The coexistence of a patent foramen ovale and obstructive sleep apnea may increase the risk of wake-up stroke in young adults

2.3.1 Case 1

When he woke up in the morning, a 29-year-old man, with a history of hypertension and headache, noted the right limb numbness. Although he had a past history of hypertension and headache, the patient had no special family history. His body weight was 110 kg, while his height was 172 cm. His general physical examination was normal and blood pressure was 150/100 mmHg. He was both alert and oriented. Even though his speech was dysarthric, it was correctly responsive to verbal commands. With bilaterally horizontal nystagmus, adduction of both eyes was preserved. Deviating to left was the tongue. Found with extensor plantar response on left lower extremity, was mild weakness of the left upper limb extensors and left lower limb flexors. Furthermore, his pain sensation of left upper and lower extremities was lost. Hyperintensity of the right basal ganglia and right occipital lobe using fluid-attenuated inversion recovery (FLAIR) sequences were revealed by brain magnetic resonance imaging (MRI) (Fig. 1A). Performed 48 hours later, Magnetic resonance angiography (MRA) of neck and intracranial arteries exhibited normal (Fig. 1B). Showing no abnormal finding was dynamic ECG, vascular ultrasound of the neck and echocardiography. The following examinations were negative: anti-neutrophil cytoplasmic antibodies, anticardiolipin antibodies, antinuclear antibodies, ENA spectrum, antithrombin, homocysteine. Blood routine examination showed hemoglobin 170 g/L, hematocrit 50.8%; Uric acid 505 umol/L; alanine transaminase (ALT) 93 U/L, glutamic oxalaceticaminopherase (GOT) 52 U/L, low density lipoprotein cholesterol (LDL) 4.06 mmol/L (Table 1). In the state of calm breathing by c-TCD test, there is no embolus signal. Detected in the fourth cardiac cycle after Valsalva action were a large number of microembolic signals (rain curtain shape, Fig. 1C). Disappearing after the end of Valsalva action was the embolism rain (Table 2). TEE examination showed PFO (Fig. 1D). Sleep stage test found normal sleep latency through whole night PSG examination. Breathing and related events: In the night sleep, more than 80% of the time in the supine position and AHI is 93.5 times/hour, of which 836 is documented as obstructive apnea (up to 64.5 seconds). The lowest and average oxygen saturation were 29% and 78%, respectively; more related to respiratory abnormalities is the micro-arousal index which measured 91.3 times per hour; Accounting for 11.0% of sleep time was snoring time. These results were in line with diagnostic criteria for severe “obstructive sleep apnea hypopnea syndrome” (Table 3). The patient was given antiplatelet treatment causing the neurological impairment recovered gradually. Examination of c-TCD showed the embolic signal was significantly reduced and classified as mild after CPAP treatment at home for 3 months.

OPEN IN VIEWER

When waking in the early morning (3:30 am), a 33-year-old male presented with persistent right limb weakness and verbal confusion. There was no record of special past history or family history. He smoked 2–5 cigarettes per day and had been drinking for 10 years. His height was 170 cm and weight 81 kg, while his blood pressure was 155/110 mmHg. The subject was alert and conscious and his speech was dysarthric with right central facial weakness. Found with extensor plantar response on right lower extremity was mild weakness of the right upper limb extensors and right lower limb flexors. Abnormal long signal of the left pontine was showed in brain MRI by FLAIR sequences (Fig. 2A). Conducting Computed Tomography Angiography (CTA) of neck and intracranial arteries revealed limited narrow on the right anterior cerebral artery A2 segment and the left anterior cerebral artery segment A3 and limited moderate stenosis on the initial segment of the right vertebral artery (Fig. 2B). Echocardiography on dynamic ECG, color Doppler ultrasound of the neck and echocardiography were found to be normal. Measurements of hemoglobin 170 g/L, hematocrit 46.1%, ALT 48 U/L, GOT 278 U/L, blood glucose 7.6 mmol/L, homocysteine 17.2 umol/L, triglyceride 10.5 mmol/L, LDL 3.38 mmol/L. Results of the examination of anti-neutrophil cytoplasmic antibodies, anticardiolipin antibodies, antinuclear antibodies, ENA spectrum and antithrombin III were all normal (Table 1). Two emboli were detected during 9th cardiac cycle when the patient breathed quietly by c-TCD test. During the 8th cardiac cycle (rain curtain) after Valsalva action, a large number of embolus signals were revealed (Fig. 2C). After Valsalva action, embolism rain disappeared (Table 2). TEE examination is not tolerated by patients. Sleep stage test reviewed normal sleep latency after whole night PSG examination. The lowest and average oxygen saturation was 72% and 93%, respectively. Snoring time accounted for 38.0% of sleep time. In summary, the diagnosis for the patient was “obstructive sleep apnea syndrome” (Table 3).

OPEN IN VIEWER

A 44-year-old male, presenting with sudden numbness, weakness throughout whole body and pain sensibility, at admission at 4:30 am, could not walk. His height was 174 cm and weight was 85 kg, and his blood pressure was 140/100 mmHg. Limb muscle strength 4 + , bilateral knee tendon reflexes (+++), lower limb pathological signs positive, and limb hyperalgesia were revealed by neurological examination. Brain MRI showed bilateral medulla medial infarction (Fig. 3A), while MRA demonstrated basal artery ranging from local mild to moderate stenosis (Fig. 3B). Showing bilateral carotid artery plaques was carotid artery color Doppler. His laboratory tests showed that hemoglobin was 168 g/L, hematocrit was 43%, triglycerides was 3.44 mmol/L, LDL was 2.99 mmol/L. Additionally, blood glucose, homocysteine, antithrombin III, and antibodies were normal (Table 1). With calm breathing state, no embolus signal was found when c-TCD test was conducted. After Valsalva action, a large number of “rain-like” micro-embolus signals appeared in the fourth cardiac cycle (Fig. 3C). However, disappearing after the end of Valsalva action was embolism rain (Table 2). TEE examination of the patent foramen ovale existed (Fig. 3D). Sleep stage test reviewed normal sleep latency founded through whole night PSG examination. The total sleep time was 8.6 h, there was a 65.4% increase of Non-rapid Eye Movement (NREM) sleep I, a 7.4% decrease of NREM sleep II, a 0.4% decrease of NREM sleep III and a 11.9% decrease of Rapid Eye Movement sleep (REM). The sleep state of this man was less continuity and efficiency. The apnea and hypopnea index was 102.4 times per hour. The patient had 492 obstructive apneas and hypopnea 353 times in the whole night’s sleep. The lowest and average oxygen saturation was 32% and 95%, respectively. Accounting for 14.4% of sleep time was snoring. This was in line with severe “obstructive sleep apnea hypopnea syndrome” diagnostic criteria (Table 3).

OPEN IN VIEWER