Brainstem infarcts predict REM sleep behavior disorder in acute ischemic stroke

Abstract

BackgroundRapid eye movement (REM) sleep behavior disorder (RBD) is a sleep disturbance in which patients enact their dreams while in REM sleep. The behavior is typically violent in association with violent dream content, so serious harm can be done to the patient or the bed partner. The prevalence of RBD is well-known in Parkinson’s disease, Lewy body dementia, and multiple systems atrophy. However, its prevalence and causes in stroke remained unclear. The aim of this study was to determine factors influencing the appearance of RBD in a prospective cohort of patients with acute ischemic stroke.MethodsA total of 2,024 patients with first-ever or recurrent acute ischemic stroke were admitted to the Acute Stroke Unit at the Prince of Wales Hospital between January 2010 and November 2011; 775 of them received an MRI scan. Within 2 days of admission, a research nurse collected demographic and clinical data and assessed the severity of each stroke using the National Institute of Health Stroke Scale (NIHSS). One hundred and nineteen of the 775 patients meeting study entry criteria formed the study sample. All eligible participants were invited to attend a research clinic 3 months after the onset of the index stroke. In the attendance, a research assistant administered the MMSE and the 13-item RBD questionnaire (RBDQ).ResultsAmong 119 stroke patients, 10.9% were exhibited RBD, defined as an REM sleep behavior disorder questionnaire score of 19 or above. The proportion of patients with acute brainstem infarct was significantly higher in RBD patients than those without RBD. Compared with patients without RBD, RBD patients were more likely to have brainstem infarcts and had smaller infarct volumes. In a multivariate analysis, in which stroke location and infarct volume were inserted, brainstem infarcts were an independent predictor of RBD (odds ratio = 3.686; P = 0.032).ConclusionsThe results support the notion of a predominant role of brainstem injury in the development of RBD and suggest that patients with brainstem infarcts RBD should be evaluated by a clinical neurologist.

Probable REM sleep behavior disorder and risk of stroke

“…[9][10][11]26 For example, in a study including 119 stroke Chinese patients, 11% had RBD and presence of RBD was significantly associated with brainstem infarcts and smaller infarct volumes. 26 In another multicenter case-control study including 318 idiopathic RBD cases and 318 matched controls (181 sleep disorder controls and 137 healthy volunteers), RBD cases reported more cardiovascular disease (odds ratio [OR] 1.6; 95% CI 1.0-2.5) relative to the controls, and the association became stronger when 181 sleep disorder controls were removed (OR 2.4; 95% CI 1.3-4.6).…”

“…[9][10][11]26 For example, in a study including 119 stroke Chinese patients, 11% had RBD and presence of RBD was significantly associated with brainstem infarcts and smaller infarct volumes. 26 In another multicenter case-control study including 318 idiopathic RBD cases and 318 matched controls (181 sleep disorder controls and 137 healthy volunteers), RBD cases reported more cardiovascular disease (odds ratio [OR] 1.6; 95% CI 1.0-2.5) relative to the controls, and the association became stronger when 181 sleep disorder controls were removed (OR 2.4; 95% CI 1.3-4.6). 27 In the same study, a correlation between RBD and a higher odds of having selfreported cerebrovascular disease was also observed (OR 1.3; 95% CI 0.7-2.6), although the association was not significant, which could be due to small number of cerebrovascular disease cases (n 5 38) and misclassification due to self-report nature.…”

REM Sleep Behavior Disorder: Diagnosis, Clinical Implications, and Future Directions

“…1 The prevalence of RBD has been estimated to be in the range of 0.5% to 2%, 2–4 yet larger population-based studies of probable dream enactment symptoms suggest that RBD is likely considerably more frequent and present in between 5% and 13% of older community-dwelling adults aged 60 to 99 years. 5–8 Rapid eye movement sleep behavior disorder appears to be more common in men than women in older adults, 9–13 yet below the age of 50 years it is equally frequent in women and men. 14–17 Rapid eye movement sleep behavior disorder is 5-fold more likely to develop in patients receiving antidepressants and 10-fold more likely to develop in those with a psychiatric diagnosis.…”

REM sleep behaviour disorder: not just a bad dream

“…RBD has also been reported in neurodevelopmental disorders such as autism 44 and Tourette syndrome, 45 as well as among a number of paraneoplastic disorders such as limbic encephalitis and cerebellar degeneration 46 . ‐ 48 RBD can also occur in the setting of discrete ischaemic, demyelinating or neoplastic lesions affecting regions of the brain (primarily brainstem pontine structures) involved in the control of REM sleep 49 , 50 …”