Wake-up stroke and TIA due to paradoxical embolism during long obstructive sleep apnoeas: a cross-sectional study.
OBJECTIVE
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.
Stroke Unit and Department of Neurology, Niguarda Ca' Granda Hospital, Milan, Italy.
Alfonso
A
Ciccone
Paola
P
Proserpio
Daria Valeria
DV
Roccatagliata
Michele
M
Nichelatti
Gian Luigi
GL
Gigli
Gianfranco
G
Parati
Carolina
C
Lombardi
Fabio
F
Pizza
Fabio
F
Cirignotta
Ignazio Michele
IM
Santilli
Vincenzo
V
Silani
Roberto
R
Sterzi
Lino
L
Nobili
D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D002908:Chronic Disease; D002940:Circadian Rhythm; D015897:Comorbidity; D003430:Cross-Sectional Studies; D019320:Embolism, Paradoxical / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology; D005260:Female; D006801:Humans; D015994:Incidence; D002546:Ischemic Attack, Transient / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011379:Prognosis; D018570:Risk Assessment; D012720:Severity of Illness Index; D012891:Sleep Apnea Syndromes / Q000175:diagnosis / Q000453:epidemiology*; D020521:Stroke / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000503:physiopathology; D016019:Survival Analysis; D017585:Ultrasonography, Doppler, Transcranial; D014851:Wakefulness