Video-Polysomnographic Assessment for the Diagnosis of Disorders of Arousal in Children

Abstract

ObjectivesTo highlight the slow wave sleep (SWS) fragmentation and validate the video-polysomnographic (vPSG) criteria and cut-offs for the diagnosis of disorders of arousal (DOA) in children, as already reported in adults.MethodsOne hundred children (66 males, 11.0±3.3y) with frequent episodes of DOA and 50 non-parasomniac children (32 males, 10.9±3.9y) underwent a vPSG recording to quantify SWS characteristics (number of N3 sleep interruptions, fragmentation index, slow/mixed and fast arousal ratios and indexes per hour) and associated behaviors. We compared SWS characteristics in the two groups and defined the optimal cut-off values for the diagnosis of DOA using the receiver operating characteristics curves.ResultsPatients with DOA had higher amounts of N3 and REM sleep, number of N3 interruptions, SWS fragmentation and slow/mixed arousal indexes than controls. The highest area under the curve (AUC) values were obtained for SWS fragmentation and slow/mixed arousal indexes with satisfactory classification performances (AUC=0.80, 95% CI=0.73-0.87; AUC=0.82, 95% CI=0.75-0.89). SWS fragmentation index cut-off value of 4.1/h reached a sensitivity of 65.0% and a specificity of 84.0%. Slow/mixed arousal index cutoff of 3.8/h reached a sensitivity of 69.0% and a specificity of 82.0%. At least one parasomniac episode was recorded in 63.0% of patients and none of the controls. Combining behavioral component by vPSG increased sensitivity of both biomarkers to 83% and 89%, respectively.ConclusionsWe confirmed that SWS fragmentation and slow/mixed arousal indexes are two relevant biomarkers for the diagnosis of DOA in children, with different cut-offs obtained than those validated in adults.

Disorders of Arousal: A Chronobiological Perspective

“…This N3 instability encountered in DoA subjects translates into the common polygraphic finding of an increased number of arousals during deep sleep, in comparison to healthy controls. In this regard, an increased number of awakenings during SWS, but not in other sleep phases, has been widely demonstrated in polysomnographic studies [23,52,53]. In particular, two recent works by the same authors validated polygraphic cut-offs to discriminate with good sensitivity and specificity subjects with DoA from healthy subjects [23,53].…”

“…The pattern described as slow arousal is largely corresponding to the A1 phase of CAP, which decreases with age [16,30]. The A1 phase of CAP is considered an anti-arousal pattern, fundamental in younger ages to preserve sleep continuity in a maturational brain process [53]. The CAP rate was previously described to be increased in children [30] and also adults with DoA, especially in the first two sleep cycles [54].…”

“…In this regard, an increased number of awakenings during SWS, but not in other sleep phases, has been widely demonstrated in polysomnographic studies [23,52,53]. In particular, two recent works by the same authors validated polygraphic cut-offs to discriminate with good sensitivity and specificity subjects with DoA from healthy subjects [23,53]. They classified the EEG patterns associated with N3 awakenings into three different categories: slow, mixed, and fast arousals.…”

“…The study in DoA adults [23] revealed that an increased index of SWS awakenings (SWS arousals per hour of N3) and a pattern characterized by slow/mixed arousals are strongly associated with DoA, with a cut-off of 6.8/h and 2.5/h, respectively. These same criteria were also validated in a pediatric population, with different cut-offs [53]. The pattern described as slow arousal is largely corresponding to the A1 phase of CAP, which decreases with age [16,30].…”

“…The studies from Lopez et al, adding a quantitative parameter, may improve the accuracy of DoA diagnosis, considering that the latter is presently based only on clinical criteria [23,53]. In future research, it could be interesting to validate Lopez et al SWS fragmentation criteria not only versus healthy subjects but also versus other sleep pathological conditions, such as sleep breathing disorders or sleep related hypermotor epilepsy, similarly characterized by increased sleep fragmentation.…”