Silvia Riccardi

Distinctive polysomnographic traits in nocturnal frontal lobe epilepsy.

Purpose:  To describe the polysomnographic features and distribution of epileptic motor events, in relation to conventional sleep measures and cyclic alternating pattern (CAP) parameters, in 40 untreated patients with nocturnal frontal lobe epilepsy (NFLE).

Sleep and respiratory sleep disorders in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is an interstitial lung disease (ILD) characterized by inflammation and progressive scarring of the lung parenchyma. IPF profoundly affects the quality of life (QoL) and fatigue is a frequently disabling symptom. The cause of fatigue is not well understood but patients with IPF often report extremely poor sleep quality and sleep-related breathing disorders (SRBD) that correlate with QoL. IPF patients present alterations in sleep architecture, including decreased sleep efficiency, slow wave sleep and rapid eye movement (REM) sleep, and increased sleep fragmentation. Moreover, sleep related hypoventilation during the vulnerable REM sleep period and obstructive sleep apnea-hypopnea syndrome (OSAHS) are frequent, but remain usually underdiagnosed. These SRBD in IPF are associated with alterations of the sleep structure, reduction of QoL and increased risk of mortality. In the absence of an effective therapy for IPF, optimizing the QoL could become the primary therapeutic goal. In this perspective the diagnosis and treatment of SRBD could significantly improve the QoL of IPF patients.

Effects of antiepileptic treatment on sleep and seizures in nocturnal frontal lobe epilepsy.

OBJECTIVE To study the effects of antiepileptic treatment on sleep parameters and video-polysomnography (VPSG) seizures in nocturnal frontal lobe epilepsy (NFLE). METHODS Twenty patients with a clinical and VPSG diagnosis of NFLE (baseline polysomnography [PSG]) underwent a clinical follow-up and performed a second VPSG after effective antiepileptic treatment lasting for at least 6 months. Conventional sleep measures, cyclic alternating pattern (CAP) parameters, and objective VPSG seizures were assessed in NFLE patients before and after treatment and were compared with the results of 20 age- and gender-matched control subjects. RESULTS Antiepileptic treatment determined a partial reduction of objective VPSG seizures of approximately 25% compared to baseline condition. Alterations of most conventional sleep measures recovered normal values, but nonrapid eye movement (NREM) sleep instability remained pathologically enhanced (CAP rate, +26% compared to controls) and was associated with persistence of daytime sleepiness. CONCLUSIONS Residual epileptic events and high levels of unstable NREM sleep can define a sort of objective resistance of both seizures and disturbed arousal system to the therapeutic purpose of the antiepileptic drugs in NFLE. This finding could determine the need for new therapeutic options in this particular form of epilepsy.

Acute shift of a case of moderate obstructive sleep apnea syndrome towards one of severe central sleep apnea syndrome after an ischemic stroke.

Article history: Received 21 December 2011 Received in revised form 12 January 2012 Accepted 27 January 2012 Available online 22 March 2012

Complex sleep apnea syndrome in stroke patients

Fig. 1. A profile of Tiberius Claudius Germanicus appears on the obverse of this silver denarius struck during the Imperial Roman Era (ca. first century CE; photo provided courtesy of A Pangerl of www.romancoins.info). To the Editor We would like to thank Dr. Sacchetti and co-workers for their interest in our article [1]. Sacchetti et al. raise the question whether a stroke may transform, in selected patients, an obstructive sleep apnea syndrome (OSAHS) into a complex-sleep apnea syndrome (Comp-SAS) and postulate that the appearance of central respiratory events may represent a stable consequence of stroke, and may complicate the treatment approach to sleep apnea. This hypothesis is supported by their preliminary data showing mixed (obstructive and central) apneas four months after the stroke. This high prevalence of central and mixed respiratory events in stable phase after stroke is higher than that found in other studies, about the time course of sleep breathing disorders and central periodic breathing in stroke patients [2,3]. These data also contradict in part the attenuation of central respiratory events within week or a few months after the stroke described by the same authors or in OSAHS patients with CompSAS [4]. In OSAHS patients some predictive factors for appearance of CompSAS during CPAP treatment have been proposed [5], which include atrial fibrillation, use of opioids, sleep disruption and features of initial sleep apnea syndrome (in term of severity of obstructive apneas and presence of relevant mixed/central events). The last two factors are probably strictly related to the fluctuations of ventilatory control system and CO2 levels, that we documented in our paper [1], as well as, the fluctuations of arousal system in NREM sleep that have been described as possible distinctive patterns of some patients with OSAHS [6]. Finally, in our opinion, the question is to clarify if these or other factors can tell us whether initial ‘‘complex’’ cases of OSAHS are more prone to develop a clear CompSAS after a stroke and, whether as suggestedbySacchetti andco-workers, tomerge this ‘‘pre-stroke’’ profile of sleep disordered breathing with ‘‘post-stroke’’ features. Thismay enable us to findout possible factors able to distinguish patientswith a transient CompSAS frompatientswith a persistent one.

Restless legs syndrome: a new entity of neuropathic pain? Treatment with prolonged release oxycodone/naloxone combination

© 2016 Gemignani et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/ terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Journal of Parkinsonism and Restless Legs Syndrome 2016:6 23–27 submit your manuscript | www.dovepress.com

Heart Rate Dynamics and their Relation with the Cyclic Alternating Pattern of Sleep in Normal Subjects and NFLE Patients

The aim of this work is to study the behavior of the autonomic system through variations in the heart rate (HR) during the Cyclic Alternating Pattern (CAP) which is formed by A-phases. The analysis was carried out in 10 healthy subjects and 10 patients with Nocturnal Front Lobe Epilepsy (NFLE) that underwent one whole night of polysomnographic recordings. In order to assess the relation of A-phases with the cardiovascular system, two time domain features were computed: the amplitude reduction and time delay of the minimum of the R-R intervals with respect to A-phases onset. In addition, the same process was performed over randomly chosen R-R interval segments during the NREM sleep for baseline comparisons. A non-parametric bootstrap procedure was used to test differences of the kurtosis values of two populations. The results suggest that the onset of the A-phases is correlated with a significant increase of the HR that peaks at around 4s after the A-phase onset, independently of the A-phase subtype and sleep time for both healthy subjects and NFLE patients. Furthermore, the behavior of the reduction in the R-R intervals during the A-phases was significantly different for NFLE patients with respect to control subjects.

Atypical patterns in portable monitoring for sleep apnoea: features of nocturnal epilepsy?

Atypical cardiorespiratory patterns can be found during routine clinical use of portable monitoring for diagnosis of sleep-disordered breathing (SDB). Over 1,000 consecutive portable recordings were analysed to study the potential ictal nature of stereotyped cardiorespiratory and motor patterns. Snoring, airflow, thoracic effort, pulse rate, body position, oxygen saturation and activity of the anterior tibialis muscles were quantified. Recordings showing stereotyped polygraphic patterns recurring throughout the night, but without the features of sleep apnoea (apnoea/hypopnoea index <5 events·h−1), were selected for investigation. Once included in the study, patients underwent attended nocturnal video polysomnography. A total of 15 recordings showing repeated polygraphic patterns characterised by a sequence of microphone activation, respiratory activity atypical for sleep and wakefulness, heart rate acceleration and limb movements, followed by body position change, were selected for investigation. Once included in the study, patients underwent attended nocturnal video polysomnography that showed frontal epileptic discharges triggering periodic electroencephalographic arousals, autonomic activation and stereotyped motor patterns. A diagnosis of nocturnal frontal lobe epilepsy (NFLE) was established for all patients. NFLE should be taken into consideration in patients with stereotyped and recurrent behavioural features during portable monitoring carried out for diagnosis of SDB.

Arousal responses to respiratory events during sleep: The role of pulse wave amplitude

The study aims at assessing the changes in electroencephalography (as measured by the A‐phases of cyclic alternating pattern) and autonomic activity (based on pulse wave amplitude) at the recovery of airway patency in patients with obstructive sleep apnea syndrome. Analysis of polysomnographic recordings from 20 male individuals with obstructive sleep apnea syndrome was carried out in total sleep time, non‐rapid eye movement and rapid eye movement sleep. Scoring quantified the combined occurrence (time range of 4 s before and 4 s after respiratory recovery) or separate occurrence of A‐phases (cortical activation), and pulse wave amplitude drops (below 30%) to apneas, hypopneas or flow limitation events. A dual response (A‐phase associated with a pulse wave amplitude drop) was the most frequent response (71.8% in total sleep time) for all types of respiratory events, with a progressive reduction from apneas to hypopneas and flow limitation events. The highly significant correlation in total sleep time (r = 0.9351; P < 0.0001) between respiratory events combined with A‐phases and respiratory events combined with pulse wave amplitude drops was confirmed both in non‐rapid eye movement (r = 0.9622; P < 0.0001) and rapid eye movement sleep (r = 0.7162; P < 0.0006). In conclusion, a dual cortical and autonomic activation is the most common manifestation at the recovery of airway patency. The significant correlation between A‐phases and relevant pulse wave amplitude drops suggests a possible role of pulse wave amplitude as a marker of cerebral response to respiratory events.