Optimization of early rehabilitation of patients with ischemic stroke and sleep-disordered breathing

Cover Page

Cite item

Full Text


Introduction. Sleep-disordered breathing (SDB) is detected in 70% of stroke patients and impedes functional rehabilitation; it also increases the length of hospital stay and the risk of stroke recurrence and fatal outcome.

Objective: to study the dynamics of SDB in its correlation with neurological disorders in stroke patients and to develop the approaches to optimization of early rehabilitation.

Materials and methods. A total of 78 patients with acute ischemic stroke were examined. SDB was verified by cardiorespiratory monitoring; the neurological deficit was assessed using the NIHSS and mRS scales. Examination was carried out upon admission (days 2–5 post stroke) and again after 3 weeks. The effect of SDB correction on effectiveness of neurological recovery was studied using positional therapy (position elevated by 30о) in combination with oxygen therapy (insufflation of O2 with the saturation level maintained no less than 95% under control of a digital sensor).

Results. Upon admission, SDB was revealed in 88% of patients; moderate and severe disorders being predominant (the apnea/hypopnea index (AHI) ≥15 h-1), most frequently presenting as obstructive apnea. In patients with AHI < 15 h-1, the positive dynamics of neurological disorders (p<0.04) were observed along with stable SDB parameters. Neurological improvement (р<0.05) was observed in patients with AHI ≥ 15 h-1, which was associated with decreased severity of SDB. A direct correlation between the severity of neurological disorders and AHI after 3 weeks was revealed: RNIHSS/AHI = 0.45 (р=0.003), RmRS/AHI = 0.44 (р=0.004). Patients with AHI ≥ 15 h-1 were distributed into 2 groups: group A (without corrective interventions) and group B (the use of positional and oxygen therapy during the night sleep during 7 days). A positive effect of the course of corrective therapy on restoration of neurological functions, along with a decrease in AHI, was revealed.

Conclusions. SDB is a frequent and persistent disorder in patients with ischemic stroke. Early detection and correction of SDB should be regarded as an important component of post-stroke rehabilitation.

About the authors

Gleb M. Lutokhin

Research Center of Neurology

Email: neurocor@mail.ru
Russian Federation, Moscow

Ludmila A. Geraskina

Research Center of Neurology

Author for correspondence.
Email: neurocor@mail.ru
Russian Federation, Moscow

Andrey V. Fonyakin

Research Center of Neurology

Email: neurocor@mail.ru
Russian Federation, Moscow

Marina Yu. Maksimova

Research Center of Neurology

Email: neurocor@mail.ru
ORCID iD: 0000-0002-7682-6672
Russian Federation, Moscow, Volokolamskoe shosse,80


  1. Suslina Z.A., Piradov M.A. (Eds.) Insult: diagnostika, lechenie, profilaktika [Stroke: diagnosis, treatment, prevention] Мoscow: MEDPRESS-INFORM, 2008. – 288 p. (In Russ.).
  2. Gudkova V.V., Stakhovskaya L.V., Kirilchenko T.D. et al. [Early rehabilitation after a stroke]. Consilium medicum 2005; 8: 692-696. (in Russ.).
  3. Kistenev B.A., Fonyakin A.V., Geraskina L.A., Petrova E.A. [Transient sick sinus syndrome as a manifestation of cerebrocardial syndrome in the acute period of stroke]. Nevrologicheskiy zhurnal [Neurological Journal] 2003; 2: 16-20. (in Russ.).
  4. Saposnik G., Kapral M.K., Liu Y. et al. Investigators of the Registry of the Canadian Stroke Network; Stroke Outcomes Research Canada (SORCan) Working Group. IScore: a risk score to predict death early after hospitalization for an acute ischemic stroke. Circulation 2011; 123: 739-49. doi: 10.1161/CIRCULATIONAHA.110.983353. PMID: 21300951
  5. Wessendorf T.E., Wang Y.M., Thilmann A.F. et al. Treatment of obstructive sleep apnoea with nasal continuous positive airway pressure in stroke. Eur Respir J 2001; 18:623-629. PMID: 11716165
  6. Hermann D.M., Bassetti C.L. Sleep-related breathing and sleep-wake disturbances in ischemic stroke. Neurology 2009;73:1313–1322. doi: 10.1212/WNL.0b013e3181bd137c. PMID: 19841384.
  7. Kaneko Y., Hajek V.E., Zivanovic V. et al. Relationship of sleep apnea to functional capacity and length of hospitalization following stroke. Sleep 2003 May 1; 26(3): 293-7. PMID: 12749548
  8. Rola R., Jarosz H., Wierzbicka A. et al. Sleep disorderd breathing and recurrence of cerebrovascular events, case-fatality, and functional outcome in patients with ischemic stroke or transient ischemic attack. J Physiol Pharmacol 2008; 59 Suppl 6: 615-621. PMID: 19218688
  9. Sahlin C., Sandberg O., Gustafson Y. et al. Obstructive sleep apnea is a risk factor for death in patients with stroke: a 10-year follow-up. Arch Intern Med 2008; 168:297-301. PMID: 18268171. doi: 10.1001/archinternmed.2007.70
  10. Yan-fang S, Yu-ping W. Sleep-disordered breathing: impact on functional outcome of ischemic stroke patients. Sleep Med 2009; 10:717-719. doi: 10.1016/j.sleep.2008.08.006. PMID: 19168390
  11. Martínez-García M.A., Soler-Cataluña J.J., Ejarque-Martínez L. et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med. 2009 Jul 1;180(1):36-41. PMID: 19406983. doi: 10.1164/rccm.200808-1341OC
  12. Parra O., Sánchez-Armengol A., Bonnin M. et al. Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial. Eur Respir J 2011; 37: 1128-1136. doi: 10.1183/09031936.00034410. PMID: 20847081
  13. Bravata D.M., Concato J., Fried T. et al. Continuous positive airway pressure: evaluation of a novel therapy for patients with acute ischemic stroke. Sleep. 2011 Sep 1;34(9):1271-7. doi: 10.5665/SLEEP.1254. PMID: 21886365
  14. Kernan W.N., Ovbiagele B., Black H.R., et al. Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack. A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160-2236. doi: 10.1161/STR.0000000000000024
  15. Hsu C.Y., Vennelle M., Li H.Y. et al. Sleep-disordered breathing after stroke: a randomised controlled trial of continuous positive airway pressure. J Neurol Neurosurg Psychiatry 2006; 77(10):1143-1149. PMCID: PMC2077531. doi: 10.1136/jnnp.2005.08668
  16. Ryan C.M., Bayley M., Green R. et al. Influence of continuous positive airway pressure on outcomes of rehabilitation in stroke patients with obstructive sleep apnea. Stroke 2011; 42(4):1062-1067. PMID: 21372306. doi: 10.1161/STROKEAHA.110.597468
  17. Svatikova A., Chervin R.D., Wing J.J. et al. Positional therapy in ischemic stroke patients with obstructive sleep apnea. Sleep Med 2011; 12:262-266. PMID: 21306949. doi: 10.1016/j.sleep.2010.12.008
  18. [National recommendations of the VNOK and OSSN for the diagnosis and treatment of CHF (third revision)]. Zhurnal Serdechnaya nedostatochnost. 2010; 1 (57): 3-62. (in Russ.).
  19. Warlow Ch.P., Dennis M.S., van Gijn J. et al. Insult. Prakticheskoe rukovodstvo dlya vedeniya bolnih [Stroke. Practical guidance for managing patients]. Saint-Petersburg. 1998. – 629 p. (in Russ.).
  20. Vereshchagin N.V., Bragina L.K., Vavilov S.B., Levina G.Ya. Kompyuternaya tomografiya mozga [Computer tomography of the brain]. Moscow: Meditsina. 1986. – 256 p. (in Russ.).
  21. Tsara V., Amfilochiou A., Papagrigorakis M.J. et al. Guidelines for Diagnosis and Treatment of Sleep-related Breathing Disorders in Adults and Children. HIPPOKRATIA 2009, 13, 3: 187-191. PMID: 19918312
  22. Young T., Peppard P.E., Gottlieb D.J. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002;165:1217-39. doi: 10.1164/rccm.2109080
  23. Young T., Palta M., Dempsey J. et al. Burden of sleep apnea: rationale, design, and major findings of the Wisconsin sleep cohort study. WMJ. 2009;108 (5):246-249. PMID: 19743755. PMCID: PMC2858234.
  24. Peppard P.E., Young T., Barnet J.H. et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9):1006. doi: 10.1161/STROKEAHA.111.000112.
  25. Kapur V.K. Obstructive sleep apnea: diagnosis, epidemiology, and economics. Respir Care 2010; 55: 1155-67. PMID: 20799998
  26. Young T., Peppard P. E., Taheri S. Excess weight and sleep-disordered breathing. Journal of applied physiology 2005; 99 (4): 1592-1599. doi: 10.1152/japplphysiol.00587.2005
  27. Garvey J.F., Pengo M.F., Drakatos P., Kent B.D. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis 2015;7 (5):920-929. doi: 10.3978/j.issn.2072-1439.2015.04.52
  28. Lutokhin G.M., Geraskina L.A., Fonyakin A.V. Sindrom narusheniya dihaniya vo sne pri ishemicheskom insulte [Sleep disordered breathing in ischemic stroke]. Zhurnal nevrologii i psihiatrii imeni S.S. Korsakova [Journal of Neurology and Psychiatry. S.S. Korsakov] 2016; 12-2: 14-20. doi: 10.17116/jnevro201611612214-20. (in Rus).
  29. Eckert D.J., Jordan A.S., Merchia P., Malhotra A. Central sleep apnea: pathophysiology and treatment. Chest Journal. 2007; Т. 131; 2: 595-607. doi: 10.1378/chest.06.2287
  30. Plum F., Posner J.B. Diagnostika stupora i komy [Diagnosis of stupor and coma]. Moscow: Meditsina, 1986. – 544 p. (in Russ.).
  31. Bassetti C., Aldrich M., Chervin R., Quint D. Sleep apnea in acute phase of TIA and stroke. Neurology 1996; 47: 1167-1173. PMID: 8909424
  32. Parra O., Arboix A., Bechich S. et al. Time course of sleep-related breathing disorders in first-ever stroke or transient ischemic attack. Am J Resp Crit Care Med. 2000; 161: 375-380. PMID: 10673174. doi: 10.1164/ajrccm.161.2.9903139
  33. Bassetti C.L., Milanova M., Gugger M. Sleep-Disordered Breathing and Acute Ischemic Stroke: Diagnosis, Risk Factors, Treatment, Evolution, and Long-Term Clinical Outcome. Stroke. 2006; 37(4): 967-972. PMID: 16543515. doi: 10.1161/01.STR.0000208215.49243.c3
  34. Harbison J., Ford G.A., James O.F., Gibson G.J. Sleep-disordered breathing following acute stroke. Q J Med. 2002; 95: 741-747. PMID: 12391386
  35. Shepard J.W. Hypertension, cardiac arrhythmias, myocardial infarction, and stroke in relation to obstructive sleep apnea. Clin Chest. 1992;13:437-458. PMID: 1521412
  36. Garvey J.F., Taylor C.T., McNicholas W.T. Cardiovascular disease in obstructive sleep apnea syndrome: the role of intermittent hypoxia and inflammation. Eur Respir J 2009;33:1195-205. doi: 10.1183/09031936.00111208
  37. Sandberg O., Franklin K.A., Bucht G. et al. Nasal continuous positive airway pressure in stroke patients with sleep apnea: a randomized treatment study. Eur Respir J. 2001; 18(4): 630-4. PMID: 11716166
  38. Palombini L, Guilleminault C. Stroke and treatment with nasal CPAP. Eur J Neurol 2006; 13:198-200. PMID: 16490054. doi: 10.1111/j.1468-1331.2006.01169.x
  39. Mehta V., Vasu T.S., Phillips B., Chung F. Obstructive sleep apnea and oxygen therapy: a systematic review of the literature and meta-analysis. J of Clin Sleep Med 2013; 9(3): 271-279. PMID: 23493498. PMCID: PMC3578679. doi: 10.5664/jcsm.2500.
  40. Epstein L.J., Kristo D., Strollo P.J., et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009; 5(3): 263-276. PMID: 19960649. PMCID: PMC2699173
  41. Pevernagie D.A., Stanson A.W., Sheedy P.F. 2nd, et al. Effects of body position on the upper airway of patients with obstructive sleep apnea. Am J Resp Crit Care Med 1995; 152: 179-185. PMID: 7599821. doi: 10.1164/ajrccm.152.1.7599821
  42. Ravesloot M.J.L., van Maanen J.P., Dun L., de Vries N. The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea – a review of the literature. Sleep Breath 2013; 17: 39-49. doi: 10.1007/s11325-012-0683-5
  43. Brunser A.M., Muñoz Venturelli P., Lavados P.M. et al. Head position and cerebral blood flow in acute ischemic stroke patients: Protocol for the pilot phase, cluster randomized, Head Position in Acute Ischemic Stroke Trial (HeadPoST pilot). Int J Stroke. 2016; 11(2): 253-9. PMID: 26783317. doi: 10.1177/1747493015620808.
  44. http://news.heart.org/international-stroke-conference-2017/

Supplementary files

Supplementary Files

Copyright (c) 2017 Lutokhin G.M., Geraskina L.A., Fonyakin A.V., Maksimova M.Y.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС 77-83204 от 12.05.2022.

This website uses cookies

You consent to our cookies if you continue to use our website.

About Cookies