Severely Disturbed Sleep in Patients With Acute Ischemic Stroke on Stroke Units: A Pilot Study

I don't think I had a dream for years post stroke. In the hospital sleeping pills were handed out like candy. Can you even get to deep sleep via sleeping pills?

Severely Disturbed Sleep in Patients With Acute Ischemic Stroke on Stroke Units: A Pilot Study

Jeannette Hofmeijer^1,2*, Ruud van Kaam^1,2, Sarah E. Vermeer² and Michel J. A. M. van Putten^1,3

• ¹Department of Clinical Neurophysiology, University of Twente, Enschede, Netherlands
• ²Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands
• ³Department of Clinical Neurophysiology, Medisch Spectrum Twente, Enschede, Netherlands

Introduction: Previous studies revealed a high prevalence of sleep-wake disturbances in subacute and chronic stroke. We analyzed sleep quantity and quality in patients with hyperacute ischemic stroke on stroke units.

Methods: We categorized sleep stages as N1, N2, N3, and REM according to the 2017 criteria of the American Academy of Sleep Medicine in 23 continuous, overnight EEG registrations from 18 patients, starting within 48 h since the onset of cortical ischemic stroke. Associations between presence and duration of sleep stages, and secondary deterioration or functional outcome were analyzed.

Results: Physiological sleep cycles were seen in none of the patients. Otherwise, sleep stages alternated chaotically, both during day- and during nighttime, with a sleep efficiency of 30% and 10.5 ± 4.4 (mean ± SD) awakenings per hour of sleep. We cannot differentiate between stroke related and external factors. Only few interruptions could be related to planned nightly wake up calls, but turbulence on stroke units may have played a role. Six patients (seven nights) did not reach deep sleep (N3), 10 patients (13 nights) did not reach REM sleep. If reached, the mean durations of deep and REM sleep were short, with 37 (standard deviation (SD) 25) and 18 (SD15) minutes, respectively. Patients with secondary deterioration more often lacked deep sleep (N3) than patients without secondary deterioration [4 (57%) vs. 2 (25%)], but without statistical significance (p = 0.12).

Conclusion: We show that sleep is severely disturbed in patients with acute ischemic stroke admitted to stroke units. Larger studies are needed to clarify associations between deprivation of deep sleep and secondary deterioration.

Introduction

Sleep-wake disturbances are highly prevalent among stroke survivors, with insomnia being reported in up to half of all patients during the first months (1). Insomnia may be a direct consequence of the infarct or associated with environmental factors (1).

In patients with brain infarction or hemorrhage, insomnia was associated with more severe stroke, less functional recovery, and depression (1). Sleep disordered breathing gave an elevated risk of death or recurrent vascular events (2) and stroke recovery was worse in patients with restless legs syndrome (3). Sleep deprivation augmented brain injury in experimental stroke models (4), and drugs to promote non-rapid eye movement (REM) and REM-sleep had a favorable effect on neuroplasticity (5). This suggests that poor sleep may be a modifiable factor, where sleep enhancement may improve recovery of patients with ischemic or hemorrhagic stroke.

Previous studies have focused on the subacute and chronic phases. We analyzed sleep quantity and quality in patients with hyperacute ischemic stroke on stroke units, and related sleep to measures of functional recovery.

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