REM sleep and muscle atonia in brainstem stroke: A quantitative polysomnographic and lesion analysis study.

Important brainstem regions are involved in the regulation of rapid eye movement sleep. We hypothesized that brainstem stroke is associated with dysregulated rapid eye movement sleep and related muscle activity. We compared quantitative/qualitative polysomnography features of rapid eye movement sleep and muscle activity (any, phasic, tonic) between 15 patients with brainstem stroke (N = 46 rapid eye movement periods), 16 patients with lacunar/non-brainstem stroke (N = 40 rapid eye movement periods), 15 healthy controls (N = 62 rapid eye movement periods), and patients with Parkinson's disease and polysomnography-confirmed rapid eye movement sleep behaviour disorder. Further, in the brainstem group, we performed a magnetic resonance imaging-based lesion overlap analysis. The mean ratio of muscle activity to rapid eye movement sleep epoch in the brainstem group ("any" muscle activity 0.09 ± 0.15; phasic muscle activity 0.08 ± 0.14) was significantly lower than in the lacunar group ("any" muscle activity 0.17 ± 0.2, p < 0.05; phasic muscle activity 0.16 ± 0.19, p < 0.05), and also lower than in the control group ("any" muscle activity 0.15 ± 0.17, p < 0.05). Magnetic resonance imaging-based lesion analysis indicated an area of maximum overlap in the medioventral pontine region for patients with reduced phasic muscle activity index. For all groups, mean values of muscle activity were significantly lower than in the patients with Parkinson's disease and polysomnography-confirmed REM sleep behaviour disorder group ("any" activity 0.51 ± 0.26, p < 0.0001 for all groups; phasic muscle activity 0.42 ± 0.21, p < 0.0001 for all groups). For the tonic muscle activity in the mentalis muscle, no significant differences were found between the groups. In the brainstem group, contrary to the lacunar and the control groups, "any" muscle activity index during rapid eye movement sleep was significantly reduced after the third rapid eye movement sleep phase. This study reports on the impact of brainstem stroke on rapid eye movement atonia features in a human cohort. Our findings highlight the important role of the human brainstem, in particular the medioventral pontine regions, in the regulation of phasic muscle activity during rapid eye movement sleep and the ultradian distribution of rapid eye movement-related muscle activity

The Neuropsychological and Emotional Profile of Adults with Parasomnia: A Case Series

Although parasomnias are nocturnal phenomena occurring during sleep or during arousals from sleep, there is increasing evidence that they are associated with daytime dysfunction as well. However, systematic studies in this field are scarce. The aim of the current case series was to investigate the sleep–wake, neuropsychological and emotional profiles of patients with parasomnias. Thirty patients with parasomnia (13 NREM, 17 REM) and 30 healthy subjects matched for age, sex and educational status were included. All participants underwent comprehensive neuropsychological, cognitive and behavioral evaluation. We found that parasomnia patients scored higher in all neuropsychological, emotional, sleep–wake and quality of life scales compared to healthy subjects. The presence of a parasomnia was associated with major impact on daytime functioning across several domains with increased levels of fatigue (FSS > 4) in 56%, sleepiness (ESS > 10) in 47%, depressive symptoms (BDI > 20) in 17%, anxiety (PSWQ > 52) in 17%, anger expression out (STAXI A > 16) in 27% and anger expression in (STAXI B > 16) in 23%, as well as a reduced average quality of life score (RAND derived from SF-36). Sleep–wake disturbances were significantly correlated with QoL scores. In the intergroup analysis between REM/NREM, we found that the REM group had worse cognitive performance and lower levels of fatigue/energy compared to NREM patients. These findings suggest that parasomnia is associated with difficulties in several aspects of daytime functioning (cognitive, affective/emotional and physical) and, therefore, parasomnia diagnostic workup should not be limited only to nocturnal phenomena

Deep Brain Stimulation: When to Test Directional?

BACKGROUND Directional deep brain stimulation (DBS) allows for steering of the stimulation field, but extensive and time-consuming testing of all segmented contacts is necessary to identify the possible benefit of steering. It is therefore important to determine under which circumstances directional current steering is advantageous. METHODS Fifty two Parkinson's disease patients implanted in the STN with a directional DBS system underwent a standardized monopolar programming session 5 to 9 months after implantation. Individual contacts were tested for a potential advantage of directional stimulation. Results were used to build a prediction model for the selection of ring levels that would benefit from directional stimulation. RESULTS On average, there was no significant difference in therapeutic window between ring-level contact and best directional contact. However, according to our standardized protocol, 35% of the contacts and 66% of patients had a larger therapeutic window under directional stimulation compared to ring-mode. The segmented contacts warranting directional current steering could be predicted with a sensitivity of 79% and a specificity of 57%. CONCLUSION To reduce time required for DBS programming, we recommend additional directional contact testing initially only on ring-level contacts with a therapeutic window of less than 2.0 mA

Management of obstructive sleep apnea in Europe – A 10-year follow-up

Funding Information: Sleep medicine has been further established and recognized in the past 10 years. This is also shown by the fact that sleep-related diseases may receive a separate chapter in the new ICD-11 (International Classification of Diseases 11th Revision) [11]. However, the initial expansion in sleep laboratories and sleep centers seems to be over, at least in Europe, which stands in contradiction to the growing need. While sleep medical care still seems to be secured by the established structures, the gap between the increasing need and existing structures is still widening [ 12–14]. There is a lack of sleep medicine specialists, new outpatient structures, and new billing models with the sponsoring institutions. Approaches to solve these problems include the establishment and expansion of home sleep apnea testing (HSAT) [15] and telemedicine-based technologies in the diagnosis and treatment of OSA [16,17]. Telemedicine found its way into sleep medicine around 10 years ago [ 18–20]. One of the very first approaches as early as 1994 used a telephone circuit and a computer-controlled support system to improve OSA treatment by improving lifestyle through tele-guidance on nutrition and exercise [21]. Publisher Copyright: © 2022 The Authors Copyright © 2022 Elsevier B.V. All rights reserved.Objective: In 2010, a questionnaire-based study on obstructive sleep apnea (OSA) management in Europe identified differences regarding reimbursement, sleep specialist qualification, and titration procedures. Now, 10 years later, a follow-up study was conducted as part of the ESADA (European Sleep Apnea Database) network to explore the development of OSA management over time. Methods: The 2010 questionnaire including questions on sleep diagnostic, reimbursement, treatment, and certification was updated with questions on telemedicine and distributed to European Sleep Centers to reflect European OSA management practice. Results: 26 countries (36 sleep centers) participated, representing 20 ESADA and 6 non-ESADA countries. All 21 countries from the 2010 survey participated. In 2010, OSA diagnostic procedures were performed mainly by specialized physicians (86%), whereas now mainly by certified sleep specialists and specialized physicians (69%). Treatment and titration procedures are currently quite homogenous, with a strong trend towards more Autotitrating Positive Airway Pressure treatment (in hospital 73%, at home 62%). From 2010 to 2020, home sleep apnea testing use increased (76%–89%) and polysomnography as sole diagnostic procedure decreased (24%–12%). Availability of a sleep specialist qualification increased (52%–65%) as well as the number of certified polysomnography scorers (certified physicians: 36%–79%; certified technicians: 20%–62%). Telemedicine, not surveyed in 2010, is now in 2020 used in diagnostics (8%), treatment (50%), and follow-up (73%). Conclusion: In the past decade, formal qualification of sleep center personnel increased, OSA diagnostic and treatment procedures shifted towards a more automatic approach, and telemedicine became more prominent.Peer reviewe

Sleep-related movement disorders and disturbances of motor control.

PURPOSE OF REVIEW Review of the literature pertaining to clinical presentation, classification, epidemiology, pathophysiology, diagnosis, and treatment of sleep-related movement disorders and disturbances of motor control. RECENT FINDINGS Sleep-related movement disorders and disturbances of motor control are typically characterized by positive motor symptoms and are often associated with sleep disturbances and consequent daytime symptoms (e.g. fatigue, sleepiness). They often represent the first or main manifestation of underlying disorders of the central nervous system, which require specific work-up and treatment. Diverse and often combined cause factors have been identified. Although recent data provide some evidence regarding abnormal activation and/or disinhibition of motor circuits during sleep, for the majority of these disorders the pathogenetic mechanisms remain speculative. The differential diagnosis is sometimes difficult and misdiagnoses are not infrequent. The diagnosis is based on clinical and video-polysomnographic findings. Treatment of sleep-related motor disturbances with few exceptions (e.g. restless legs/limbs syndrome) are based mainly on anecdotal reports or small series. SUMMARY More state-of-the-art studies on the cause, pathophysiology, and treatment of sleep-related movement disorders and disturbances of motor control are needed

REM Sleep Behavior Disorder.

Rapid eye movement sleep behavior disorder (RBD) is a brain disorder, characterized by the dream enactment during rapid eye movement (REM) sleep due to a lack of physiologic muscle atonia and increased muscle twitching. Schenk was the first to describe this disorder in 1986; however, few authors reported in the 1970-1980s loss of physiological muscle atonia combined with dream enactment in the course of brainstem disorders and as a consequence of alcoholism and antidepressant treatment. RBD affects less than 1% of the adult population, but can be found in up to 25-50% of neurodegenerative disorders including Parkinson's disease, multisystem atrophy, and dementia with Lewy body. In the last decade, many studies provided evidence that RBD precedes parkinsonian motor signs by several years, suggesting that RBD should no longer be considered a complication but a part of the prodromal phase of these diseases. Etiologically, primary (idiopathic RBD) and several secondary forms in addition to neurodegeneration (related to focal brainstem damage, narcolepsy, autoimmune disorders, and drugs) are known. Pathophysiologically, brainstem and supratentorial mechanisms involving glutamatergic, glycinergic, and GABA-ergic neurotransmission have been implicated. Recently, an animal model of RBD has been described. Clinical features consist of characteristic nocturnal behaviors, but also daytime symptoms including excessive sleepiness and cognitive alterations. The diagnosis of RBD is made according to international diagnostic criteria, based on medical history, and video-polysomnographic features. Current treatment strategies include actions which ensure a safe sleep environment, the avoidance of triggering/exacerbating factors and if necessary pharmacological (mainly clonazepam and melatonin) and non-pharmacological (e.g., behavioral measures) interventions. Future research should clarify the exact sleep-wake characteristics of RBD (also beyond REM sleep) and their evolution over time, the contribution of brainstem but also supratentorial mechanisms to its pathophysiology, and the (early?) diagnostic and (causative?) treatment consequences of RBD in the context of neurodegeneration

Sleep-wake disturbances in the premotor and early stage of Parkinson's disease.

PURPOSE OF REVIEW Review of recent literature pertaining to frequency, associations, mechanisms, and overall significance of sleep--wake disturbances (SWD) in the premotor and early phase of Parkinson's disease. RECENT FINDINGS SWD are frequent in Parkinson's disease and their prevalence increases with disease progression. Recent studies confirm previous findings that SWD can appear as initial manifestation of Parkinson's disease even decades before motor signs appear and highlight their clinical associations in these early stages. More intriguingly, new evidence underpins their role as risk factors, predictors, or even as driving force for the neurodegenerative process. As our understanding of sleep--wake neurobiology increases, new hypotheses emerge concerning the pathophysiology of SWD in early Parkinson's disease stages involving dopaminergic and nondopaminergic mechanisms. SUMMARY SWD are predictors for the development of parkinsonian syndromes including Parkinson's disease. This may offer the opportunity of developing new preventive strategies and interventions at an early stage of this neurodegenerative disease