Original articleSleep disorders in multiple system atrophy: a correlative video-polysomnographic study
Introduction
Several sleep-related respiratory and motor disturbances have been reported in multiple system atrophy (MSA). Subjective sleep complaints reported by patients or relatives include insomnia, excessive daytime sleepiness (EDS), snoring or other respiratory noises, and motor restlessness while asleep, sleep talking or overt violent behaviours [1]. Video-polysomnographic recordings (VPSG) demonstrate abnormal sleep architecture, respiratory disturbances such as nocturnal alveolar hypoventilation [2], [3], [4], obstructive and central sleep apnoeas [5], [6], [7], [8] and nocturnal stridor [9], [10], [11], [12], [13] and motor abnormalities including periodic limb movements during sleep (PLMS) [14] and REM sleep behaviour disorder (RBD), the latter often forerunning the disease [15], [16], [17], [18], [19].
The relation between abnormal motor control and sleep-related breathing abnormalities in MSA, and the occurrence in the same patient of sleep-related breathing and motor abnormalities have not been systematically analysed, except by questionnaire analysis [1], which may be open to criticism when not checked against VPSG recordings.
We performed VPSG recordings in 19 consecutive MSA patients, monitoring respiration, heart (HR) and breathing rate (BR) and limb muscular EMG activity, to define the extent and reciprocal relation of sleep-related autonomic and motor disturbances in MSA.
Section snippets
Patients
Nineteen consecutive patients (13 men and 6 women) fulfilling criteria for clinically probable MSA [20] were admitted for diagnostic purposes in our Neurological Department, which has an interest in sleep disorders. Patients were not selected on the basis of sleep, respiratory or motor problems. Thirteen of these patients had probable cerebellar type MSA (MSA-C) and six had probable parkinsonian type MSA (MSA-P) [20]. Nine patients died during follow-up with a median survival of 9.2 years
Methods
A history of sleep patterns and disorders was obtained from each patient according to a structured interview and checked with interviews of close relatives. Patients underwent VPSG including EEG (C3-A2, O2-A1, Cz-A1), right and left EOG, surface EMG from submental, intercostalis (electrodes placed at least 2 cm apart on the second anterior intercostal space lateral to the sternum), diaphragm (electrodes at the seventh/eighth intercostal space on the anterior axillary line, on the right to
MSA: subjective complaints and clinical findings
All patients complained of autonomic symptoms and 15 had mild–moderate symptomatic postural hypotension (dizziness, syncope and visual disturbances). The most frequent sleep-related subjective complaints were abnormal violent motor behaviours during sleep and respiratory noises.
Eight out of the 19 patients (42%), six with MSA-C (three men) and two with MSA-P (one man) complained of nocturnal stridor upon admission. Mean BMI was 25.9 (24.1 in patients without stridor). Remarkably, RBD was
Wake–sleep architecture and parameters
Our patients with MSA had abnormal sleep structure, with reduced NREM deep sleep and decreased sleep efficiency. Though these findings probably relate at least in part to a first night effect, the decreased sleep efficiency, striking in MSA compared to the OSAS patients who were subjected to the same procedures, seems to indicate that lack of sleep is characteristic of MSA, and cannot be attributed entirely to the disturbing effects of our investigational procedures.
Lack of sleep is also a
Acknowledgements
A. Laffi gave invaluable secretarial help, and A. Collins corrected the English manuscript. Supported by MURST ex-60% 2000, MURST ex-40% cofin 2000 prot. MM06244347_004 and MURST ex-40% cofin 1999 prot. 9906037938 grants.
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