Atlas of Sleep Medicine

401 Pages·2014·245.341 MB·English

by  Sudhansu Chokroverty (Auth.)

Atlas
of Sleep
Medicine
Sudhansu Chokroverty, SECOND EDITION
MD, FRCP, FACP
Professor and Co-Chair of Neurology
Program Director
Clinical Neurophysiology and Sleep Medicine
New Jersey Neuroscience Institute
at JFK Medical Center and Seton Hall University
Edison, New Jersey
Clinical Professor of Neurology
Robert Wood Johnson Medical School
New Brunswick, New Jersey
Robert J. Thomas, MD, MMSc
Associate Professor of Medicine
Harvard Medical School
Department of Medicine
Division of Pulmonary, Critical Care, and Sleep
Beth Israel Deaconess Medical Center
Boston, Massachusetts
iii
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF SLEEP MEDICINE ISBN: 978-1-4557-1267-0
Copyright © 2014, 2005 by Saunders, an imprint of Elsevier Inc.
Video Vignettes 1 to 8, “Narcolepsy,” “Obstructive Sleep Apnea Associated With Cerebral Hypoxemia,”
“The Rapid Eye Movement Sleep Behavior Disorder Leading to a Subdural Hemorrhage,” “Isolated
Sleep Paralysis,” “Confusional Arousals,” “Sleepwalking,” “Hypnagogic Hallucination,” and “Sleep
Terrors” by Mark Eric Dyken. Mark Eric Dyken retains copyright to his original video vignettes.
No part of this publication may be reproduced or transmitted in any form or by any means, elec-
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical treat-
ment may become necessary. Practitioners and researchers must always rely on their own experi-
ence and knowledge in evaluating and using any information, methods, compounds, or experiments
described herein. In using such information or methods, they should be mindful of their own safety
and the safety of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check
the most current information provided (i) on procedures featured or (ii) by the manufacturer of
each product to be administered to verify the recommended dose or formula, the method and
duration of administration, and contraindications. It is the responsibility of practitioners, relying
on their own experience and knowledge of their patients, to make diagnoses, to determine dosages
and the best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors
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tions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Chokroverty, Sudhansu, author.
Atlas of sleep medicine / Sudhansu Chokroverty, Robert J. Thomas. -- Second edition.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4557-1267-0 (hardback : alk. paper)
I. Thomas, Robert J. (Professor of medicine), author. II. Title.
[DNLM: 1. Sleep Disorders--diagnosis--Atlases. 2. Polysomnography--Atlases. WL 17]
RC547
616.8’498--dc23 2013032574
Content Strategist: Helene Caprari
Content Development Specialist: Maria Holman
Publishing Services Manager: Anne Altepeter
Senior Project Manager: Doug Turner
Design Direction: Louis Forgione
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife, Manisha Chokroverty, MD, my love and gratitude
for your lifelong support in my academic endeavors despite
being left alone for days and weeks during the production
of this and other books
SC
To my wife, Shubha, who has developed the steel will
to deal with my never-ending hyperdrive,
and to my best friend, Sudha, who played a very important
part in sculpting me into who I am today
RJT
Preface
The field of sleep medicine continues to expand exponen- behavior disorder (RBD) has expanded in terms of clinical
tially and is now reaching a wider audience in the world. presentation and relevance as a prodromal manifestation
There is increasing awareness of the importance of sleep of future neurodegenerative disease, driving investigators
and the impact of its deprivation (either from lifestyle or to develop quantifiable diagnostic criteria in the prodromal
disorders of sleep). An early diagnosis of sleep disorder is a stage. Also, now there is PSG requirement for diagnosis of
must to prevent consequences that include morbidity and RBD as mentioned in the International Classification of Sleep
mortality. Laboratory techniques, particularly polysomno- Disorders (ICSD), Second Edition. Furthermore, evidence
graphic (PSG) study and simultaneous audio-video record- in the literature points to the heterogeneity of electromyo-
ings, remain the cornerstones for a definitive diagnosis of graphic (EMG) findings in RBD patients, showing dissocia-
sleep disorders. It is, therefore, important to be conversant tion among cranial and upper- and lower-limb muscle tonic
with laboratory techniques and familiar with illustrations and phasic activities, requiring multiple muscle recordings.
illuminating the diagnostic features of sleep disorders. Chapters from the previous edition of this book have
As noted in the first edition, the fundamental purpose of been revised with new text and illustrations. Some chapters
an atlas is that the text can be augmented with illustrations, have been added that contain new materials (see Chapters
proving the adage that a picture is worth a thousand words. 5, 7, 13, and 16) to address recent advances in our under-
In addition, in the second edition we include online video standing of sleep disorders, and topics missing from the first
segments of clinical events, permitting clinical-physiological edition have been included. The goal of this edition remains
correlations of normal, abnormal, and unusual sleep-related the same as in the first edition: to produce a comprehensive
events. Eight video vignettes are discussed in the appendix, and contemporary atlas that provides examples of PSG and
with cross references to chapters that illustrate abnormal other tracings, while also adding short video segments with
motor events including nocturnal seizures, motor para- clinical vignettes that correlate behavioral- physiological
somnias, and sleep-related movement disorders, as well as features for correct diagnosis of normal, abnormal, and
events that are apparently normal variants or of uncertain uncommon sleep-related events. This book is intended for
significance. In some of these video vignettes, duplicate fig- a multidisciplinary field of clinicians taking care of patients
ures have been intentionally kept for the convenience of with sleep disorders and, therefore, should be useful to
the reader. neurologists, pulmonologists, and other internists including
Since the publication of the first edition of the Atlas of cardiologists, psychiatrists, psychologists, dentists, otolar-
Sleep Medicine in 2005, there has been an increasing inter- yngologists, and pediatricians. It is also intended for others
est and demand for visual display of interesting and educa- who have an interest in advancing the practical knowledge
tionally satisfying sleep-related events and recordings. Many in sleep medicine, such as electroencephalography and PSG
topics are better served by pictorial or video display. A case technologists, respiratory therapists, fellows, residents, and
in point is movement triggered by sleep or preferentially medical students.
occurring during sleep (e.g., parasomnias, nocturnal frontal
lobe epilepsy). In addition, new sleep disorders have been Sudhansu Chokroverty, MD, FRCP, FACP
described (e.g., catathrenia, complex sleep apnea, alternat-
Robert J. Thomas, MD, MMSc
ing leg muscle activation) and the spectrum of REM sleep
vii
Acknowledgments
We are most grateful to the contributing authors for their at Elsevier, for their time, patience, help, and toleration
scholarly contributions. We would like to acknowledge Else- of the editors’ idiosyncrasies. We also wish to thank Jenny
vier’s Adrianne Brigido, who initiated the project but left to Rodriguez, secretary at the NJ Neuroscience Institute, for
accept a position in another department, and Helene Cap- help with typing.
rari, this title’s current content strategist, for her dedication Finally, our patients and trainees deserve our thanks for
and professionalism; two content development specialists continuously challenging our conventional wisdom, driving
(Julia Bartz, Gabrielle Goodman White) who were initially us to deliver the highest standard of care and education, and
assigned to this project to try to speed up the process with shaking our foundations when we thought we “got it right.”
utmost dedication before they left for other assignments;
Maria Holman, the current content development special- Sudhansu Chokroverty, MD, FRCP, FACP
ist; Doug Turner, senior project manager; Anne Altepeter,
Robert J. Thomas, MD, MMSc
publishing services manager; and Louis Forgione, designer,
ix
Contributors
FERNANDA R. ALMEIDA, DDS, MSc, PhD THIEN THANH DANG-VU, MD, PHD
Department of Oral Health Sciences Neurologist and Assistant Professor
Faculty of Dentistry Center for Studies in Behavioral Neurobiology
University of British Columbia Department of Exercise Science
Vancouver, British Columbia, Canada Concordia University
Montreal, Quebec, Canada
ALON Y. AVIDAN, MD, MPH
Professor of Neurology FERNANDO DE PAOLIS, MD
Director, UCLA Sleep Disorders Center Sleep Disorders Center
Director, UCLA Neurology Clinic Department of Neuroscience
David Geffen School of Medicine at UCLA University of Parma
Los Angeles, California Parma, Italy
SIDDHARTH BAJPAI, MB BS, MS MARTIN DESSEILLES, MD, PhD
Chief Resident Psychiatry Head, Department of Psychology
Department of Psychiatry University of Namur Medical School
Roy J. and Lucille A. Carver College of Medicine Namur, Belgium
University of Iowa
Iowa City, Iowa MARK ERIC DYKEN, MD, FAHA, FAASM
Professor of Neurology
SUSHANTH BHAT, MD Director, Department of Neurology Sleep Disorders Center
Assistant Attending Roy J. and Lucille A. Carver College of Medicine
New Jersey Neuroscience Institute at JFK Medical Center University of Iowa
and Seton Hall University Iowa City, Iowa
Edison, New Jersey
RAFFAELE FERRI, MD
JEFFREY BOYLE, MD, PhD Sleep Research Centre
Chief Resident Department of Neurology I.C.
Department of Neurology Sleep Disorders Center Oasi Research Institute (IRCCS)
Roy J. and Lucille A. Carver College of Medicine Troina, Italy
University of Iowa
Iowa City, Iowa JOHN A. FLEETHAM, MD, FRCP(C)
Professor
SUDHANSU CHOKROVERTY, MD, FRCP, FACP Department of Medicine
Professor and Co-Chair of Neurology The University of British Columbia
Program Director Vancouver, British Columbia, Canada
Clinical Neurophysiology and Sleep Medicine
New Jersey Neuroscience Institute at JFK Medical Center CHRISTINE L. GLENN, RPSGT, RST, REEG T
and Seton Hall University Chief Clinical Laboratory Technologist
Edison, New Jersey Department of Neurology Sleep Disorders Center
Clinical Professor of Neurology Roy J. and Lucille A. Carver College of Medicine
Robert Wood Johnson Medical School University of Iowa
New Brunswick, New Jersey Iowa City, Iowa
ELENA COLIZZI, MD TIMOTHY F. HOBAN
Physician (Geriatrics) Professor of Pediatrics and Neurology
Department of Clinical and Experimental Medicine The Michael S. Aldrich Sleep Disorders Laboratory
Section of Geriatrics University of Michigan
Endocrinology of Aging Unit Ann Arbor, Michigan
University of Parma
Parma, Italy
xi
xii CONTRIBUTORS
BIRGIT HÖGL, MD ELI S. NEIMAN, DO
Head of the Sleep Disorders Clinic Attending Neurologist and Epileptologist
Department of Neurology Comprehensive Epilepsy Center
Innsbruck Medical University New Jersey Neuroscience Institute
Innsbruck, Austria JFK Medical Center
Edison, New Jersey
NIVEDITA JERATH, MD Assistant Professor of Neurology
Fellow in Clinical Neurophysiology Seton Hall University School of Graduate Medical
Department of Neurology Sleep Disorders Center Education
Roy J. and Lucille A. Carver College of Medicine South Orange, New Jersey
University of Iowa
Iowa City, Iowa LIBORIO PARRINO, MD
Professor of Neuroscience
PATRICK LÉVY, MD, PhD Department of Neuroscience
Director, HP2 Laboratory University of Parma
President, Joseph Fourier University Parma, Italy
Professor
Locomotion Rehabilitation and Physiology Department JEAN-LOUIS PÉPIN, MD, PhD
Grenoble University Hospital Head of Clinical Physiology, Sleep, and Exercise Clinic
Grenoble, France HP2 Laboratory
Head of the Clinical Research Team
DEBORAH C. LIN-DYKEN, MD, FAAP Joseph Fourier University
Clinical Associate Professor of Pediatrics Professor
Division of Pediatric Neurology, Development, and Locomotion Rehabilitation and Physiology Department
Behavior Grenoble University Hospital
Roy J. and Lucille A. Carver College of Medicine Grenoble, France
University of Iowa
Iowa City, Iowa FEDERICA PROVINI, MD, PhD
Assistant Professor of Neurology
RAMAN K. MALHOTRA, MD IRCCS Istituto delle Scienze Neurologiche di Bologna
Assistant Professor of Neurology Department of Biomedical and Neuromotor Sciences
Co-Director, SLUCare Sleep Disorders Center University of Bologna
Department of Neurology and Psychiatry Bellaria Hospital
Saint Louis University School of Medicine Bologna, Italy
St. Louis, Missouri
GEORGE B. RICHERSON, MD, PhD
RONEIL MALKANI, MD Professor and Head, Neurology
Assistant Professor Professor, Molecular Physiology and Biophysics
Department of Neurology The Roy J. Carver Chair in Neuroscience
Northwestern University Feinburg School of Medicine Roy J. and Lucille A. Carver College of Medicine
Chicago, Illinois University of Iowa
Iowa City, Iowa
MAURO MANCONI, MD, PhD
Head of Service RENAUD TAMISIER, MD, PhD
Sleep and Epilepsy Center Clinical Physiology, Sleep, and Exercise Clinic
Neurocenter of the Southern Switzerland HP2 Laboratory
Civic Hospital of Lugano Joseph Fourier University
Lugano, Switzerland Associate Professor
Locomotion Rehabilitation and Physiology Department
PIERRE MAQUET, MD, PhD Grenoble University Hospital
Professor and Director Grenoble, France
Cyclotron Research Centre
Department of Neurology MARIO GIOVANNI TERZANO, MD
University of Liège Professor of Neurology
Liège, Belgium Department of Neuroscience
University of Parma
JASON MAXFIELD, MD Parma, Italy
Fellow in Sleep Medicine
Department of Neurology Sleep Disorders Center
Roy J. and Lucille A. Carver College of Medicine
University of Iowa
Iowa City, Iowa
CONTRIBUTORS xiii
ROBERT J. THOMAS, MD, MMSc MARCO ZUCCONI, MD
Assistant Professor of Medicine Physician
Harvard Medical School Sleep Disorders Center
Instructor in Medicine, Pulmonary, Critical Care, and Department of Clinical Neurosciences
Sleep Division San Raffaele Institute and Hospital
Beth Israel Deaconess Medical Center Milan, Italy
Boston, Massachusetts
PHYLLIS C. ZEE, MD, PhD
Benjamin and Virginia T. Boshes Professor in Neurology
Professor of Neurobiology
Director, Sleep Disorders Center
Northwestern University Feinburg School of Medicine
Chicago, Illinois
C H A P T E R 1
Polysomnographic
Recording
Technique
Sudhansu Chokroverty
Sushanth Bhat
The most important initial step in the evaluation of a Patient Preparation and Laboratory
patient with sleep complaints is a detailed and focused in- Environment
clinic interview and physical examination by an experienced
provider, which helps generate a differential diagnosis. In The goal of a PSG study is to recreate a typical night’s sleep
selected patients the diagnostic polysomnogram (PSG) for the patient so that recorded parameters are most clini-
then plays a pivotal role in confirming the clinician’s suspi- cally relevant. Towards this end, most modern sleep labora-
cions and helps guide further management. tories have bedrooms that are quiet, clean, comfortable, and
A routine overnight PSG records multiple physiologi- tastefully decorated. Televisions, Internet and telephone
cal characteristics simultaneously during sleep. In general, access, adjacent bathrooms, and individual temperature
patients spend one entire night in the sleep laboratory control are standard in most laboratories. Many patients are
with the goal of capturing a typical night’s sleep. The study encouraged to bring their own pillows, blankets, pajamas,
assesses wakefulness and sleep stages, respiration, cardio- and reading material to improve the sense of familiarity,
pulmonary function, and body movements. Electroenceph- which eases patient anxiety and makes sleep easier. Within
alography (EEG), electro-oculography (EOG), and chin reason, lights-out and lights-on times (the beginning and the
muscle electromyography (EMG) channels are used to stage ending of the recording) should match the patient’s regular
sleep. Airflow and respiratory effort channels are used to bedtime and waking time, so as to prevent falsely shortened
score sleep-disordered breathing. The finger pulse oximetry or prolonged sleep onset and rapid eye movement (REM)
channel provides additional data in this regard, as well as sleep latencies. Children being studied in the sleep labora-
being helpful in identifying sleep hypoxemia independent of tory may often present with special needs, and this is dis-
apneic and hypopneic events. In patients undergoing contin- cussed in depth in Chapter 17.
uous positive airway pressure (CPAP) titration for obstruc- It is equally important that the technologist performing the
tive sleep apnea (OSA), the C-flow channel provides the study have a basic understanding of PSG equipment (includ-
airflow signal, and CPAP pressure is continuously adjusted ing amplifiers, filters, sensitivities, and simple troubleshoot-
during the night to eliminate respiratory events. Limb EMG ing), as well as knowledge of important sleep disorders and
channels are typically placed on the legs (usually the tibialis the reason a particular patient is being studied in the sleep lab-
anterior muscle) and aid in the scoring and evaluation of limb oratory. Well-designed questionnaires and a succinct clinical
movements. Additional limb EMG channels may be used in summary from the referring physician help a great deal in this
special montages (see Electromyography Recording During regard. With this information an experienced technician can
Standard Polysomnography ). A single-channel electrocar- make the necessary protocol adjustments so that the desired
diography (ECG) channel and a snore channel are part of clinical data are obtained through an efficient recording. Tech-
the typical PSG setup. Video and audio recording are essen- nicians should also be ever vigilant for artifacts that may occur
tial for recording position and evaluating abnormal move- during the recording and address them as soon as possible.
ments and behavior in sleep (such as bruxism, catathrenia, As mentioned, simultaneous video and audio recording
and various other parasomnias). Video-audio PSG (video- to monitor behavior during sleep is invaluable during the
PSG) is now the recommended technique for in-labora- PSG. It is advantageous to use two cameras to view the
tory evaluation of sleep disorders. Special techniques, not entire body. A low-light-level camera should be used to
part of routine recording in most laboratories but used in obtain good quality video in the dark, and an infrared light
selected patients, include measurements of intraesophageal source should be available after turning the laboratory lights
pressure in patients with suspected upper airway resistance off. The monitoring station should have remote control that
syndrome (UARS), which helps distinguish obstructive and can zoom, tilt, or pan the camera for adequate viewing, and
central apneas; esophageal pH in patients with nocturnal technicians should be alert to any abnormal movements
gastroesophageal reflux disease; and penile tumescence for and adjust the view accordingly. The camera should be
assessment of patients with erectile dysfunction. These are mounted on the wall across from the head end of the bed.
described in greater detail later. An intercom from a microphone near the patient should be
1
2 Atlas of Sleep Medicine
available. Technicians should also document the nature of environmental noise, which is likely to be seen at the two
any abnormal behavior and whether the patient was easily electrodes, is subtracted out and therefore cannot contami-
awakened from it, and they should regularly inquire about nate the recording. The ability of the amplifier to suppress
recollection of the episode, as well as dream recall (espe- an extraneous signal such as noise that is simultaneously
cially in a patient with suspected REM behavior disorder). present in both electrodes is measured by the common
mode rejection ratio. Ideally this ratio must exceed 1000
to 1, but most contemporary PSG amplifiers use a ratio in
Technical Considerations and
excess of 10,000 to 1.
Polysomnography Equipment
The amplifiers used consist of both alternating current
Biological signals recorded during PSG are of very small (AC) and direct current (DC) amplifiers. The AC ampli-
amplitude (EEG, EOG, and EMG activity is in the micro- fiers are used to record physiological characteristics showing
volt range) and need to be amplified to be displayed and high frequencies, such as EEG, EOG, EMG, and ECG. The
analyzed. These waveforms also need to be filtered to best AC amplifier contains both high- and low-frequency filters.
visualize activity of interest and exclude artifact. PSG equip- DC amplifiers have no low-frequency filters and are typi-
ment is thus basically a series of amplifiers that records and cally used to record potentials with slow frequency, such
amplifies this activity and then passes it through adjustable as the output from the oximeter, the output from the pH
filters for display at different sensitivity settings. meter, CPAP titration pressure changes, and intraesopha-
High-frequency (or low-pass) filters attenuate all activity geal pressure readings. AC or DC amplifiers may be used to
at frequencies higher than the value at which they are set, record respiratory flow and effort.
while allowing lower frequency activity to pass. For exam- Sensitivity is expressed in microvolts per millimeter or
ple, EEG channels are typically set with a high-frequency millivolts per centimeter. Sensitivity switches should be
filter at 70 Hz. This setting would attenuate any activity adjusted to obtain sufficient amplitude for interpretation.
above 70 Hz but allows lower-frequency activity to pass Sensitivity and filter settings vary according to the physi-
through unchanged. Low-frequency (or high-pass) filters, ological characteristics recorded (Table 1.1).
on the other hand, attenuate all activity lower than the value The standard speed for recording traditional PSG is 10
at which they are set, while allowing faster-frequency activ- mm/sec so that each monitor screen is a 30-second epoch,
ity to pass. EEG channels, typically set at 0.3 Hz, would making sleep staging easiest. A 30-mm/sec speed is the tra-
therefore attenuate out any activity slower than 0.3 Hz but ditional speed at which EEGs are analyzed, because it allows
allow higher-frequency activity to pass through unchanged. easy identification of epileptiform activities. While review-
These filters can be adjusted to eliminate known sources ing the PSG at the traditional 10-mm/sec speed, the poly-
of artifact. For example, decreasing the high-frequency fil- somnographer may pick up EEG abnormalities that can be
ter from 70 Hz to 35 Hz may eliminate faster-frequency better analyzed by slowing the recording down to 30 mm/
artifacts like muscle artifact, whereas increasing the low- sec. On the other hand, with experience, polysomnogra-
frequency filter from 0.3 Hz to 1 Hz may attenuate slower- phers may choose a 5-mm/sec speed, rendering a 60-second
frequency artifacts like sweat artifact. Most PSG amplifiers epoch, to better visualize respiratory events.
also have a 60-Hz notch filter, which attenuates the main
frequency while attenuating activity of surrounding fre-
Electroencephalography
quency less extensively. This is particularly useful in studies
contaminated by 60-Hz artifact (the frequency of electrical The main purpose of EEG recording performed during PSGs
activity in North America; the frequency in other countries is to distinguish between wakefulness and the various stages
is usually 50 Hz), generally seen if the electrode application of sleep. This is further elaborated on in Chapter 3. Accord-
and impedance are suboptimal. The use of the notch filter, ing to the 2007 AASM Manual for the Scoring of Sleep and
however, is generally discouraged because some important Associated Events, a minimum of three channels (F4-M1,
components in the recording, such as muscle activity and C4-M1, O2-M1) representing the right frontal, central, and
epileptiform spikes, may be attenuated. Thus the technician occipital electrodes referenced to the contralateral mastoid
should ideally attempt to eliminate this artifact at the time electrode is recommended, with corresponding backup
of recording by reapplying electrodes and attempting to iso- electrodes over the left hemisphere (F3-M2, C3-M2,
late and eliminate the source of the artifact. The differential O1-M2) referenced to the contralateral mastoid electrode,
amplifier is generally sufficient to reject 60-Hz artifacts. in case of malfunction of the primary electrodes. Although
PSG equipment uses differential amplifiers, which the montage just described would theoretically be suffi-
amplify the potential difference between the two ampli- cient to detect a posterior dominant rhythm in wakefulness
fier inputs. The result of this is that unwanted extraneous (best seen in occipital leads) and major sleep architecture
Table 1.1 Filter and Sensitivity Settings for Polysomnographic Studies
Characteristics High-Frequency Filter (Hz) Time Constant (sec) Low-Frequency Filter (Hz) Sensitivity
Electroencephalogram 70 or 35 0.4 0.3 5-7 μV/mm
Electro-oculogram 70 or 35 0.4 0.3 5-7 μV/mm
Electromyogram 90 0.04 5.0 2-3 μV/mm
Electrocardiogram 15 0.12 1.0 1 mV/cm to start; adjust
Airflow and effort 15 1 0.1 5-7 μV/mm; adjust