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Wake-up stroke and TIA due to paradoxical embolism during long obstructive sleep apnoeas: a cross-sectional study
  1. Alfonso Ciccone1,2,
  2. Paola Proserpio3,
  3. Daria Valeria Roccatagliata1,
  4. Michele Nichelatti4,
  5. Gian Luigi Gigli5,
  6. Gianfranco Parati6,
  7. Carolina Lombardi6,
  8. Fabio Pizza7,
  9. Fabio Cirignotta7,
  10. Ignazio Michele Santilli1,
  11. Vincenzo Silani8,
  12. Roberto Sterzi1,
  13. Lino Nobili3,
  14. the D.A.RI.A (Detection of Sleep Apnea as Risk Factor in Acute Stroke) Investigators*
  1. 1Stroke Unit and Department of Neurology, ‘Niguarda Ca’ Granda’ Hospital, Milan, Italy
  2. 2Stroke Unit and Department of Neurology, ‘C.Poma’ Hospital, Mantua, Italy
  3. 3Sleep Medicine Center, ‘Niguarda Ca’ Granda’ Hospital, Milan, Italy
  4. 4Service of Biostatistics, Hematology Department, ‘Niguarda Ca’ Granda’ Hospital, Milan, Italy
  5. 5Neurological Clinic and Sleep Center, University of Udine, Udine, Italy
  6. 6Department of Cardiology, Sleep Medicine Lab, ‘San Luca’ Hospital, IRCCS Istituto Auxologico Italiano, University of Milano-Bicocca, Milan, Italy
  7. 7Unit of Neurology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
  8. 8Stroke Unit and Department of Neurology, ‘San Luca’ Hospital, IRCCS Istituto Auxologico Italiano, Università degli Studi di Milano, Milan, Italy
  9. *The D.A.RI.A Investigators are listed in the online appendix.
  1. Correspondence to Lino Nobili, Sleep Medicine Center, Department of Neurosciences, Niguarda “Cà Granda” Hospital, Piazza Ospedale Maggiore 3, 20164, Milan, Italy; lino.nobili{at}ospedaleniguarda.it

Abstract

Background and purpose Long obstructive sleep apnoeas (LOSAs) can cause brain ischaemia through paradoxical embolism since they can lead to right to left shunting (RLSh) but this has never been assessed as a risk factor for stroke. We investigated whether the combination of LOSA and RLSh is associated with ischaemic stroke or transient ischaemic attack (TIA) on waking (wake-up stroke).

Methods We prospectively considered patients aged over 18 years, admitted to 13 stroke units for acute ischaemic stroke or TIA. Patients had to be able to give consent, to specify whether the event occurred on waking, and to cooperate sufficiently to undergo contrast transcranial Doppler examination and cardiorespiratory sleep study within 10 days of the onset of symptoms. Single LOSA events, lasting 20 s or more, were considered a possible harbinger of RLSh.

Results Between April 2008 and March 2010, 335 patients (109 women; 61 TIA, mean age 64 years) were enrolled; 202 (60%) had at least one LOSA and 116 (35%) a RLSh; 69 (21%) had both. There were significantly more wake-up strokes/TIAs in subjects with RLSh plus LOSA than those without this association (27/69 vs 70/266; OR 1.91, controlled for age, sex, hypertension, diabetes, atrial fibrillation, antithrombotic therapy; 95% CI 1.08 to 3.38; p=0.03). No other risk factor was associated with an increase in the incidence of events on waking.

Conclusions The study suggests that the combination of LOSA and RLSh could be a new major, potentially treatable risk factor for cerebrovascular ischaemic events.

  • Sleep apnoea

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