Prevalence of sleep-disordered breathing after stroke and TIA: A meta-analysis

P3a, P3b Characteristics of OSA Patients in the Acute Stroke Population

Objective: To investigate the neurophysiological and cognitive impairments in patients with obstructive sleep apnea (OSA) among the acute stroke population. Methods: A total of 268 acute ischemic stroke patients with OSA underwent sleep monitoring within 24 h of admission and event-related potential tests within three days. They were categorized into groups based on their AHI: stroke only, and stroke with mild, moderate, or severe OSA. This classification served to analyze the electrophysiological profiles associated with stroke and OSA severity. Results: Compared with the control group, in the P3b series, the P3b-FZ amplitude was significantly reduced in the stroke with mild, moderate, and severe OSA group; the N2-PZ latency was significantly prolonged in the stroke with severe OSA group; and the P3b-FZ, P3b-CZ, and P3b-FZ latencies were significantly prolonged in the stroke with mild, moderate, and severe OSA group; in the P3a series, the N2-CZ amplitude was decreased in the stroke with severe OSA group, P2-FZ latency was significantly prolonged in the stroke with mild and moderate OSA group, P3a-FZ latency was significantly prolonged in the stroke with mild OSA group, P3a-CZ latency was significantly prolonged in the stroke with severe OSA group, and P3a-PZ latency was significantly prolonged in the stroke with mild and severe OSA group. Conclusions: The electrophysiologic changes compared with the stroke-only group were mainly characterized by prolonged latencies of the endogenous components P3a and P3b, suggesting that they are related to attention allocation and cognitive control.

Autonomic dysfunction after stroke: an overview of recent clinical evidence and perspectives on therapeutic management

PURPOSE

Central autonomic dysfunction is common in acute stroke and is associated with cardiovascular complications and increased mortality. The aim of this review is to present novel diagnostic and therapeutic approaches to the management of this disorder and the latest data on its impact on the clinical outcome after stroke.

METHODS

We performed a narrative review of recent literature, with a particular focus on articles related to underlying pathophysiological mechanisms of cardiac autonomic dysregulation, the role of cardiac autonomic dysregulation in the activation of neuroinflammatory response and the development of cardiovascular, respiratory and metabolic complications in patients with ischemic and hemorrhagic stroke.

RESULTS

The assessment of central autonomic dysfunction by non-invasive diagnostic techniques, including heart rate variability and baroreflex sensitivity, has gained wide practical application in recent years, and they may have a predictive role for evaluating disease prognosis. The emerging evidence derived from recent trials demonstrates that the presence of autonomic imbalance may lead to increased mortality and have an adverse effect on post-stroke rehabilitation.

CONCLUSION

The early detection and treatment of central autonomic system dysfunction may lead to improved survival of patients with stroke. Among the available therapeutic approaches, neuromodulatory techniques and pharmacological interventions are promising strategies which may be implemented as part of standard acute stroke care to improve patient recovery. Future studies are warranted to address the long-term effects of potential therapeutic agents on the modulation of cardiovascular autonomic function in stroke survivors.

Alpha-1 antitrypsin deficiency and risk of sleep apnea: a nationwide cohort study

OBJECTIVES

α1-Antitrypsin deficiency is a disease characterized by increased neutrophil elastase activity leading to tissue getting less elastic and robust. It is known that if tissue in the pharynx becomes less elastic and robust, it could contribute to obstructive sleep apnea. This paper seeks to investigate whether patients with α1-antitrypsin deficiency have an increased risk of sleep apnea.

METHODS

We tested this hypothesis by doing a nationwide cohort study of 2702 individuals diagnosed with α1-antitrypsin deficiency compared with 26,750 individuals without α1-antitrypsin deficiency matched on sex, age, and municipality. All individuals were followed from birth and were censored at the time of outcome, emigration, death, or end of follow-up 31st of December 2018, whichever came first.

RESULTS

Individuals with α1-antitrypsin deficiency had a higher risk of sleep apnea with an adjusted hazard ratio of 1.81 (95% CI 1.36-2.40) compared to controls without α1-antitrypsin deficiency. Similarly, the risk of obstructive sleep apnea was nominally higher in individuals with α1-antitrypsin deficiency compared to controls without the disease (1.47, 95% CI 0.95-2.28). In stratified analysis, the risk of sleep apnea was higher in individuals without chronic obstructive pulmonary disease (2.33, 95% CI 1.54-3.51) (P for interaction < 0.05). The increased risk of SA was unaffected when the analysis was stratified by ischemic heart disease, ischemic cerebrovascular disease, type 2 diabetes, hypertension, and liver cirrhosis.

CONCLUSION

Individuals with α1-antitrypsin deficiency have a higher risk of sleep apnea in the Danish population.

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.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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.

Study on the Mechanisms of Ischemic Stroke Impacting Sleep Homeostasis and Circadian Rhythms in Rats

OBJECTIVE

This study aimed to investigate the impact of ischemic stroke (IS) on sleep homeostasis and circadian rhythms in rats, as well as the underlying mechanisms.

METHODS

The middle cerebral artery occlusion model was employed to induce IS in rats. Sixty young and sixty aged rats were randomly divided into six groups for experiments. Neurological function was assessed using the Garcia score, and infarct size was evaluated through 2,3,5-triphenyltetrazolium chloride staining. Sleep-wake cycles were monitored by implanting electrodes into the neck muscles to record electroencephalograms and electromyograms. Parameters such as sleep latency, waking time, non-rapid eye movement (NREM) sleeping, rapid eye movement sleeping, NREM delta power, and waking theta power were measured. Serum cortisol and melatonin levels were measured using enzyme-linked immunosorbent assay. Gene and protein expression of circadian regulators period 1 (Per1) and cryptochrome 1 (Cry1) in the pineal gland were assessed using real-time quantitative reverse transcription polymerase chain reaction and western blot.

RESULTS

Compared to the sham groups, IS-induced rats showed a decrease in Garcia scores and an increase in cerebral infarction area. Besides, relative to young rats, aged rats exhibited more severe cerebral infraction damage, lower melatonin levels, higher cortisol levels, disrupted sleep-wake cycles, and altered gene and protein expression levels of Per1 and Cry1 in the pineal gland.

CONCLUSIONS

IS can lead to neurological impairments and brain damage, with aged rats showing more severe effects. IS also disturbs melatonin and cortisol levels, affects sleep homeostasis, and results in disordered Per1 and Cry1 gene and protein expression levels. These findings underscore the role of circadian disruption and stress response in the pathology of IS, especially in aging populations.

Stroke recurrence and all-cause mortality in CPAP-treated sleep-disordered-breathing patients

BACKGROUND

Obstructive sleep apnea (OSA) affects about 70 % of stroke patients and is closely linked to stroke development. It is unclear whether treatment with continuous positive airway pressure (CPAP) reduces the risk of stroke recurrence or mortality in post-stroke patients, partly due to limited follow-up time and small sample sizes of previous studies. To close this knowledge gap, this study investigated changes in stroke recurrence and mortality among CPAP-treated post-stroke patients with sleep-disordered breathing.

METHODS

We conducted a retrospective cohort study using data from the Danish National Patient Registry covering the period from 2003 to 2016, involving 1821 patients diagnosed with sleep-disordered breathing and a prior ischemic stroke or transient ischemic attack (TIA). Patients were categorized into three groups: CPAP users, CPAP-non-users, and no CPAP treatment. We used Cox hazard regression to assess the risk of recurrent stroke or TIA over a 5-year follow-up period, and all-cause mortality over a 14-year follow-up period.

RESULTS

CPAP treatment improved survival rate in CPAP users compared to patients categorized as no CPAP treatment (hazard ratio 0.75, 95 % CI [0.60;0.92], p = 0.007). This effect persisted after adjusting for age, sex, and pre-existing comorbidities within three years (the Quan-updated Charlson Comorbidity Index). There was no difference in recurrence of stroke/TIA among the three CPAP groups.

CONCLUSIONS

In this registry-based study, we found that CPAP was associated with a reduction in all-cause mortality in post-stroke/TIA patients with sleep-disordered breathing. CPAP treatment did not seem to affect the risk of re-stroke/TIA during the five years of follow-up.

Screening prediction models using artificial intelligence for moderate-to-severe obstructive sleep apnea in patients with acute ischemic stroke

BACKGROUND

Obstructive sleep apnea (OSA) is common after stroke. Still, routine screening of OSA with polysomnography (PSG) is often unfeasible in clinical practice, primarily because of how limited resources are and the physical condition of patients. In this study, we used several artificial intelligence techniques to predict moderate-to-severe OSA and identify its features in patients with acute ischemic stroke.

METHODS

A total of 146 patients with acute ischemic stroke underwent PSG screening for OSA. Their baseline demographic characteristics, including age, sex, body mass index (BMI), Epworth Sleepiness Scale (ESS) score, and stroke risk factors, were recorded. Logistic regression analysis was conducted to identify significant features associated with moderate-to-severe OSA in patients with stroke. These significant features were used with six machine learning and ensemble learning algorithms, namely decision tree, support vector machine, random forest, extreme gradient boosting (XGBoost), adaptive boosting (AdaBoost), and gradient boosting, to compare the performance of several predictive models.

RESULTS

Multivariate logistic regression analysis revealed that age, sex, BMI, neck circumference, and ESS score were significantly associated with the presence of moderate-to-severe OSA. According to the machine learning and ensemble learning results, the XGBoost model achieved the highest performance, with an area under the receiver operating characteristic curve of 0.89 and an accuracy and F1 score of 0.80.

CONCLUSION

This study identified key factors contributing to moderate-to-severe OSA in patients with ischemic stroke. The XGBoost model exhibited high predictive performance, indicating it has potential as a supporting tool for decision-making in health-care settings.

Addressing Systemic Complications of Acute Stroke: A Scientific Statement From the American Heart Association

Systemic, nonneurological complications are common after ischemic and hemorrhagic strokes, affect different organ systems, and have a major impact on patient outcomes. Despite their obvious implications, this area in stroke management remains inadequately researched, and current literature offers fragmentary guidance for care. The purpose of this scientific statement is to elucidate the major systemic complications of strokes that occur during hospitalization, to synthesize evidence from current literature and existing guidelines, to address gaps in knowledge, and to provide a coherent set of suggestions for clinical care based on interpretation of existing evidence and expert opinion. This document advocates for improved interdisciplinary collaboration, team effort, and effective implementation strategies to reduce the burden of these events in clinical practice. It also calls for further research on strategies for preventing and managing systemic complications after stroke that improve outcomes in stroke survivors.

Respiratory Pathology and Cardiovascular Diseases: A Scoping Review

Respiratory diseases and cardiovascular diseases (CVDs) have high prevalence and share common risk factors. In some respiratory diseases such as sleep apnoea and COPD, the evidence of their negative impact on the prognosis of CVDs seems clear. However, in other diseases it is less evident whether there is any direct relationship. With this in mind, our objective was to provide information that may be helpful to better understand the relationship between respiratory pathology and CVDs. There are different reasons for this relationship, such as shared risk factors, common pathophysiological mechanisms, side effects of treatment and the direct effect in the heart and great vessels of respiratory diseases. Indeed, aging and smoking are risk factors for CVDs and also for respiratory diseases such as obstructive sleep apnea (OSA), COPD and interstitial lung diseases (ILD). Furthermore, there are common pathophysiological mechanisms that affect both respiratory diseases and CVDs, such as accelerated atherosclerosis, microvascular dysfunction, endothelial dysfunction, inflammation, hypoxemia and oxidative stress. Besides that, it is well known that lung cancer, sarcoidosis and amyloidosis may directly affect the heart and great vessels. Finally, side effects of drugs for respiratory diseases and the discontinuation of treatments that are necessary for CVDs, such as β-blockers and aspirin, may have a deleterious impact on the cardiovascular system. In conclusion, the coexistence of respiratory diseases and CVDs is very common. It makes modifying diagnostic and therapeutic management necessary and is also a relevant prognostic factor.

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.

Evolution of Sleep Apnea and Arousals in Patients with Ischemic Stroke: A Longitudinal Follow-Up Study

BACKGROUND AND OBJECTIVES

Sleep-disordered breathing (SDB) is characterized by pauses or shallow breathing during sleep. It is linked to poorer outcomes and increased stroke recurrence in stroke patients. We aimed to evaluate the proportion, severity, type, and evolution of SDB and arousals in ischemic stroke patients.

METHODS

Ischemic stroke patients were recruited to evaluate SDB. Patients underwent overnight polysomnography (PSG) twice - within 1 month of stroke onset and again after 3 months. Clinical outcomes were evaluated at 6, 18, and 24 months.

RESULTS

Of 141 acute ischemic stroke patients screened, 111 patients recruited in the study and 105 patients had technically adequate polysomnography. The mean age of patients was 50.5 years (standard deviation [SD]: 12.30), 78.4% of the patients were males, and the mean body mass index was 26 (SD: 5.4). Results showed that 81.9% had an apnea-hypopnea index (AHI) ≥5, with 12.5% having an AHI >30. The median arousal index (ArI) was 15.4 (interquartile range [IQR]: 0.5-50.5), which increased as the apnea increased. During follow-up, 56.8% patients had an AHI ≥5, with 12.5% having severe apnea. The median ArI decreased from 15.4 (IQR: 0.5-50.5) initially to 11.54 (IQR: 0.5-21.1) at follow-up. Numerical change in AHI severity categories were noted during the follow-up (mild: 8 vs 15; moderate: 17 vs 11; severe 19vs 7). For AHI >30, ArI decreased from 24.63 (IQR: 0.7-50.05) to 10.54 (IQR: 7.1-15.07) at follow-up. Sleep efficiency and rapid eye movement (REM) sleep duration increased on follow-up.

CONCLUSIONS

The study showed a high proportion of SDB in acute ischemic stroke patients. In the follow-up, SDB improved, as reflected in AHI and ArI changes.

Clinic and ambulatory blood pressures, blood pressure phenotypes and mortality in patients with a previous stroke

There is scarce evidence of the role of clinic and ambulatory BP indices, as well as blood pressure phenotypes in the prognosis of stroke survivors. We aimed to evaluate the association between ambulatory BP indices and mortality in patients with a previous stroke. Our study was an observational cohort study from individuals included in the Spanish Ambulatory Blood Pressure Registry from March 2004 to December 2014. The Cox model was used to estimate associations between usual clinic and ambulatory BP and mortality, adjusted for confounders and additionally for alternative measures of BP. Two thousand one hundred and eighty-three patients with a previous stroke were included. During a median of 9.2 years, 632 (28.9%) patients died: 236 (10.8%) from cardiovascular causes. In the confounder-adjusted model, clinic systolic BP was not associated with the risk of all-cause or cardiovascular mortality. In contrast, systolic BP indices obtained through ABPM (24 h, day and night) were all associated with all-cause and cardiovascular death. In the simultaneous adjustment of daytime and night-time systolic BP, only night-time systolic BP remained significantly associated with all-cause and cardiovascular death: HR 1.35 (95% CI 01.21-1.51) and 1.44 (1.20-1.72), respectively. For diastolic BP, only night-time BP was associated with all-cause and cardiovascular mortality: HR 1.32 (1.18-1.48) and 1.57 (1.31-1.88), respectively. According to the circadian pattern, a riser pattern was associated with all-cause and cardiovascular mortality: HR 1.49 (1.18-1.87) and 1.70 (1.14-2.52), respectively. In conclusion, in patients who have suffered a stroke, night-time BP is the BP estimate most closely associated with all-cause and cardiovascular mortality.

Sleep apnea after stroke: A novel target

Sleep apnea is an independent risk factor for cerebrovascular diseases. Its prevalence in stroke survivors is high and the disorder negatively affects patients' outcomes. Despite the importance of sleep apnea assessment is highlighted also in the current guidelines, a high proportion of patients remain undiagnosed and lose the potential benefit of positive airway pressure treatment. The current paper describes links between sleep apnea and stroke. It focuses on the challenges of the diagnostic and therapeutical process and provides a brief insight into ongoing trials that could help to identify appropriate diagnostic and therapeutic approaches, their timing, and the patient population for whom treatment could be most beneficial.

Urinary Epinephrine Sulfate Can Predict Cardiovascular Risk in Moderate-to-Severe OSA: A Metabolomics-Based Study

Purpose

There are currently no ideal indicators for predicting the cardiovascular risk of obstructive sleep apnea (OSA). This study aimed to employ urinary metabolomics to detect early cardiovascular risk in patients with moderate-to-severe OSA.

Patients and Methods

Male participants who underwent polysomnography from November 2020 to May 2021 were screened. Clinical data, polysomnography data and urine samples were collected. Untargeted metabolomics analyses of urine were performed. Multivariate analyses and receiver operating characteristic (ROC) curve analyses were subsequently performed to identify potential biomarkers. Associations between metabolites and clinical indicators and cardiovascular risk were examined through linear regression analyses with interaction and mediation analyses.

Results

Thirty-six male participants were included in the study, comprising 22 males with moderate-to-severe OSA and 14 age-matched controls, with an average age of 39.6 ± 9.2 years. We identified 65 metabolites in the study, involving pathways including pyrimidine, androgen, estrogen, vitamin B6 and sulfate/sulfite metabolism. Among them, epinephrine sulfate was the most significantly altered metabolite. ROC analyses highlighted that epinephrine sulfate had the highest area under the curve (AUC=0.883) for detecting moderate-to-severe OSA. Epinephrine sulfate was statistically correlated with OSA severity, hypoxia-related indicators (apnea-hypopnea index: r=0.685; oxygen desaturation index: r=0.743, p<0.0001), arterial stiffness (arterial augmentation index: r=0.361, p=0.031) and long-term cardiovascular risk (Framingham cardiovascular risk: r=0.375, p=0.024). Linear regression analysis revealed that epinephrine sulfate was significantly associated with an increased in the Framingham risk (β = 0.004, 95% CI = 0.000-0.009, p = 0.049), with the effect partly mediated by systolic blood pressure (27.6%) and not moderated by other factors. Additionally, it also significantly associated with the increased in the arterial augmentation index (β = 0.019, 95% CI = 0.000-0.037, p = 0.046), with the effect fully mediated by blood pressure and not moderated by other indices statistically.

Conclusion

There are significant metabolic pathway alterations in moderate-to-severe OSA patients. Urinary epinephrine sulfate markedly predicts early cardiovascular risk in OSA patients.

Strengthening oropharyngeal muscles as an approach to treat post-stroke obstructive sleep apnea: A feasibility randomised controlled trial

This study aimed to determine the feasibility of a randomised controlled trial (RCT) evaluating oropharyngeal exercise (OPE) intervention as an alternative therapy for obstructive sleep apnea (OSA) in patients with stroke or transient ischaemic attack (TIA). Despite the high prevalence of OSA in this population, the standard therapy, continuous positive airway pressure (CPAP), is often poorly tolerated. Thirty stroke/TIA patients with OSA unable to tolerate CPAP were randomly assigned to an oropharyngeal exercise or sham exercise protocol. They performed exercises for 6 weeks, 5 days per week, 30 minutes twice per day. Feasibility was ascertained by the proportion of enrolled patients who completed more than 80% of the OPE regimen. Isometric tongue pressures, apnea-hypopnea index (AHI), oxygen desaturation index (ODI), daytime sleepiness, and quality of life (QOL) outcomes were collected at baseline, post-training (6-week follow-up), and retention (10-week follow-up) to document preliminary efficacy. Adherence to study exercises was excellent, with 83% of participants completing more than 80% of the exercises. The isometric tongue pressures were observed to improve in the oropharyngeal exercise group (compared with the sham group), along with a decrease in OSA severity (measured by the AHI and ODI), reduced daytime sleepiness, and enhanced quality of life outcomes following the exercise programme. Only the effects on posterior isometric tongue pressure and daytime sleepiness remained significantly different between groups at the retention session. In conclusion, an RCT evaluating the efficacy of oropharyngeal exercises on post-stroke/TIA OSA is feasible and our preliminary results suggest a clinically meaningful effect.

Sex Differences in Obstructive Sleep Apnea after Stroke

BACKGROUND AND OBJECTIVES

Obstructive sleep apnea (OSA) is prevalent after stroke and associated with recurrent stroke, prolonged hospitalization, and decreased functional recovery. Sex differences in post-stroke OSA remain underexplored. The objective of this study was to evaluate sex differences in functional outcomes, stroke and OSA severity, and clinical manifestations of OSA in stroke patients with OSA.

METHODS

We retrospectively evaluated data from three previously conducted studies. Study patients had an imaging-confirmed stroke and had been found to have OSA (apnea-hypopnea index [AHI] ≥ 5) on either in-laboratory polysomnography or home sleep apnea testing performed within 1 year of their stroke. Linear regression models were used to evaluate study outcomes.

RESULTS

In total, 171 participants with post-stroke OSA (117 males [68.4%] and 54 females [31.6%]) were included. Female sex was an independent predictor for greater functional impairment (β = 0.37, 95% CI 0.029-0.71, p = 0.03), increased stroke severity (β = 1.009, 95% CI 0.032-1.99, p = 0.04), and greater post-stroke depressive symptoms (β = 3.73, 95% CI 0.16-7.29, p = 0.04). Female sex was associated with lower OSA severity, as measured by the AHI (β = -5.93, 95% CI -11.21- -0.66). Sex was not an independent predictor of specific symptoms of OSA such as daytime sleepiness, snoring, tiredness, and observed apneas.

CONCLUSION

Females with post-stroke OSA had poorer functional outcomes and more severe strokes compared to males, despite having lower OSA severity. Females with post-stroke OSA also exhibited more depressive symptoms. Understanding sex differences in patients with post-stroke OSA will likely facilitate better recognition of OSA and potentially improve clinical outcomes.

Pooled prevalences of obstructive sleep apnea and heart failure: a systematic review and meta-analysis

Obstructive sleep apnea (OSA) is a disease with intermittent hypoxemia during sleep. It has been shown that OSA is related to several cardiovascular diseases including heart failure. Both OSA and heart failure have a close association bidirectionally. This study aimed to estimate the pooled prevalence of OSA in patients with heart failure as well as pooled prevalence of heart failure in patients with OSA. This was a systematic review with a meta-analysis. The inclusion criteria were observational or epidemiological studies conducted in adult patients with heart failure to evaluate the prevalence of OSA and patients with OSA to evaluate the prevalence of heart failure. The outcomes of this study were prevalence of OSA in patients with heart failure and prevalence of heart failure in patients with OSA. Four databases were used for systematic searching including PubMed, Science Direct, Scopus, and CINAHL Plus. Manual searches for related studies were also conducted. Proportion meta-analyses using a random-effects model were conducted to identify pooled proportion (prevalence) of heart failure in patients with OSA and vice versa. Among 3,941 articles from the four databases met the study criteria. Thirty-three studies showed the prevalence of OSA in patients with heart failure, while thirteen studies presented the prevalence of heart failure in patients with OSA. The prevalence of OSA in patients with heart failure was 38.4% (95% CI 31.9 to 45.2; I2 of 96.1%). Using a diagnostic criterion of OSA of more than 10 events/hr had the highest prevalence of OSA in patients with heart failure at 53.4% (95% CI 42.0 to 64.5). The highest prevalence of OSA in patients with heart failure was 60.1% (95% CI 51.4 to 68.3) in a report from India. The pooled prevalence of heart failure in patients with OSA was 12.8% (95% CI 8.1 to 19.5; I2 of 94.6%). The prevalence in Romania was highest at 22.6% (95% CI 20.4 to 24.9). The pooled prevalence of OSA in patients with heart failure was higher than the pooled prevalence of heart failure in patients with OSA. The pooled prevalence rates of these associations varied among the diagnostic criteria of OSA and countries.

Sleep apnoea, gut dysbiosis and cognitive dysfunction

Sleep disorders are becoming increasingly common, and their distinct effects on physical and mental health require elaborate investigation. Gut dysbiosis (GD) has been reported in sleep-related disorders, but sleep apnoea is of particular significance because of its higher prevalence and chronicity. Cumulative evidence has suggested a link between sleep apnoea and GD. This review highlights the gut-brain communication axis that is mediated via commensal microbes and various microbiota-derived metabolites (e.g. short-chain fatty acids, lipopolysaccharide and trimethyl amine N-oxide), neurotransmitters (e.g. γ-aminobutyric acid, serotonin, glutamate and dopamine), immune cells and inflammatory mediators, as well as the vagus nerve and hypothalamic-pituitary-adrenal axis. This review also discusses the pathological role underpinning GD and altered gut bacterial populations in sleep apnoea and its related comorbid conditions, particularly cognitive dysfunction. In addition, the review examines the preclinical and clinical evidence, which suggests that prebiotics and probiotics may potentially be beneficial in sleep apnoea and its comorbidities through restoration of eubiosis or gut microbial homeostasis that regulates neural, metabolic and immune responses, as well as physiological barrier integrity via the gut-brain axis.

Association between sleep-disordered breathing and post-stroke fatigue in patients with ischemic stroke

OBJECTIVES

Post-stroke fatigue (PSF) is common and often disabling. Sleep-disordered breathing (SDB) is highly prevalent among stroke survivors and can cause fatigue. We explored the relationship between SDB and PSF over time.

MATERIALS AND METHODS

Ischemic stroke (IS) patients within the BASIC project were offered SDB screening with a well-validated cardiopulmonary sleep apnea test at 0, 3-, 6-, and 12-months post-stroke. The primary exposure was the respiratory event index (REI; sum of apneas plus hypopneas per hour). The primary outcome was PSF, measured by the SF-36 vitality scale. Associations between REI and PSF were evaluated using linear regression including time-by-REI interactions, allowing the effect of REI to vary over time.

RESULTS

Of the 411 IS patients who completed at least one outcome interview, 44 % were female, 61 % Mexican American (MA), 26 % non-Hispanic white, with a mean age of 64 (SD 10). Averaged across timepoints, REI was not associated with PSF. In a time-varying model, higher REI was associated with greater PSF at 3-months (β = 1.75, CI = 0.08, 3.43), but not at 6- or 12-months. Across timepoints, female sex, depressive symptoms, and comorbidity burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF.

CONCLUSIONS

Higher REI was associated with modestly greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. SDB may be a modest modifiable risk factor for early PSF, but its treatment is unlikely to have a substantial impact on long-term PSF. MA ethnicity seems to be protective against PSF.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Nomogram for predicting moderate-to-severe sleep-disordered breathing in patients with acute ischaemic stroke: a retrospective cohort study

OBJECTIVES

Moderate-to-severe sleep-disordered breathing (SDB) is prevalent in patients with acute ischaemic stroke (AIS) and is associated with an increased risk of unfavourable prognosis. We aimed to develop and validate a reliable scoring system for the early screening of moderate-to-severe SDB in patients with AIS, with the objective of improving the management of those patients at risk.

STUDY DESIGN

We developed and validated a nomogram model based on univariate and multivariate logistic analyses to identify moderate-to-severe SDB in AIS patients. Moderate-to-severe SDB was defined as an apnoea-hypopnoea index (AHI) ≥15. To evaluate the effectiveness of our nomogram, we conducted a comparison with the STOP-Bang questionnaire by analysing the area under the receiver operating characteristic curve.

SETTING

Large stroke centre in northern Shanghai serving over 4000 inpatients, 100 000 outpatients and emergency visits annually.

PARTICIPANTS

We consecutively enrolled 116 patients with AIS from the Shanghai Tenth People's Hospital.

RESULTS

Five variables were independently associated with moderate-to-severe SDB in AIS patients: National Institutes of Health Stroke Scale score (OR=1.20; 95% CI 0.98 to 1.47), neck circumference (OR=1.50; 95% CI 1.16 to 1.95), presence of wake-up stroke (OR=21.91; 95% CI 3.08 to 156.05), neuron-specific enolase level (OR=1.27; 95% CI 1.05 to 1.53) and presence of brainstem infarction (OR=4.21; 95% CI 1.23 to 14.40). We developed a nomogram model comprising these five variables. The C-index was 0.872, indicated an optimal agreement between the observed and predicted SDB patients.

CONCLUSIONS

Our nomogram offers a practical approach for early detection of moderate-to-severe SDB in AIS patients. This tool enables individualised assessment and management, potentially leading to favourable outcomes.

Causal association between snoring and stroke: a Mendelian randomization study in a Chinese population

Background

Previous observational studies established a positive relationship between snoring and stroke. We aimed to investigate the causal effect of snoring on stroke.

Methods

Based on 82,339 unrelated individuals with qualified genotyping data of Asian descent from the China Kadoorie Biobank (CKB), we conducted a Mendelian randomization (MR) analysis of snoring and stroke. Genetic variants identified in the genome-wide association analysis (GWAS) of snoring in CKB and UK Biobank (UKB) were selected for constructing genetic risk scores (GRS). A two-stage method was applied to estimate the associations of the genetically predicted snoring with stroke and its subtypes. Besides, MR analysis among the non-obese group (body mass index, BMI <24.0 kg/m2), as well as multivariable MR (MVMR), were performed to control for potential pleiotropy from BMI. In addition, the inverse-variance weighted (IVW) method was applied to estimate the causal association with genetic variants identified in CKB GWAS.

Findings

Positive associations were found between snoring and total stroke, hemorrhagic stroke (HS), and ischemic stroke (IS). With GRS of CKB, the corresponding HRs (95% CIs) were 1.56 (1.15, 2.12), 1.50 (0.84, 2.69), 2.02 (1.36, 3.01), and the corresponding HRs (95% CIs) using GRS of UKB were 1.78 (1.30, 2.43), 1.94 (1.07, 3.52), and 1.74 (1.16, 2.61). The associations remained stable in the MR among the non-obese group, MVMR analysis, and MR analysis using the IVW method.

Interpretation

This study suggests that, among Chinese adults, genetically predicted snoring could increase the risk of total stroke, IS, and HS, and the causal effect was independent of BMI.

Funding

National Natural Science Foundation of China, Kadoorie Charitable Foundation Hong Kong, UK Wellcome Trust, National Key R&D Program of China, Chinese Ministry of Science and Technology.

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.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke

BACKGROUND

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke.

METHODS

In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events.

RESULTS

Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]).

CONCLUSIONS

Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

A Systematic Review and Meta-Analysis on the Identification of Predictors Associated With Insomnia or Sleep Disturbance in Post-stroke Patients

The aim of this study was to identify the factors associated with sleep disturbances in individuals after a stroke. To systematically identify relevant studies, an extensive search strategy was devised. We conducted comprehensive searches in major electronic databases including PubMed, Embase, PsycINFO, and Cochrane Library. The search was limited to articles published in English between January 1, 2011, and February 10, 2024. Pooled effect estimates, such as odds ratio (OR) or mean difference (MD) along with their confidence interval (CIs), were calculated using random-effects models for categorical variables and continuous variables, respectively. A total of nine studies were included in this meta-analysis. The pooled prevalence of insomnia across the included studies was determined to be 40% (95% CI = 30%-49%), with individual study prevalence ranging from 22% to 72%. A pooled analysis showed that gender demonstrated a statistically significant association with sleep disturbance, with females exhibiting a higher likelihood (OR = 1.49, 95% CI = 1.16-1.91, p = 0.002) compared to males. The National Institutes of Health Stroke Scale (NIHSS) score, a measure of stroke severity, was associated with sleep disturbance (MD = 0.86, 95% CI = 0.56-1.17, p = 0.001), indicating that patients with severe strokes may be more prone to sleep disturbances. These findings underscore the importance of comprehensive evaluation and targeted interventions to address sleep-related issues in stroke patients, particularly those with severe neurological impairment.

Impact of Sleep Disorders and Disturbed Sleep on Brain Health: A Scientific Statement From the American Heart Association

Accumulating evidence supports a link between sleep disorders, disturbed sleep, and adverse brain health, ranging from stroke to subclinical cerebrovascular disease to cognitive outcomes, including the development of Alzheimer disease and Alzheimer disease-related dementias. Sleep disorders such as sleep-disordered breathing (eg, obstructive sleep apnea), and other sleep disturbances, as well, some of which are also considered sleep disorders (eg, insomnia, sleep fragmentation, circadian rhythm disorders, and extreme sleep duration), have been associated with adverse brain health. Understanding the causal role of sleep disorders and disturbances in the development of adverse brain health is complicated by the common development of sleep disorders among individuals with neurodegenerative disease. In addition to the role of sleep disorders in stroke and cerebrovascular injury, mechanistic hypotheses linking sleep with brain health and biomarker data (blood-based, cerebrospinal fluid-based, and imaging) suggest direct links to Alzheimer disease-specific pathology. These potential mechanisms and the increasing understanding of the "glymphatic system," and the recognition of the importance of sleep in poststroke recovery, as well, support a biological basis for the indirect (through the worsening of vascular disease) and direct (through specific effects on neuropathology) connections between sleep disorders and brain health. Given promising evidence for the benefits of treatment and prevention, sleep disorders and disturbances represent potential targets for early treatment that may improve brain health more broadly. In this scientific statement, we discuss the evidence supporting an association between sleep disorders and disturbances and poor brain health ranging from stroke to dementia and opportunities for prevention and early treatment.

Severely obese 14-year-old boy with central sleep apnea several years after head trauma

Central sleep apnea (CSA) is rare in older children. Although CSA mostly arises from neurological diseases such as Chiari malformation, the frequency of CSA is significantly higher in obese children. Herein, we describe the case of a 14-yr-old boy who presented with CSA secondary to severe obesity and a history of traumatic lateral medullary syndrome at 8 yr of age. Polysomnography revealed severe sleep apnea syndrome with apnea-hypopnea index of 41.4 per hour and central apnea index of 8.9 per hour. Magnetic resonance imaging of the head showed no new brainstem or cerebellar infarcts; however, old changes in the cerebellar infarction persisted. Obesity is primarily associated with obstructive sleep apnea. However, obesity can result in CSA through pharyngeal collapse and the reduction of oxygen reserves caused by reduced thoracic volume, which suppresses respiratory center stimulation. Because the respiratory center disorder owing to head injury sequelae improved after the acute stage, obesity was deemed the cause of CSA in this case. Hence, children with severe obesity may require CSA monitoring.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Approach the Patient With Obstructive Sleep Apnea and Obesity

Obstructive sleep apnea (OSA) and obesity are highly prevalent and bidirectionally associated. OSA is underrecognized, however, particularly in women. By mechanisms that overlap with those of obesity, OSA increases the risk of developing, or having poor outcomes from, comorbid chronic disorders and impairs quality of life. Using 2 illustrative cases, we discuss the relationships between OSA and obesity with type 2 diabetes, dyslipidemia, cardiovascular disease, cognitive disturbance, mood disorders, lower urinary tract symptoms, sexual function, and reproductive disorders. The differences in OSA between men and women, the phenotypic variability of OSA, and comorbid sleep disorders are highlighted. When the probability of OSA is high due to consistent symptoms, comorbidities, or both, a diagnostic sleep study is advisable. Continuous positive airway pressure or mandibular advancement splints improve symptoms. Benefits for comorbidities are variable depending on nightly duration of use. By contrast, weight loss and optimization of lifestyle behaviors are consistently beneficial.

Alleviating sleep disturbances and modulating neuronal activity after ischemia: Evidence for the benefits of zolpidem in stroke recovery

AIMS

Sleep disorders are prevalent among stroke survivors and impede stroke recovery, yet they are still insufficiently considered in the management of stroke patients, and the mechanisms by which they occur remain unclear. There is evidence that boosting phasic GABA signaling with zolpidem during the repair phase improves stroke recovery by enhancing neural plasticity; however, as a non-benzodiazepine hypnotic, the effects of zolpidem on post-stroke sleep disorders remain unclear.

METHOD

Transient ischemic stroke in male rats was induced with a 30-minute middle cerebral artery occlusion. Zolpidem or vehicle was intraperitoneally delivered once daily from 2 to 7 days after the stroke, and the electroencephalogram and electromyogram were recorded simultaneously. At 24 h after ischemia, c-Fos immunostaining was used to assess the effect of transient ischemic stroke and acute zolpidem treatment on neuronal activity.

RESULTS

In addition to the effects on reducing brain damage and mitigating behavioral deficits, repeated zolpidem treatment during the subacute phase of stroke quickly ameliorated circadian rhythm disruption, alleviated sleep fragmentation, and increased sleep depth in ischemic rats. Immunohistochemical staining showed that in contrast to robust activation in para-infarct and some remote areas by 24 h after the onset of focal ischemia, the activity of the ipsilateral suprachiasmatic nucleus, the biological rhythm center, was strongly suppressed. A single dose of zolpidem significantly upregulated c-Fos expression in the ipsilateral suprachiasmatic nucleus to levels comparable to the contralateral side.

CONCLUSION

Stroke leads to suprachiasmatic nucleus dysfunction. Zolpidem restores suprachiasmatic nucleus activity and effectively alleviates post-stroke sleep disturbances, indicating its potential to promote stroke recovery.

Functional recovery after ischemic stroke: Impact of different sleep health parameters

Sleep disturbances after ischaemic stroke include alterations of sleep architecture, obstructive sleep apnea, restless legs syndrome, daytime sleepiness and insomnia. Our aim was to explore their impacts on functional outcomes at month 3 after stroke, and to assess the benefit of continuous positive airway pressure in patients with severe obstructive sleep apnea. Ninety patients with supra-tentorial ischaemic stroke underwent clinical screening for sleep disorders and polysomnography at day 15 ± 4 after stroke in a multisite study. Patients with severe obstructive apnea (apnea-hypopnea index ≥ 30 per hr) were randomized into two groups: continuous positive airway pressure-treated and sham (1:1 ratio). Functional independence was assessed with the Barthel Index at month 3 after stroke in function of apnea-hypopnea index severity and treatment group. Secondary objectives were disability (modified Rankin score) and National Institute of Health Stroke Scale according to apnea-hypopnea index. Sixty-one patients (71.8 years, 42.6% men) completed the study: 51 (83.6%) had obstructive apnea (21.3% severe apnea), 10 (16.7%) daytime sleepiness, 13 (24.1%) insomnia, 3 (5.7%) depression, and 20 (34.5%) restless legs syndrome. Barthel Index, modified Rankin score and Stroke Scale were similar at baseline and 3 months post-stroke in the different obstructive sleep apnea groups. Changes at 3 months in those three scores were similar in continuous positive airway pressure versus sham-continuous positive airway pressure patients. In patients with worse clinical outcomes at month 3, mean nocturnal oxygen saturation was lower whereas there was no association with apnea-hypopnea index. Poorer outcomes at 3 months were also associated with insomnia, restless legs syndrome, depressive symptoms, and decreased total sleep time and rapid eye movement sleep.

[Brain-derived neurotrophic factor in the acute and early recovery period of ischemic stroke: the role of nocturnal hypoxemia]

OBJECTIVE

To study the relationship between brain-derived neurotrophic factor (BDNF) and the severity of nocturnal hypoxemia in patients in the acute and early recovery period of ischemic stroke (IS).

MATERIAL AND METHODS

We enrolled 44 patients (27 men, 17 women), aged 18-85 years, in the acute phase of IS. At 3-month follow-up, 35 people were examined (21 men and 14 women). In the acute period, in addition to routine diagnostic procedures, respiratory monitoring was carried out, and the serum level of BDNF was measured by enzyme-linked immunosorbent assay. BDNF level was also evaluated at 3-month follow-up visit. Neurological status and its dynamics in the acute period of stroke were assessed as part of the clinical routine according to the National Institutes of Health Stroke Scale (NIHSS) at admission and discharge.

RESULTS

We found a direct correlation between the duration of hypoxemia with SpO2 less than 90% (r=0.327, p=0.035) and less than 85% (r=0.461, p=0.003) and BDNF level in the acute phase of IS. BDNF level in the acute period of IS was negatively correlated with the minimum saturation value (r=-0.328, p=0.034). There was a direct relationship between BDNF level in the early recovery period and the duration of hypoxemia with SpO2 less than 85% (r=-0.389, p=0.028). A regression model showed that BDNF level was associated with the minimum SpO2 level. No significant associations were found with indicators of sleep-disordered breathing severity, such as the apnea-hypopnea index and the oxygen desaturation index.

CONCLUSION

The severity of nocturnal hypoxemia is associated with the increase in BDNF levels both in the acute and recovery periods of IS, regardless of the presence of concomitant breathing disorders during sleep.

Prevalence of central sleep apnea in people with tetraplegic spinal cord injury: a retrospective analysis of research and clinical data

STUDY OBJECTIVES

Over 80% of people with tetraplegia have sleep-disordered breathing (SDB), but whether this is predominantly obstructive or central is unclear. This study aimed to estimate the prevalence of central sleep apnea (CSA) in tetraplegia and the contributions of central, obstructive, and hypopnea respiratory events to SDB summary indices in tetraplegia.

METHODS

Research and clinical data from 606 individuals with tetraplegia and full overnight polysomnography were collated. The proportions of different respiratory event types were calculated; overall and for mild, moderate, and severe disease. The prevalence of Predominant CSA (Central Apnea Index [CAI] ≥ 5 and more central than obstructive apneas) and Any CSA (CAI ≥ 5) was estimated. Prevalence of sleep-related hypoventilation (SRH) was estimated in a clinical sub-cohort.

RESULTS

Respiratory events were primarily hypopneas (71%), followed by obstructive (23%), central (4%), and mixed apneas (2%). As severity increased, the relative contribution of hypopneas and central apneas decreased, while that of obstructive apneas increased. The prevalence of Predominant CSA and Any CSA were 4.3% (26/606) and 8.4% (51/606) respectively. Being male, on opiates and having a high tetraplegic spinal cord injury were associated with CSA. SRH was identified in 26% (26/113) of the clinical sub-cohort.

CONCLUSIONS

This is the largest study to characterize SDB in tetraplegia. It provides strong evidence that obstructive sleep apnea is the predominant SDB type; 9-18 times more prevalent than CSA. The prevalence of CSA was estimated to be 4%-8%, significantly lower than previously reported.

Effects of inspiratory muscle training on the severity of obstructive sleep apnea in individuals after stroke: a protocol for a randomized controlled trial

BACKGROUND

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing in cerebrovascular diseases, requiring a multidisciplinary approach. There are few studies evaluating the effects of inspiratory muscle training (IMT) in individuals with OSA and the findings regarding the possible effect on apnea hypopnea index (AHI) reduction are controversial.

OBJECTIVE

This protocol for a randomized clinical trial will assess the effects of IMT on the severity of obstructive sleep apnea, sleep quality, and daytime sleepiness in individuals after stroke participating in a rehabilitation program.

METHODS

This study will be a randomized controlled trial with blinded assessors. Forty individuals after stroke will randomized to two groups. For 5 weeks, both groups will participate in the rehabilitation program activities, including aerobic exercise, resistance training, and educational class when they will receive guidance on the behavioral management of OSA. The experimental group will also perform high-intensity IMT 5 times a week, for 5 weeks, consisting initially of five sets of five repetitions achieving 75% of the maximal inspiratory pressure, increasing one set each week, totaling nine sets at the end of training. The primary outcome will be the severity of OSA measured as AHI at 5 weeks. Secondary outcomes will include sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness measured by Epworth Sleepiness Scale (ESS). Outcomes will be collected by a researcher blinded to group allocation at baseline (week 0), after intervention (week 5), and 1 month beyond intervention (week 9).

TRIAL REGISTRATION

Clinical Trials Register: NCT05135494.

An automated respiratory data pipeline for waveform characteristic analysis

Comprehensive and accurate analysis of respiratory and metabolic data is crucial to modelling congenital, pathogenic and degenerative diseases converging on autonomic control failure. A lack of tools for high-throughput analysis of respiratory datasets remains a major challenge. We present Breathe Easy, a novel open-source pipeline for processing raw recordings and associated metadata into operative outcomes, publication-worthy graphs and robust statistical analyses including QQ and residual plots for assumption queries and data transformations. This pipeline uses a facile graphical user interface for uploading data files, setting waveform feature thresholds and defining experimental variables. Breathe Easy was validated against manual selection by experts, which represents the current standard in the field. We demonstrate Breathe Easy's utility by examining a 2-year longitudinal study of an Alzheimer's disease mouse model to assess contributions of forebrain pathology in disordered breathing. Whole body plethysmography has become an important experimental outcome measure for a variety of diseases with primary and secondary respiratory indications. Respiratory dysfunction, while not an initial symptom in many of these disorders, often drives disability or death in patient outcomes. Breathe Easy provides an open-source respiratory analysis tool for all respiratory datasets and represents a necessary improvement upon current analytical methods in the field. KEY POINTS: Respiratory dysfunction is a common endpoint for disability and mortality in many disorders throughout life. Whole body plethysmography in rodents represents a high face-value method for measuring respiratory outcomes in rodent models of these diseases and disorders. Analysis of key respiratory variables remains hindered by manual annotation and analysis that leads to low throughput results that often exclude a majority of the recorded data. Here we present a software suite, Breathe Easy, that automates the process of data selection from raw recordings derived from plethysmography experiments and the analysis of these data into operative outcomes and publication-worthy graphs with statistics. We validate Breathe Easy with a terabyte-scale Alzheimer's dataset that examines the effects of forebrain pathology on respiratory function over 2 years of degeneration.

Identification of sleep quality clusters among stroke patients: A multi-center Latent Profile Analysis study

BACKGROUND

Quality sleep plays a crucial role in maintaining good health. Nevertheless, sleep disruption is a common and complex issue after a stroke. It can increase the likelihood of stroke recurrence by influencing modifiable risk factors. However, there is currently a lack of research on the latent classes or clusters of sleep quality and its predictive factors among stroke patients.

OBJECTIVES

This study aims to identify latent classes of sleep quality and explore the predictive factors associated with different sleep quality clusters among stroke patients.

METHODS

A total of 500 participants were recruited through cluster random sampling from January 2023 to May 2023. Latent profile analysis was conducted to identify latent classes of sleep quality within the sample of stroke patients. Additionally, multinomial regression analyses were employed to investigate the predictors associated with the different latent classes identified in the analysis.

RESULTS

Out of the 500 participants, 458 (91.6 %) completed the survey, and 71 % of them reported experiencing sleep problems. The analysis revealed three latent profile classes: the "good sleep quality-deficient duration" group (65.4 %), the "moderate sleep quality-more disturbances" group (14.1 %), and the "poor sleep quality-low efficiency" group (20.5 %). Factors associated with sleep quality were identified. Protective factors for sleep quality included being male, having the TOAST type of large-artery atherosclerosis, having a good education, high household income, no family history of stroke, residing in rural areas, and having better environmental and social support (all p < 0.05). Risk factors for sleep quality included smoking, high perceived stress, and a greater number of comorbidities (all p < 0.05).

CONCLUSIONS

This study has successfully identified three distinct latent profile classes of sleep quality and their associated predictors among stroke patients in China. The findings offer both theoretical guidance and practical insights for the development of targeted intervention programs aimed at enhancing the sleep quality of stroke patients.

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.

Sleepiness in neurological disorders

Sleepiness is a frequent and underrecognized symptom in neurological disorders, that impacts functional outcomes and quality of life. Multiple and potentially additive factors might contribute to sleepiness in neurological disorders, including sleep quality alterations, circadian rhythm disorders, drugs, and sleep disorders including sleep apnea or central disorders of hypersomnolence. Physician awareness of the possible symptoms of hypersomnolence, and associated causes is of crucial importance to allow proper identification and treatment of underlying causes. This review first provides a brief overview on clinical aspects of excessive daytime sleepiness, and diagnosis tools, then examines its frequency and mechanisms in various neurological disorders, including neurodegenerative disorders, multiple sclerosis, autoimmune encephalitis, epilepsy, and stroke.

Periodic Limb Movements during Sleep in Acute Stroke: Prevalence, Severity and Impact on Post-Stroke Recovery

BACKGROUND

Periodic Limb Movements during Sleep (PLMS) have been described to be frequently present in stroke patients. We aimed to evaluate the prevalence and severity of PLMS in acute stroke patients and clarify the association between PLMS and coexisting Sleep Disordered Breathing (SDB). Additionally, we focused on identifying variables that could independently predict the presence of PLMS in patients with acute stroke. The potential impact of PLMS on stroke outcome at three months was investigated as well.

METHODS

In this study, we performed overnight polysomnography on consecutive stroke patients within 72 h from symptom onset. Data regarding clinical and imaging characteristics were prospectively collected. National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS) and Epworth-Sleepiness Scale (ESS) were used to evaluate stroke severity on admission, stroke outcome at three months and history of daytime sleepiness, respectively. We documented PLMS and SDB using standard polysomnography criteria.

RESULTS

We prospectively assessed 126 patients with acute stroke [109 with ischemic and 17 with hemorrhagic stroke, mean age 60 ± 11 years, 68% men, median NIHSS score on admission: 3 (IQR: 2-7)]. The overall rate of PLMS in our cohort was 76%, and the rate of SDB among patients with PLMS was 83%. PLMS detection rates differed significantly (p-value: <0.001) according to SDB, with PLMS prevalence increasing with greater SDB severity. SDB could independently (OR:4.869, 95% CI: 1.884-12.784, p-value: 0.001) predict the presence of PLMS in the acute stroke phase in multivariable analyses adjusting for potential confounders. Moreover, baseline stroke severity (NIHSS-score increase in per-1 point: OR: 0.819, 95% CI: 0.737-0.895, p-value < 0.001) and PLMS (OR:0.099, 95% CI: 0.009-0.482, p-value = 0.015) were significantly associated with the likelihood of excellent functional outcome (mRS-scores: 0-1) at 3 months.

CONCLUSION

The common presence of mostly severe PLMS in patients with acute stroke and their negative effect on stroke outcomes point out the necessity for early PLMS detection and treatment.

Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials

STUDY OBJECTIVES

This meta-analysis aimed to investigate the feasibility and effectiveness of continuous positive airway pressure (CPAP) treatment in stroke patients with sleep apnea.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched from inception until July 28, 2022, for randomized controlled trials comparing the use of CPAP and usual treatment in patients with stroke or transient ischemic attack and sleep apnea. The primary outcome measures were the feasibility of CPAP therapy, neurological function, and functional status.

RESULTS

After screening 5,747 studies, 14 studies with 1,065 patients were included in this meta-analysis. Overall, 8 of the 14 studies recorded CPAP use, and the mean CPAP use was 4.47 hours per night (95% confidence interval [CI]: 3.85-5.09). The risk ratio of discontinuing CPAP was 1.50 (95% CI: 0.76-2.94; P = .24). Analysis of the neurofunctional scales showed that CPAP treatment improved neurological function (standardized mean difference: 0.28; 95% CI: 0.02-0.53), but there was substantial heterogeneity (I2 = 57%, P = .03) across the studies. CPAP treatment had no significant effect on functional status vs the control (standardized mean difference: 0.25; 95% CI: -0.01 to 0.51), but the studies also had substantial heterogeneity (I2 = 55%, P = .06).

CONCLUSIONS

CPAP treatment is feasible in patients with stroke and sleep apnea and may improve neurological outcomes in these patients. However, this finding should be interpreted with caution because of the substantial heterogeneity of current trials.

CITATION

Fu S, Peng X, Li Y, Yang L, Yu H. Effectiveness and feasibility of continuous positive airway pressure in patients with stroke and sleep apnea: a meta-analysis of randomized trials. J Clin Sleep Med. 2023;19(9):1685-1696.

Adherence to positive airway pressure therapy initiated in the early subacute phase of ischemic stroke: a PRESS study follow-up

BACKGROUND

Sleep-disordered breathing (SDB) is frequent in stroke patients and negatively affects stroke outcomes. Positive airway pressure (PAP) is the standard first-line treatment for patients with moderate-to-severe SDB. Despite a strong link between PAP adherence and therapeutic response, rates of post-stroke PAP adherence remain underexplored. Our study aimed to determine PAP adherence in patients undergoing comprehensive sleep apnea assessment and in-lab PAP titration in the early subacute phase of stroke.

METHODS

In-hospital screening pulse oximetry was performed in consecutive patients with imaging-confirmed acute ischemic stroke. Subjects with desaturation index ≥ 15.3/h were selected as PAP candidates, and polysomnography was recommended. In a sleep laboratory setting, subjects underwent a diagnostic night followed by a titration night, and PAP therapy was initiated in subjects with apnea-hypopnea index ≥ 15/h. Adherence to PAP therapy was assessed at a 6-month follow-up visit.

RESULTS

Of 225 consecutive patients with acute ischemic stroke, 116 were PAP candidates and 52 were able to undergo polysomnography. PAP therapy was initiated in 35 subjects. At a 6-month follow-up visit, out of 34 stroke survivors, PAP adherence (PAP use of > 4 h per night) was present in 47%. Except for the significantly lower minimal nocturnal O2 saturation determined from the polysomnography (74.6 ± 11.7% vs. 81.8 ± 5.2%, p = 0.025), no other significant difference in characteristics of the groups with PAP adherence and PAP non-adherence was found.

CONCLUSIONS

Less than half of the stroke subjects remained adherent to PAP therapy at 6 months post-PAP initiation. Special attention to support adaptation and adherence to PAP treatment is needed in this group of patients.

Sleep-Disordered Breathing and Prognosis after Ischemic Stroke: It Is Not Apnea-Hypopnea Index That Matters

BACKGROUND

Sleep-disordered breathing (SDB) is highly prevalent after stroke and is considered to be a risk factor for poor post-stroke outcomes. The aim of this observational study was to evaluate the effect of nocturnal respiratory-related indices based on nocturnal respiratory polygraphy on clinical outcomes (including mortality and non-fatal events) in patients with ischemic stroke.

METHODS

A total of 328 consecutive patients (181 (55%) males, mean age 65.8 ± 11.2 years old) with confirmed ischemic stroke admitted to a stroke unit within 24 h after stroke onset were included in the analysis. All patients underwent standard diagnostic and treatment procedures, and sleep polygraphy was performed within the clinical routine in the first 72 h after admission. The long-term outcomes were assessed by cumulative endpoint (death of any cause, new non-fatal myocardial infarction, new non-fatal stroke/transient ischemic attack, emergency revascularization, emergency hospitalization due to the worsening of cardiovascular disease). A Cox-regression analysis was applied to evaluate the effects of nocturnal respiratory indices on survival.

RESULTS

The mean follow-up period comprised 12 months (maximal-48 months). Patients with unfavourable outcomes demonstrated a higher obstructive apnea-hypopnea index, a higher hypoxemia burden assessed as a percent of the time with SpO₂ < 90%, a higher average desaturation drop, and a higher respiratory rate at night. Survival time was significantly lower (30.6 (26.5; 34.7) versus 37.9 (34.2; 41.6) months (Log Rank 6.857, p = 0.009)) in patients with higher hypoxemia burden (SpO₂ < 90% during ≥2.1% versus <2.1% of total analyzed time). However, survival time did not differ depending on the SDB presence assessed by AHI thresholds (either ≥5 or ≥15/h). The multivariable Cox proportional hazards regression (backward stepwise analysis) model demonstrated that the parameters of hypoxemia burden were significantly associated with survival time, independent of age, stroke severity, stroke-related medical interventions, comorbidities, and laboratory tests.

CONCLUSION

Our study demonstrates that the indices of hypoxemia burden have additional independent predictive value for long-term outcomes (mortality and non-fatal cardiovascular events) after ischemic stroke.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Positive airway pressure treatment for sleep-disordered breathing is rare during the first year after stroke: The BASIC project

OBJECTIVE/BACKGROUND

Sleep-disordered breathing (SDB) is very common after ischemic stroke, and its treatment may have a positive impact on recovery from stroke and on secondary stroke prevention. This study sought to determine the prevalence of positive airway pressure (PAP) use after stroke.

PATIENTS/METHODS

Participants in the Brain Attack Surveillance in Corpus Christi (BASIC) project underwent a home sleep apnea test shortly after ischemic stroke. Demographics and co-morbidities were ascertained from the medical record. Self-reported PAP use (present vs absent) was assessed at 3, 6, and 12 months after stroke. Fisher exact tests and t-tests were used to compare PAP users versus non-users.

RESULTS

Of 328 participants who were found to have SDB after stroke, only 20 (6.1%) indicated using PAP at any point during the 12-month follow up period. High pre-stroke sleep apnea risk based on Berlin Questionnaire score, neck circumference, and co-morbid atrial fibrillation were associated with any self-reported PAP use; race/ethnicity, insurance status and other demographic variables were not associated with PAP use.

CONCLUSIONS

Only a small proportion of individuals with ischemic stroke and SDB received treatment with PAP during the initial year after stroke among participants in this population-based cohort study in Nueces County, Texas. Closing the substantial treatment gap for SDB after stroke might improve sleepiness and neurologic recovery.