Relationship between sleep disorders and the prognosis of neurological function after stroke

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Relationship between sleep disorders and the prognosis of neurological function after stroke

Yajing Zhang¹, Xiaoshuang Xia², Ting Zhang¹, Chao Zhang¹, Ran Liu¹, Yun Yang¹, Shuling Liu¹, Xin Li² and Wei Yue^1*

• ¹Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
• ²Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China

Objective: This study aims to investigate the effects of sleep disorders on the prognosis of neurological function after stroke and other factors affecting the prognosis after stroke.

Method: We designed a cohort study. A total of 1,542 patients with their first stroke were hospitalized in the department of neurology of Tianjin Huanhu Hospital from 2015.6.1 to 2016.12.31. We recorded the personal histories of patients. The MMSE (mini-mental state examination), MoCA (Montreal Cognitive Assessment), HAMD (Hamilton Depression Scale), National Institutes of Health Stroke Scale (NIHSS) score, mRS (Modified Rankin Scale), BI (Barthel Index), PSQI (Pittsburgh Sleep Quality Index), ESS (Epworth Sleepiness Scale), Berlin questionnaire, and nocturnal TST (Total sleep time) were assessed before discharge, 3 months, 6 months, and 4 years (2019–2020) after stroke.

Result: Low sleep quality (OR 2.019, 95%CI 1.199–3.398, p = 0.008), nocturnal TST (<7 h) (OR 4.060, 95%CI 1.494–11.034, p = 0.006), nocturnal TST (>8 h) (OR 5.928, 95% CI 2.134–16.464, p = 0.001) were risk factors for poor neurological function recovery at 3 months after stroke. Nocturnal TST (<7 h) (OR 13.042, 95%-CI 2.576–66.027, p = 0.002) and nocturnal TST (>8 h) (OR 11.559, 95%-CI 2.108–63.390, p = 0.005) were risk factors for poor neurological function at 6 months after stroke. Nocturnal TST (<7 h) (OR 2.668, 95% CI 1.250–5.698, p = 0.011) and nocturnal TST (>8 h) (OR 2.516, 95% CI 1.080–5.861, p = 0.033) were risk factors for poor neurological function at 4 years after stroke. High risk of OSA (HR 1.582, 95%CI 1.244–2.012, p < 0.001) was a risk factor for all-cause death in patients followed up for 4 years after stroke.

Conclusion: Low sleep quality is associated with short-term poor neurological function after stroke. Unusual nocturnal TST (long or short) is associated with short-term or long-term poor neurological function after stroke. A high risk of OSA is associated with a higher risk of all-cause death after stroke.

Introduction

Stroke is a common cerebrovascular disease. Approximately 16 million people worldwide experience their first stroke each year, of which ~5.7 million die, and another approximately five million people are left with a disability. Stroke is the third leading cause of death in men after heart disease and lung cancer, and the second leading cause of death in women (1).

Stroke is one of the leading causes of disability. Neurological function after stroke varies greatly in different individuals. The recurrence rate of stroke within 5 years is up to 17% (2). Thrombolytic drugs and endovascular therapy have revolutionized the status of acute stroke patients. However, for the vast majority of patients who remain disabled after treatment, there are significant challenges in improving neurological recovery and preventing stroke recurrence.

Stroke is the leading cause of death in China, accounting for 20% of all deaths every year. Understanding the risk factors for stroke is essential for better treatment. Hypertension, diabetes, atrial fibrillation, obesity, and smoking have been shown to be risk factors for stroke. The number of stroke patients, morbidity, mortality, and the associated social burden are high and increasing in China. The high burden of a stroke may be explained by the less significant changes in traditional risk factors and the persistent influence of the less recognized risk factors (3). However, there are few domestic studies on the relationship between sleep disorders and stroke. Screening for post-stroke sleep disorders has not yet become part of the standard of routine care, and screening coverage is low.

Sleep disorders after stroke are common, and about 20–78% of patients have sleep disorders (4). The role of sleep disorders in stroke outcomes has become a thorny problem. Sleep disorders can cause intracranial cerebral atherosclerosis or small vessel diseases (5–8).

Sleep disorders after stroke are underestimated and generally overlooked because of the lack of awareness of sleep disorders among stroke patients. Although polysomnography (PSG) is the gold standard for diagnosing or differentiating sleep disorders, PSG cannot be applied to all stroke patients due to its high cost and limited accessibility. Other tools are also needed to screen for sleep disorders, such as valid sleep questionnaires, such as the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Sleepiness Scale, and Berlin questionnaire.

The purpose of this cohort study was to investigate the influence of longitudinal changes on sleep disorders (including sleep quality, sleepiness, nocturnal TST (Total sleep time), and obstructive sleep apnea (OSA), as measured by sleep questionnaires on neurological function and all-cause death in patients with stroke. Other factors affecting the neurological function of patients after stroke were also analyzed.

Research object

A total of 1,542 patients with the first stroke, including cerebral infarction, TIA, and cerebral hemorrhage, were hospitalized in the department of neurology of Tianjin Huanhu Hospital from 2015.6.1 to 2016.12.31. (1) The inclusion criteria were as follows: ① the patients were all admitted 72 h after onset, and ② the diagnosis of ischemic stroke meets the diagnostic criteria of the 2014 Chinese Guidelines for diagnosis and treatment of acute ischemic stroke (9). The intracerebral hemorrhage diagnosis met the guidelines for the management of spontaneous intracerebral hemorrhage—a guideline for healthcare professionals from the American Heart Association/American Stroke Association (10). The diagnosis of TIA met the diagnostic criteria for definition and evaluation of transient ischemic attacks—a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease (11). ③ Patients who can provide written informed consent and are willing to follow the 4-year follow-up protocol. (2) The exclusion criteria were as follows: ① patients under 18 years of age; ② patients with obvious liver and kidney dysfunction, heart failure, severe infection, or malignant disease; ③ patients with a prior history of brain disease and cognitive impairment; ④ patients with specific genetic diseases; ⑤ patients with aphasia, apraxia, disturbance of consciousness, visual and hearing impairment, and other conditions that make it difficult to perform functional tests, as well as those who cannot accurately provide reliable information; and ⑥ patients with sleep disorders before stroke (we specifically excluded people with a previous diagnosis of OSA, heavy snoring, nocturnal TST <7 h and >8 h, and those who considered themselves to be extremely sleepy during the day).