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Postgraduate Education CornerContemporary Reviews In Sleep MedicineSleep-Related Problems in Neurologic Diseases
Section snippets
Hypersomnias of Central Origin
Hypersomnia is a primary complaint of excessive sleepiness. Neurologic problems affecting the CNS frequently directly cause dysfunction of central waking mechanisms (Table 1).2 Hypersomnia has been reported with a variety of neurodegenerative and genetic disorders, stroke, head trauma, encephalitis, and brain tumors.2, 3, 4, 5, 6 Wakefulness mechanisms that function through the ascending reticular activating system involve the brainstem, hypothalamus, basal forebrain, and the thalamus (Fig 1).3
Sleep Apnea
Sleep apnea has been associated with stroke, dementia, and encephalitis, especially when there is injury to central respiratory centers.3, 28, 29, 30, 31 Automatic respiration (subject to modulation by multiple CNS sites) depends on the medullary respiratory center, which is composed of the dorsal respiratory group (DRG) (the nucleus solitarius) and the ventral respiratory group (VRG) (includes the nucleus ambiguus) (Fig 4).28, 32, 33 Central sleep apnea has been documented after stroke
Insomnia Due to Medical Condition
Damage to CNS sleep centers can lead to insomnia (difficulties initiating and/or maintaining sleep) (Fig 5).3, 5, 51 In one study of 277 patients with new stroke, 18.7% suffered insomnia acutely, whereas 56.7% developed insomnia within 4 months after stroke.52 In another study of 336 stroke patients, insomnia was most prevalent with brain stem, frontal lobe, and basal ganglion lesions.53 The “sleep switch,” located in the preoptic area of the hypothalamus, uses the neurotransmitters
Circadian Rhythm Sleep Disorder Due to Medical Condition
The ICSD-2 definition of a circadian rhythm sleep disorder is based upon the existence of a persistent or recurrent sleep disturbance that is due to an alteration of systems that affect the timing of sleep. Nevertheless, to truly be considered a disorder, the problem must lead to a level of insomnia or excessive daytime sleepiness that impairs normal functioning.2
Restless Legs Syndrome and Periodic Limb Movements in Sleep
Restless legs syndrome (RLS) is a clinical diagnosis, whereas periodic limb movements during sleep (PLMS) require PSG documentation for accurate definition. RLS is clinically defined by the symptom acronym “URGE”: Urge to move the limbs, worst at Rest, relieved by attempts to Go (move the limbs), and most disturbing in the Evening.2 RLS can lead to insomnia, sleepiness, and problems with concentration, memory, motivation, anxiety, and depression. PLMS are found in up to 90% of patients with
The REM Sleep Behavior Disorder
RBD is a parasomnia: an undesired physical phenomenon during sleep, associated with CNS activation primarily evidenced as increased skeletal muscle activity.2 RBD occurs during REM sleep and is associated with violent dream (oneiric) behaviors, followed by arousals during which the patient describes dreams that parallel the observed behaviors (isomorphism).76 Up to 77.1% of patients with RBD report dream-related injuries, which include subdural hemorrhage.2, 76 Normally during REM (“paralyzed”
Sleep-Related Epilepsy
Nocturnal seizures can occur with elevated motor and autonomic activation, and as such the initial differential diagnosis can include “sundowning” and RBD.3, 76, 86 Analysis of the stereotypic behaviors during continuous, prolonged video-EEG monitoring using an extended montage can confirm the diagnosis.
Patients with cortical lesions from stroke, tumors, trauma, and dementia are prone to seizures. Epileptiform activity associated with generalized seizures tends to increase in non-REM (N) sleep,
Summary
There is a strong association between neurologic diseases and sleep problems, especially when there is injury to central sleep-wake mechanisms. A fundamental knowledge concerning the basic anatomy and physiology of these mechanisms provides a rationale for pharmacologic interventions. Nevertheless, nonpharmacologic treatments are important as these patients are often prone to the adverse effects of many routinely prescribed medications. Nonpharmacologic treatments include the use of CPAP and
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Dyken is a paid advisor on an advisory board for UCB, Inc and has been recently selected as a primary investigator for industry support research by NCGS, Inc. Although the following relationships have been dissolved, Dr Dyken, within the last three years, received grant monies for industry supported research from Merck and Cephalon and has been on speaker bureaus for Cephalon and
References (89)
- et al.
Narcolepsy and disorders of excessive somnolence
- et al.
Sleep state switching
Neuron
(2010) - et al.
Alzheimer's disease and other dementias
- et al.
Poststroke hypersomnia
Sleep Med Clin
(2006) Sleep and stroke
- et al.
Methylphenidate in early poststroke recovery: a double-blind, placebo-controlled study
Arch Phys Med Rehabil
(1998) - et al.
Effect of levodopa in combination with physiotherapy on functional motor recovery after stroke: a prospective, randomised, double-blind study
Lancet
(2001) Other neurological disorders
- et al.
Symptomatic narcolepsy, cataplexy and hypersomnia, and their implications in the hypothalamic hypocretin/orexin system
Sleep Med Rev
(2005) - et al.
Obstructive sleep apnea and stroke
Chest
(2009)
Respiratory physiology: breathing in normal subjects
Noninvasive ventilation for chronic respiratory failure
Nasal intermittent positive pressure ventilation. Long-term follow-up in patients with severe chronic respiratory insufficiency
Chest
Respiratory assistance with a non-invasive ventilator (Bipap) in MND/ALS patients: survival rates in a controlled trial
J Neurol Sci
Randomised trial of preventive nasal ventilation in Duchenne muscular dystrophy
Lancet
The sleep switch: hypothalamic control of sleep and wakefulness
Trends Neurosci
Anatomy of the mammalian circadian system
Melatonin receptors mediate potentiation of contractile responses to adrenergic nerve stimulation in rat caudal artery
Eur J Pharmacol
Melatonin treatment of a non-24-hour sleep-wake cycle in a blind retarded child
Biol Psychiatry
Restless legs syndrome and periodic limb movements during sleep
Restless legs syndrome and periodic limb movements after ischemic stroke in the right lenticulostriate region
Parkinsonism Relat Disord
REM sleep parasomnias
Melatonin for treatment of REM sleep behavior disorder in neurologic disorders: results in 14 patients
Sleep Med
“Sleep in America” Poll. National Sleep Foundation Web site
International Classification of Sleep Disorders, 2nd ed.: Diagnostic and Coding Manual
Management of sleep disorders in stroke
Curr Treat Options Neurol
Treatment of hypersomnias
Hypothalamic regulation of sleep and circadian rhythms
Nature
Compulsive pre-sleep behavior and apathy due to bilateral thalamic stroke: response to bromocriptine
Neurology
Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study
Brain
Sleep disturbances and hypocretin deficiency in Niemann-Pick disease type C
Sleep
Decreased hypocretin-1 (Orexin-A) levels in the cerebrospinal fluid of patients with myotonic dystrophy and excessive daytime sleepiness
Sleep
Identification of 25 new mutations in 40 unrelated Spanish Niemann-Pick type C patients: genotype-phenotype correlations
Clin Genet
Images in clinical medicine. Myotonic dystrophy
N Engl J Med
Loss of serotonin-containing neurons in the raphe of patients with myotonic dystrophy: a quantitative immunohistochemical study and relation to hypersomnia
Neurology
Narcolepsy caused by acute disseminated encephalomyelitis
Arch Neurol
Reversal of symptomatic tumoral narcolepsy, with normalization of CSF hypocretin level
Neurology
CSF hypocretin-1 levels in narcolepsy, Kleine-Levin syndrome, and other hypersomnias and neurological conditions
J Neurol Neurosurg Psychiatry
The Kleine-Levin syndrome - effects of treatment with lithium
Neuropediatrics
Kleine-Levin syndrome: an autoimmune hypothesis based on clinical and genetic analyses
Neurology
Investigating the relationship between sleep apnea and stroke [abstract]
Sleep Res
Investigating the relationship between stroke and obstructive sleep apnea
Stroke
Transient obstructive sleep apnea and asystole in association with presumed viral encephalopathy
Neurology
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