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Sleep apnea linked to silent strokes
February 1st, 2012
09:00 AM ET

Sleep apnea linked to silent strokes

Lisa Shives, M.D., is the founder of Northshore Sleep Medicine in Evanston, Illinois. She blogs regularly on The Chart. Read more from her at Dr. Lisa Shives’ Sleep Better Blog.

This week, a study was presented at the American Stroke Association’s International Stroke Conference that caught my eye.  It's a small study that adds further evidence to what most sleep experts already know - that obstructive sleep apnea (OSA) is linked with a high risk of having silent strokes.

OSA is the most common form of sleep apnea, according to the National Institutes of Health.  More than 12 million Americans are believed to suffer from this sleep disorder. People with sleep apnea stop breathing for 10 to 20 seconds or longer and this can happen at least 20 to 30 times an hour. 

In this new study, researchers at Dresden University in Germany, looked at silent strokes and the prevalence of OSA in 56 patients who had been hospitalized for a major stroke.

What’s the difference between a major stroke and a silent stroke?  Silent strokes are usually only detected by imaging the brain with an MRI and/or CT scan which can show areas of damage even though the person was not aware of an obvious neurological deficit at the time of the scarring.

Silent strokes have been linked to an increase risk for a major stroke. Therefore, if we can establish and then eliminate risk factors for silent stroke, theoretically, we can prevent major strokes that kill and disable.

The stroke victims in the study were broken into two groups: Those who had evidence of silent strokes and those who did not.  They also looked at those who had evidence of chronic damage to the small blood vessels in the brain and those who did not.  They wanted to see if OSA was more prevalent in those with silent stroke and chronic vascular damage.

Ninety-one percent of the study’s patients had obstructive sleep apnea, identified by an overnight sleep test.  This is an extremely high prevalence rate for OSA if we consider that the rate for general population of middle age and older adults is 20 to 25%.

Unfortunately, this high prevalence rate makes it difficult for researchers to study the question that most interests them: Is OSA a predictor and possibly contributing cause of silent stroke?

Almost everyone in the study had OSA, whether they had evidence of silent stroke or not, so it's hard to say that OSA is an independent predictor of silent stroke.  OSA is not only a risk factor for major stroke, but can be a consequence of stroke. Therefore, we cannot assume that OSA preceded the major stroke or the silent strokes.

All limitations aside, this study looks at important questions. Obstructive sleep apnea is still an under-diagnosed disorder, and given the strong association with stroke, it behooves researchers to uncover any links between the two.

Here’s some more on sleep apnea:

OSA is defined as a collapse of the upper airway that occurs when the tissues in the throat relax with sleep.   When the soft tissue in the back of the throat is relaxed, it can block the flow of air.  This leads to a drop in oxygen, a rise in carbon dioxide, an increase in adrenalin, an increase in blood pressure and an increase in arousals from sleep that can be so brief that the patient is unaware of them.

OSA is significant if it occurs more than 5 times per hour and is associated with daytime sleepiness, cognitive dysfunction, hypertension, and cardiovascular disease.

Even in the absence of associated symptoms or diseases, if you stop breathing more and 15 times per hour, it's considered unhealthy and treatment is recommended.  Moderate-to-severe OSA increases the risk not just of stroke, but also heart disease, high blood pressure, diabetes and obesity.

Those who are overweight or have a small throat are at greatest risk.  Men are twice as likely as women to have OSA, but after menopause that gender difference disappears and women are just as likely to have it.  This could be one of the reasons why many women who had no previous trouble with sleep find that during and after menopause, their sleep is plagued with frequent awakenings.

It is important to keep in mind that children and teenagers can have OSA too, often due to enlarged tonsils and can be misdiagnosed with behavioral, learning and psychiatric disorders when the root of the problem is actually something as easy to diagnose and treat as sleep apnea.

The good news is that one overnight sleep study, whether in a sleep center or at home, can easily detect apnea. There are several effective types of treatment including continuous positive airway pressure (CPAP), mandibular advancing devices and Provent, a new therapy that can stent the airways using non-mechanical airflow resistance.


soundoff (43 Responses)
  1. ksmahoney

    Increasing your regular physical activity can reduce the severity of sleep apnea, even in the absence of weight loss.
    Sara from http://www.losingtogether.com

    February 1, 2012 at 09:48 | Report abuse | Reply
  2. palintwit

    This article goes a long way to explain why Sarah Palin is brain dead.

    February 1, 2012 at 10:22 | Report abuse | Reply
    • Stephanie

      I am in no way a Palin fan. In fact, I don't like the woman. But even so, I cannot find the relevence in your comment.

      February 1, 2012 at 13:09 | Report abuse |
    • Steve J.

      Ok, that made me laugh out loud!

      February 1, 2012 at 21:47 | Report abuse |
    • Mr. Turdstool

      You must have contracted the "Moochelle Disorder" in which shtt oozes from your mouth (or keystroke, in this instance).

      February 13, 2012 at 15:53 | Report abuse |
    • EricF

      So, you felt that a serious article about sleep apnea and strokes was the appropriate forum for a negative comment about Sarah Plain? What does that say about your maturity level?

      March 22, 2012 at 01:46 | Report abuse |
    • Yyusuff

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      April 8, 2012 at 10:55 | Report abuse |
  3. Bob

    I have been recently diagnosed with sleep apnea. I apparently wake up 20-30 times in an hour, at the worst. This is frustrating because I exercise regularly, have no problems with my weight, and do not smoke. Plus I am only 44 and am upset that I will be tethered to a CPAP machine for the rest of my life. Surgery won't help me, according to the docs. It stniks because there seems to be no effort on curing this for people like me – just treating it.

    February 1, 2012 at 10:32 | Report abuse | Reply
    • Nancy

      There is a dental device you can look into that may help with your sleep apnea. I have heard that it is used by US soldiers serving in combat zones who have sleep apnea. I would ask my dentist about it.

      Good luck and hope this helps

      February 1, 2012 at 11:17 | Report abuse |
    • diabetic

      Welcome to the world of chronic diseases. I'm young and perfectly healthy but I'm hooked to an insulin pump for the rest of my foreseeable future, and the likelihood that a completely effective cure will be found within the next 20 years is extremely low thanks to the still not quite understood genetic mechanisms behind type 1 diabetes. (near perfect treatment, perhaps yes, but certainly not a cure)

      I wish I could tell you something else but unfortunately you will just have to live with it. Be thankful for the health that you do have and that your daily life is not affected. Looking at the negatives for too long will only make your life worse.

      February 1, 2012 at 11:40 | Report abuse |
    • xeno

      I know the thought of a CPAP machine forever is very frustrating, especially when you don't fit the typical apnea profile, but I have been working in a sleep lab for 13 years, and one of the most memorably bad apnea cases I have seen was a 95 pound, extremely healthy female. I would be willing to bet that it's an inherited issue for you and that other members of your family might need to visit the sleep lab, too! Also, there are people looking to cure apnea, but the surgical options were such a catastrophic and surprising failure, I think they're having to start from scratch. If you are only 44, I think there's plenty of hope that something will come along in your lifetime.

      February 1, 2012 at 12:37 | Report abuse |
    • John

      I'm a few years older than you (49) and have been using a CPAP for 5 years. Like you, although a big guy, I'm not overweight, excercise regularly, don't drink too much, watch what I eat. I had a heart attack at 42, which the cause was not properly diagnosed. At 44, I was lovingly forced into a sleep lab where they finally figured out the reason! And honestly, after the first two or three nights of fighting with the machine, I've never looked back. If they come out with another effective treatment, I'm first in line. But I've been pretty happy with the CPAP treatment–although, traveling is always a bit of a pain having to lug the machine around. I sleep great every night. It's almost like a meditation at this point. Once I put on the mask, I'm alseep within minutes. It certainly ain't sexy, but neither is snoring and freaking your partner out with worry as to whether or not you're going to breathe again. And, it's a heck of a lot better than having a heart attack or stroke! Good luck!

      February 2, 2012 at 11:02 | Report abuse |
    • Blood Disorder

      Bob,

      I am 25 years old and I have been diagnosed with a blood disorder and daily-chronic-migraines and now I have to have treatment for the rest of my life.
      During all the endless testing I have endured, at Mayo Clinic, in the last 2 years my doctors also discovered that I have Sleep Apnea too (I am average weight for my height).I understand that it is not "sexy" at all but understand that CPAP is 99% effective at treating it; others routes like Night Guard are not as effective and surgery which is gruesome may or may not work.
      Believe me being this young and having to carry this machine when I travel or visit family and friends was hard to accept and embarrassing–but thankfully everyone was extremely supportive and now I am more comfortable with it. And to be quiet honest I will never, ever get used to this machine, but it's the machine or my health.
      I hope you have great doctors who are willing to sit with you and educate you, but also educate yourself too. I can write to you a lot more but point is that things can always be much worse. Many people wish to have just what you have, believe me.

      February 10, 2012 at 03:00 | Report abuse |
    • John

      I underwent surgery for OSA just last week because I couldn't tolerate the CPAP system so be thankful you can avoid the surgery because surgery is not a guaranteed cure. CPAP is still the best solution for OSA at the moment. I won't know whether the surgery has fixed or even reduced my problem for another couple of months.
      One thing you may want to look into is Provent. I don't work for the company but I did try it out in my last sleep study prior to surgery and it reduced my episodes from 35/hr to 19/hr. Not a cure for me but depending on the severity of your situation it might be an alternative.
      I'm hoping that if the surgery doesn't completely resolve the problem that the Provent might be able to make up the difference. It was much easier to tolerate than the CPAP (for me anyway) and the device is small and disposable (daily) so overall I think just easier to deal with than the CPAP from a travel and maintenance perspective. However, unlike a CPAP system, no data can be recorded about your sleep and that may be important in some situations so it may not work for everyone. but it's pretty new and not many doctors are even aware of it yet (my doctor had not yet heard of it when I brought it to his attention) so you should ask about it if it wasn't mentioned as an option.

      February 28, 2012 at 09:28 | Report abuse |
  4. Jenny

    I got a CPAP machine last week after years & years of extreme exhaustion. I was very reluctant to get a machine I would have to use each night, but the past couple months I have been so tired I could not even think straight, even after mutliple days a week of napping. I have only been on CPAP for 7 nights & feel a world of difference when it comes to how I feel. It definitely takes an open mind to use one of the machines, as it is a hassle and can be uncomfortable, but it is a small price to pay for having a good nights sleep. I have been doing a lot of online research on the side effects of apnea & it seems there are many. I recommend anyone who doesn't feel they are getting good sleep to go in for a sleep study to see if you have apnea. You will be glad you did.

    February 1, 2012 at 11:34 | Report abuse | Reply
  5. Bob

    Thanks Nancy. The stuff the dentists make usually work better for those with mild apnea, according to my dentist who I trust. My apnea is classified as severe. Because I wanted to try anything else than the CPAP machine, my dentist recommended trying the "Pure Sleep" anti-snoring device as an intermediary step.before paying the high cost to have a dental device made. Apparently it works along the same principles as the more costly dental device but does not last as long. I did buy it and it only was a marginal helpful. I guess the only good news here is that I did not wind up paying extra $$ for devices or surgery that did not work. I do appreciate the suggestion.

    February 1, 2012 at 11:40 | Report abuse | Reply
  6. Bubba

    I have apnea. I was first diagnosed in the late 90's and was told I have 70 episodes in one hour. 5 years ago I lost a lot of weight. I went from a high of 360 lbs to present day 190. My last sleep study showed that I no longer have apnea. However, I still must use my CPAP machine because of heart problems. When I stop using the CPAP my weight goes up from fluid retension. There needs to be more studies done.

    February 1, 2012 at 11:41 | Report abuse | Reply
    • xeno

      That's fantastic about your weight loss! No doubt it has improved your apnea a lot. Also, I'm glad that you're still using the CPAP–one of the little known facts for patients is that the "rules" that stipulate the definition of an apnea have changed since the 90s, which actually results in fewer apneas being counted, raising the bar for how much disruption must occur to receive the diagnosis. This is frustrating when research is beginning to show that even "events" that don't qualify a person as having sleep apnea are nonetheless detrimental to health. More studies needed, indeed!

      February 1, 2012 at 12:17 | Report abuse |
  7. Armand

    I too was diagnosed with severe sleep apnea and have tried just about everything out there. CPAP machines, all kinds of different masks, dental devices, straps to keep you jaw closed, even the Provent. I have not tried surgery because of the really bad pain involved (I'm 63) and no guarantee it will work. Best so far is the soft mask made of cloth but you still have tubes and straps. As someone else remarked, welcome to the world of chronic diseases. Can't cure it just put a mask on.

    February 1, 2012 at 12:18 | Report abuse | Reply
    • Qasir

      I recently odicsvered your own article and have already been reading through together. I wish to convey my admiration of the composing ability and capability to help to make visitors study right from the start towards the end. I must read more recent posts and to reveal my personal ideas along with you.

      April 14, 2012 at 11:56 | Report abuse |
  8. Jason

    It was speculated ever since I was in high school that I had sleep apnea, but it wasn't until recently that a doctor investigating some anxiety problems suggested I get checked. It was found that I have severe apnea. Now that I'm on a CPAP, I'm more awake, relaxed, and my blood pressure (which I've had trouble with since my early 20s) is dropping nicely.

    February 1, 2012 at 12:52 | Report abuse | Reply
  9. Joe Flanks

    It could be worse you could have an ascending aortic aneurysm repair and metal aortic valve, be on blood thinners for life, tick like a watch constantly and have a CPAP to boot like me. Without a CPAP you risk damaging your heart permanently, higher blood pressure so you're at a higher risk of an aneurysm. The only thing I have to question is if you get used to the CPAP if can ever live without it. I believe they cause a permanent dependency if your apnea is caused by weight as its letting your muscles be lazy. Just like old blood pressure meds once your on them you never come off even if you lose weight and exercise because the old ones shutdown your body's ability to regulate. If so many people have apnea how have we made it this far as a human race, it would seem their is another underlying cause.

    February 1, 2012 at 13:23 | Report abuse | Reply
  10. Mike

    I'm sorry, but I do not put any stock in this test! I have apnea. I was diagnosed 20 years ago by my wife. She had worked in the medical care field, and had attended a seminar telling the sounds of apnea. Apnea is best diagnosed by someone else! This test does not say how many being tested were already on CPAP. From what I read, there were none. How can the two be connected?

    February 1, 2012 at 15:03 | Report abuse | Reply
  11. Dee

    I complain about the annoying drymouth caused by the CPAP machine but, I have been sleeping better.

    February 1, 2012 at 15:27 | Report abuse | Reply
    • Someone

      Do you have a humidifier with your machine? It may help.

      February 1, 2012 at 15:59 | Report abuse |
    • Trudy

      Dee, Dry mouth was a real problem for me even though my machine has a humidifier. I have had to switch my mask to a full face type...chin straps didn't work. This has made a big difference for me.

      February 11, 2012 at 20:05 | Report abuse |
  12. Bojidoc

    Dental reposition appliances are now approved for mild and moderate sleep apnea and are just as effective as cpap. I have used mine for 6 moths and sleep much better. ( My wife sleeps much bettter as well which makes life much smoother!) Bottom line, if you are tired, snore or your spouse reports you stoip breathing, have a sleep test and get some help.

    February 1, 2012 at 16:50 | Report abuse | Reply
  13. Linda S.

    It all sounds rather fishy to me. Silent strokes due to sleep apnea. I would think there would be other symptoms, i.e. numbness, mild paralysis, dizziness, headaches, double vision. I think you would be having more severe symptoms having sustained "mini-strokes" then just being constantly tired and fuzzy brained.

    February 1, 2012 at 17:05 | Report abuse | Reply
    • Tdaldan

      I have sleep apnea, and I'm tired, careless during the day at work. http://www.jobnak.com I hope to stay unemployed.

      February 2, 2012 at 03:43 | Report abuse |
  14. Steve J.

    I have OSA and when I applied for private health insurance (as I am self-employed) I was turned down for coverage. They listed 4 reasons why I was "too much of a risk" to insure. One was laughable; when I was a teen, 30 years ago, I was cautioned that I might be getting scoliosis. Nothing ever came of it, but it was in still in my medical record. The other 3 were borderline hypertension, anxiety disorder and finally OSA. I cringe when I read articles and studies like this as they are just the things that jittery insurance underwriters use as reasons for refusal of coverage. The headline of the article is "Sleep Apnea Linked to Silent Strokes" but the study showed that most of the group had OSA, whether or not they had had silent strokes. It was also a very small study sample. The arcticle also doesn't tell if the study investigated other possible risks that might have been present (ie obesity, level of activity, etc). I believe that this study may suggest further studies into the matter, but by no means does it imply what the headline says. Please be careful what you write; it effects people in ways that you might not expect. Thank you!

    February 1, 2012 at 21:43 | Report abuse | Reply
    • Stentor

      And yet people complain about the Health Care Reform Act as somehow being socialism because it forces them to get coverage, which is complete BS, as it is more about holding the for-profit insurance companies feet to the fire to stop them from excluding pre-existing conditions on a whim, because in your case, they clearly have no merit. I guess the word of warning to everyone out there, and parents of small children is to not allow any sort of potentially damaging commentary inserted into the medical record, or stipulate that it be removed after a specific time period has elapsed.

      February 2, 2012 at 13:04 | Report abuse |
  15. Kathryn (Kathy) (Bogala) Calgary Alberta

    Weight loass and exercise is a big help in reducing sleep problems!

    February 2, 2012 at 15:06 | Report abuse | Reply
    • RM

      Not always...I exercise 6 days a week, sometimes twice a day and have lost 35 pounds, went from 205 to 170 and I still have sleep apnea and insomnia. The CPAP treatment took care of my sleep apnea and starting a routine of daily meditaion and other lifestyle changes tookcare of the insomnia.

      March 28, 2012 at 12:02 | Report abuse |
    • SOKB

      Kathy, weight loss and exercise are not necessarily a cure for sleep apnea. You tend you over simplify any serious medical problem you read about, be it sleep apnea, or cancer. It's most disturbing that you feel you know the answer to other peoples chronic health issues and that they are all very simple.

      April 10, 2012 at 17:14 | Report abuse |
  16. deauntay McKinney

    deauntay mckinney says: Wow this is very good and lifesaving information

    February 26, 2012 at 21:15 | Report abuse | Reply
  17. Sheri

    My husband and I found out the hard way that private insurance will deny you coverage if you have sleep apnea. He was diagnosed with borderline apnea and no other health issues, but I couldn't sleep in the same room with him due to his hereditary snoring so he got the CPAP. After I quit my job and we applied for private health insurance he was told that no insurance company would cover him b/c of the apnea and it did not matter to what degree he had it. He's now black listed from getting private insurance and we had to elect to go on the Pre-Exisiting Condition Plan thru the gov't. Thank God for that option! And for those who don't know, we pay for the policy, it's not free or discounted. It's $300/mth with a $1500 deductible per person.

    March 27, 2012 at 12:48 | Report abuse | Reply
  18. SOKB

    RM, Kathy fancies herself an expert with respect to a variety of chronic health issues. If you don't eat well, you get cancer; don't exercise or diet, you'll have sleep apnea. Wow, I wonder if doctors realize how simple life threatening illnesses really are? While eating well, exercising, etc. can help you lead a healthy life they do not by any means guarantee you will avoid serious illness.

    April 10, 2012 at 17:19 | Report abuse | Reply
  19. Sairra

    I must say, as a lot as I enjoyed raeidng what you had to say, I couldnt help but lose interest after a while. Its as if you had a wonderful grasp to the topic matter, but you forgot to include your readers. Perhaps you should think about this from additional than one angle. Or maybe you shouldnt generalise so much. Its better if you think about what others may have to say instead of just going for a gut reaction to the topic. Think about adjusting your personal believed process and giving others who may read this the benefit of the doubt

    April 14, 2012 at 13:57 | Report abuse | Reply
    • Edo

      Know your insurance caogrvee/DME/referrals/deductibles. BUY DIRECT local or online DME suppliers. They can and will provide service, support replacement parts. Let the Sleep Center provide your doctor/physician, they STILL CAN read your equipment get the data needed. Make CERTAIN you can use products from different manufacturers. A CPAP machine from ResMed, mask / headgear from Resprionics or whatever combination fits YOU best. Not what is best for their bottom line and their convenience.

      May 24, 2012 at 06:19 | Report abuse |
  20. Gerald

    Kaiser Permanente only use the entire facemask type. They gave it to me to test myself and at 2:30am it quit and I fought to remove the mask and did before smothering. This one looks a lot better not blocking mouth and nose.

    May 13, 2012 at 11:03 | Report abuse | Reply
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    July 31, 2012 at 02:41 | Report abuse | Reply
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  23. Chelsea Sawyer

    Very informative content. I never knew sleep apnea could lead to stroke. All I know is that it could cause heart disease. I read this from Lifestyle Menu. Thank you for enlightening all of us.

    August 19, 2013 at 04:09 | Report abuse | Reply

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