20/h) or no SDB (AHI < 5/h). Patients with significant SDB are randomized to treatment (ASV+ group) or no treatment (ASV- group) from the second night after stroke. In all patients, clinical, physiological and magnetic resonance imaging studies are performed between day 1 (visit 1) and days 4-7 (visit 4) and repeated at day 90 ± 7 (visit 6) after stroke.

DISCUSSION

The trial will give information on the feasibility and efficacy of ASV treatment in patients with acute stroke and SDB and allows assessing the impact of SDB on stroke outcome. Diagnosing and treating SDB during the acute phase of stroke is not yet current medical practice. Evidence in favour of ASV treatment from a randomized multicentre trial may lead to a change in stroke care and to improved outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02554487 , retrospectively registered on 16 September 2015 (actual study start date, 13 August 2015), and www.kofam.ch (SNCTP000001521).