CPAP, weight loss, or both for obstructive sleep apnea

BACKGROUNd: Obesity and obstructive sleep apnea tend to coexist and are associated with inflammation, insulin resistance, dyslipidemia, and high blood pressure, but their causal relation to these abnormalities is unclear. METHODS: We randomly assigned 181 patients with obesity, moderate-to-severe obstructive sleep apnea, and serum levels of C-reactive protein (CRP) greater than 1.0 mg per liter to receive treatment with continuous positive airway pressure (CPAP), a weight-loss intervention, or CPAP plus a weight-loss intervention for 24 weeks. We assessed the incremental effect of the combined interventions over each one alone on the CRP level (the primary end point), insulin sensitivity, lipid levels, and blood pressure. RESULTS: Among the 146 participants for whom there were follow-up data, those assigned to weight loss only and those assigned to the combined interventions had reductions in CRP levels, insulin resistance, and serum triglyceride levels. None of these changes were observed in the group receiving CPAP alone. Blood pressure was reduced in all three groups. No significant incremental effect on CRP levels was found for the combined interventions as compared with either weight loss or CPAP alone. Reductions in insulin resistance and serum triglyceride levels were greater in the combined-intervention group than in the group receiving CPAP only, but there were no significant differences in these values between the combined-intervention group and the weight-loss group. In per-protocol analyses, which included 90 participants who met prespecified criteria for adherence, the combined interventions resulted in a larger reduction in systolic blood pressure and mean arterial pressure than did either CPAP or weight loss alone. CONCLUSIONS: In adults with obesity and obstructive sleep apnea, CPAP combined with a weight-loss intervention did not reduce CRP levels more than either intervention alone. In secondary analyses, weight loss provided an incremental reduction in insulin resistance and serum triglyceride levels when combined with CPAP. In addition, adherence to a regimen of weight loss and CPAP may result in incremental reductions in blood pressure as compared with either intervention alone. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT0371293 .)

Abstract Number ‐ 200: Aneurysmal versus “Benign” Perimesencephalic Subarachnoid Hemorrhage

Introduction Perimesencephalic subarachnoid hemorrhage (PMSAH) is characterized by bleeding centered in the basal cisterns anterior to the midbrain and pons without intraparenchymal or overt intraventricular extension. The term “benign” is often attached, because typically no source of bleeding is identified on high‐resolution vascular imaging, and recovery if often uncomplicated. Rarely, however, PMSAH can be secondary to ruptured vertebrobasilar aneurysms, and outcomes of these patients is underreported. Methods Retrospective analysis of patients with PMSAH to determine the rate of underlying ruptured aneurysm or vascular abnormality, associated complications, and outcomes. Age, sex, vascular risk factors, presenting symptoms, Hunt and Hess grade, modified Fisher grade, rate of underlying ruptured aneurysm, vasospasm, re‐bleed, hydrocephalus, and modified Rankin scale (mRS) were collected. Primary outcome was good functional status at discharge (mRS 0–2), reported as odds ratio (OR) with 95% confidence interval (CI). Results A total of 74 patients with PMSAH between 2007 and 2022 were identified. Mean age was 55.5± 10 years, and 60% were male. Hypertension and smoking were reported in 57% and 35% of patients, respectively. The most common presenting symptom was thunderclap headache in 89% of patients. Median (IQR) ofHunt and Hess grade was 2 (1‐2), and modified Fisher grade was 3 (1‐3). An underlying ruptured aneurysm was found in 3 patients (4%); two of which were in the vertebrobasilar system and one in the posterior communicating artery. Most common complications in this cohort was vasospasm in 28%, followed by hydrocephalus in 11%. Among patients with aneurysmal bleed, vasospasm and hydrocephalus occurred in 66% of patients each, compared to 8.5% and 27%, respectively in patients with non‐aneurysmal PMSAH. Re‐bleeding occurred only in one patient (1.3%); which occurred in a patient with non‐aneurysmal source of hemorrhage. A total of 88% of patients in our cohort had a favorable functional outcome (mRS 0–2) at discharge. An underlying ruptured aneurysm and acute hydrocephalus were associated with poor functional status(OR = 18.3, [1.5–228], P < 0.024), and OR = 25.8, [4.5–149], P < 0.001), respectively. However, vasospasm was noted to be asymptomatic in most cases (90%) and was not associated with unfavorable outcomes (OR = 0.75, [0.14–3.9], P < 0.73). Conclusions “Benign” PMSAH pattern was associated with a ruptured aneurysm in 4% of patients in our cohort.An underlying aneurysm and acute hydrocephalus were associated with poor outcomes. However, vasospasm was incidental and was not associated with unfavorable outcomes in patients with PMSAH