Lourdes M. DelRosso

The Cerebellum and Sleep

The importance of the cerebellum in sleep disorders, and vice versa, is only beginning to be understood. Advanced neuroimaging modalities have revealed cerebellar changes in both common and rare sleep disorders. Sleep disorders in those with genetic cerebellar disease, such as spinocerebellar ataxia, Friedreich ataxia, Joubert syndrome, and ataxia-telangiectasia, include excessive daytime sleepiness, restless legs syndrome, periodic limb movements of sleep, obstructive apnea, central apnea, and rapid eye movement behavior disorder. Sleep medicine is an important and under-recognized part of the neurologic evaluation in those with cerebellar disease.

Sleep-wake pattern following gunshot suprachiasmatic damage.

BACKGROUND The suprachiasmatic nucleus (SCN) plays a critical role in maintaining melatonin and sleep-wake cycles. METHODS/PATIENT We report a case of 38-year-old woman who, after gunshot wound to the right temple, developed a sleep complaint of multiple nocturnal awakenings and several naps throughout the day. RESULTS Computerized tomography and magnetic resonance imaging revealed bilateral optic nerve and optic chiasm damage. Diagnostic polysomnography and actigraphy revealed an irregular sleep wake rhythm. CONCLUSIONS We speculate concurrent damage of the SCN and optic nerves bilaterally resulted in the posttraumatic irregular sleep-wake rhythm.

Epidemiology and Diagnosis of Pediatric Obstructive Sleep Apnea

b O structive sleep apnea syndrome (OSAS) affects 1.2–5.7% of children. OSAS affects children of all ages but the peak prevalence occurs at 2–8 years of age, which coincides with the peak age of tonsillar and adenoidal hypertrophy. African American ethnicity, increased body mass index, tobacco exposure, and reduced family income correlate with an increased severity of OSAS. A study in children younger than 2 years old revealed an increased incidence of OSAS in those with a history of prematurity, males, children with Trisomy 21, African Americans, and in those attending daycare. In prepubertal children, the incidence of OSAS is similar in boys than in girls. After puberty OSAS is more common in boys. Children with craniofacial abnormalities, certain genetic conditions with structural factors that lead to airway narrowing and children with neuromuscular disorders are at increased risk of OSAS (Table 1).

Manual Characterization of Sleep Spindle Index in Patients with Narcolepsy and Idiopathic Hypersomnia

This is a retrospective review of PSG data from 8 narcolepsy patients and 8 idiopathic hypersomnia (IH) patients, evaluating electrophysiologic differences between these two central hypersomnias. Spindles were identified according to the AASM Manual for the Scoring of Sleep and Associated Events; and counted per epoch in the first 50 epochs of N2 sleep and the last 50 epochs of N2 sleep in each patients PSG. Spindle count data (mean ± standard deviation) per 30 second-epoch (spindle index) in the 8 narcolepsy patients was as follows: 0.37 ± 0.73 for the first 50 epochs of N2; 0.65 ± 1.09 for the last 50 epochs of N2; and 0.51 ± 0.93 for all 100 epochs of N2. Spindle index data in the 8 IH patients was as follows: 2.31 ± 2.23 for the first 50 epochs of N2; 2.84 ± 2.43 for the last 50 epochs of N2; and 2.57 ± 2.35 for all 100 epochs of N2. Intergroup differences in spindle count in the first 50 N2 epochs, the last 50 N2 epochs, and all 100 epochs of scored N2 were significant (P < 0.01) as were the intragroup differences between the first 50 N2 epochs and the last 50 N2 epochs.

Central apnea at electroencephalographic seizure onset

2013 Elsevier B.V. All rights reserved. tachycardia, bradycardia, tonic contraction on surface electromyography of mentalis muscles and tibialis anterior muscles, and seizure semiology on video were all absent. Fig. 1B shows a 30-s epoch at the termination of the central apnea. Electrodecre

Characterization of REM sleep without atonia in patients with narcolepsy and idiopathic hypersomnia using AASM scoring manual criteria.

INTRODUCTION The AASM Manual for the Scoring of Sleep and Associated Events (Manual) has provided standardized definitions for tonic and phasic REM sleep without atonia (RSWA). This study used Manual criteria to characterize REM sleep in patients with narcolepsy and idiopathic hypersomnia (IH). METHODS A retrospective review of PSG data from ICSD-2 defined patients with narcolepsy or IH, performed by two board certified sleep medicine physicians. Data compiled included REM sleep epochs and the presence in REM sleep of epochs scored as sustained muscle activity (tonic), and excessive transient muscle activity (phasic) as defined by Manual criteria. RESULTS PSG data from 8 narcolepsy patients (mean age: 27.5 years; age range: 11-55) showed mean ± standard deviation values for: total REM sleep epochs 205 ± 46.1; RSWA/ phasic epochs 56.1 ± 25.4; and RSWA/tonic epochs 15.0 ± 10.7. PSG data from 8 IH patients (mean age: 33.1 years; age range: 20-57) showed mean ± standard deviation values of total REM sleep epochs 163.8 ± 67.9; RSWA/phasic epochs 6.2 ± 3.5; and RSWA/tonic epochs 0.2 ± 0.4. Comparison revealed intergroup differences in phasic REM sleep (p < 0.01) and tonic REM sleep (p < 0.01) were significantly increased in narcoleptics compared to IH. CONCLUSION Our retrospective analysis showed that RSWA phasic activity and RSWA tonic activity are significantly increased in patients meeting ICSD-2 criteria for narcolepsy compared to patients meeting ICSD-2 criteria for IH. This robust difference, with further validation, could be useful as electrophysiological criteria differentiating the two disorders and understanding the physiological differences.

“Why Did My CPAP Beat Me Up?” Bilateral Periorbital Ecchymosis Associated with Continuous Positive Airway Pressure Therapy

T he patient is a 63-year-old man with past medical history of hypertension, coronary artery disease, diabetes mellitus, hyperlipidemia, gastroesophageal refl ux disease, and obstructive sleep apnea (OSA) diagnosed at the age of 58. Medications include aspirin 325 mg daily and clopidogrel 75 mg daily for 2 years without complication; clonazepam 1 mg daily, gemfi brozil 600 mg twice daily, metoprolol 12.5 mg twice daily, niacin 500 mg daily, ranitidine 150 mg twice daily, rosuvastatin 10 mg daily, and valsartan 160 mg daily. Two months ago he started using vitamin E 1000 international units per day and fi sh oil supplements. For 5 years he has been compliant with continuous positive airway pressure (CPAP) of 10 cm through a soft nasal pillow interface and soft head gear without complication. CPAP compliance card report indicates 100% CPAP use > 4 h/day, average use 9 h/day, and no signifi cant air leaks. He now presents with 2 episodes of bruising around his eyes upon awakening following nocturnal CPAP use. He initially noticed bruising around the left eye which resolved over the course of one month. He did not pursue evaluation or treatment. Then he noticed new bruising around the right eye. He denied history of trauma, headaches, eye dryness or pain, vision changes, cough, sinus pain, or nasal discharge. He denied strenuous exercise or weight lifting. Signifi cant air leak from his CPAP mask was not detected. He denied any other bleeding, including gums, urinary tract, or rectum. figure 1—Periorbital ecchymosis associated with continuous positive airway pressure therapy for obstructive sleep apnea The photograph on the left shows the patient with periorbital ecchymosis around the left eye, which resolved. The photograph on the right was taken one month later and showed a new right periorbital ecchymosis.

Legal and Regulatory Aspects of Sleep Disorders

Sleep disorders may interact with the law, making awareness important. Insufficient sleep and obstructive sleep apnea (OSA) are prevalent and associated with excessive sleepiness. Patients with excessive sleepiness may have civil or criminal liability if they fall asleep and cause a motor vehicle accident. Awareness of screening and treatment of OSA is increasing in certain industries. Parasomnia associated sleep-related violence represents a challenge to clinicians, who may be called on to consider parasomnia as a contributing, mitigating, or exculpatory factor in criminal proceedings. Improving access to sleep medicine care is an important aspect in reducing the consequences of sleep disorders.

The Role of Co-Morbidities

Medical conditions can impact sleep and breathing in children. Gastroesophageal reflux disease, allergic rhinitis and asthma are common in children and often coexist with obstructive sleep apnea. Appropriate identification and management of these conditions can improve nocturnal and diurnal symptoms of sleep disordered breathing. We discuss the relationship between these medical conditions and obstructive sleep apnea in children.

Continuous Positive Airway Pressure Device Time to Procurement in a Disadvantaged Population.

Introduction. The management of obstructive sleep apnea (OSA) in patients who cannot afford a continuous positive airway pressure (CPAP) device is challenging. In this study we compare time to CPAP procurement in three groups of patients diagnosed with OSA: uninsured subsidized by a humanitarian grant (Group 1), uninsured unsubsidized (Group 2), and those with Medicare or Medicaid (Group 3). We evaluate follow-up and adherence in Group 1. We hypothesize that additional factors, rather than just the ability to obtain CPAP, may uniquely affect follow-up and adherence in uninsured patients. Methods. 30 patients were in Groups 1 and 2, respectively. 12 patients were in Group 3. Time of CPAP procurement from OSA diagnosis to CPAP initiation was assessed in all groups. CPAP adherence data was collected for Group 1 patients at 1, 3, 6, and 9 months. Results. There were no significant differences between groups in gender, age, body mass index, or apnea hypopnea index. The mean time to procurement in Group 1 was shorter compared to Group 2 but not significant. Compared to both Group 1 and Group 2, Group 3 patients had significantly shorter times to device procurement. Conclusion. Time to procurement of CPAP was significantly shorter in those with Medicaid/Medicare insurance compared to the uninsured.