- Email: [email protected]
Sleep and psychiatric disorders
S76
Sleep and psychiatric disorders Ip 17.01
The effects of temazepam on sleep quality, EEG slow waves and sleep spindles are correlated
Ip17-03
I
The value of ambulatory poly somnography in th e diagnosis of excessive da ytime sleepiness
B. Kemp , K. Zwinderman . Center for Sleep and Wake Disorders, MCHwesteinde Hospital, Den Haag, The Netherlands
RJ . Schirnsheimer , M.M.R. Verhelst Center fur Sleep and Wake Disorders, MCH, Westeinde Hospital, The Hague , The Netherlands
Benzodiazepines such as temazepam enhance sleep spindle activity, reduce EEG slow-w ave activity and improve slee p qualit y. We have analyzed these effects by accurate automatic quantification of EEG slowwave time, spindle time and subjectively assessed sleep quality. In 22 subjects, PzOz EEG was recorded during 2 nig hts that were at least I week apart. Each subject took 20 mg of temazepam on one of the two nights. Temazepam enhanced spindle time by (on average, per night) 90 min (P < 0.00 1), reduced slow-wave time by 70 min (P < 0.001), and improved sleep quality by 4 on a scale of 16 (P < 0.002). Despite the tem azepam -induced reduction of slow-wave time, we found a significant (P < 0.03) pos itive correlation (r = 0.48) between sleep quality and slowwave time and also a significant (P < 0.03) positive correlation (r = 0.52) betwee n spindle time and slow-wave time. Apparently, more improved slee p quality and more enhan ced spindle time correspo nd to less decreased slow-wave time. This ca n be ex plained by assuming that the spindle generator exe rts a direct influence on the slow-wave generator. Tn that case, regression analysis shows that the 90-min increase of spindle time causes a l OO-min increase of slow-wave time. Without this effect, temaz epam would have reduc ed slow-wave time by 170 min. Partial correlation analysis showed that both spindle time and slow-wave time are positively corre lated (P = 0.05 and P = 0.05, r = 0.36 and r = 0.37, respectively) to sleep quality. In this view, sleep qu ality dete riorates by the direct temazepaminduced slow-wave red uction, but both the direct increase of spindle time and the resulting compe nsatory increase in slow-w ave time improve sleep quality more.
Background: Tn our sleep cen ter ambulatory polyso mnography (APSG) is used the day and night before the MSLT to survey the quality of the night before the MSLT . Hence the question is raised if APSG can be used to diagnose excessive daytime sleepiness (EDS). To answer this question we retrosp ectively studied the result of the APSG the day and night before the MSLT. Method s: APSGs and MSLT s of 23 patients were reviewed - 12 men, II women, varying from 18 to 66 years of age. APSG is started in the afternoon of the day precedin g the MSLT . The mean registration duration during the day and evening, excluding night sleep, was 09.08 h. Results: MSLTwas positi ve in II patients, 6 patients showed REM sleep onset in one or more test periods. Nine out of these I I showed one or more naps during the APSG. MSLT was negative in 12, 6 out of these 12 showe d naps during the APSG. If we use MSLT as the go ld standa rd and classify APSG positive if there are 3 or more naps than the positive predicti ve value of the polysomnography is 80% and the negative predictive value 6 1% with a sensitivity of 36% and a specificity of 91%. From 6 patient s with REM periods in their MSLT 3 showed REM periods in thei r naps and polyso mnograph y and 3 did not. Concl usion: APSG can be used in the diagnosis of EDS. The positive predictive value is moderate. It can be optimize d when AP is performed the whole day under standardised conditio ns.
jP17.02
I
FFT analysis of MSLT recordings classified by visual adaptive scoring
S.-L. Himanen", J. Virkkala", A. Saastamoinen", M. Oksanen", J. Hasan", "Depart ment of Clinical Neurophysiology, Tampere University Hospital; "Institute of Occupational Health, Helsinki; ' Digiral Media Institute , Tampere University of Technology, Finland The scoring system of Rechtschaffen and Kales (RKS, 1968) is characterized by fixed, long epoc hs and insufficient number of sleep stages . In order to overcome these limitations we de veloped a method of visual adaptive scoring (VASS). Epochs of variable length and more stage catego ries than in RKS are used. The purpose is to obtain electro physiologicaJIy more stationary epochs . Multiple sleep latency test (MSLT) record ings from 6 apnea patients and 4 healthy volunteers were performed by recording of EEG, EOG. and EMG. The recordings were visually scored by RKS and VASS. The following VASS stages were defined by morphology: 3 stages of wakefulness, two drowsy stages , 4 arousal types. two light sleep stages and Stage 2. Mean frequen cy spectra of each RK S and VASS stage were calcu lated by FFr. FFr analysis of VASS segments resulted in improved distinction between wakefulness and light sleep as com pared to analysis of RKS epoc hs. Differences in spectra l characteristics of VASS stages were found (Friedman and Wilcoxon tests, P < 0.05). The results are in agreement with the idea that more distinctive resu lts in analysis of especially the sleep onse t period can be obtained with shorter, preferably adaptive segments as com pared to the use of 30 s epochs.
Ip 17. 04
I
Comparison of th e alpha attenuation test with the maintenance of wakefulness test
J. Virkkala, S. Pihl, M. Harma, K. Muller. BrainWork Laboratory, Finnish Institute of Occupation al Health, Helsinki, Finland There is a clear need for sim ple objective sleepiness tests to evalu ate, e.g. daytime somnolence. Most commonly used tests arc multiple sleep latency test (MSLT) and maintenance of wakefulness test (MWT). One of the other tests is the alpha attenuati on test (AAT) where the ratio of alpha power is calcu lated between eyes closed and eyes open. A smaller alph a attenuation coefficient (AAC) ratio indicates greater sleepiness. We measured AAT and MWT from 79 traffic safety workers after a baseline night by using the Somnologica software. AAT was admi nistered at 13:30 and MWT at 14:00. Subjects were instructed by a handheld co mputer to close and open eyes in I min periods during the 6 min AAT test. 02-A I channel was analyzed in 2.56 s artifact free epochs with the custom Matlab program . For both eyes closed and eyes open the mean, standard devia tion and median of power spectrum epochs were calc ulated . We compare d the spectrum of groups having at least a single sleep epoch in MWT to a group with no sleep epochs in MWT. Six subjects were excluded because their eyes closed alpha power was above 80%. From the remaining 73 subjec ts, there were 24 males and 6 females who had at least a single sleep epoc h. Th irty-seven males and 6 females had no slee p epochs . The spectrum of eyes closed and eyes open was different betwee n these groups. The main effect was seen in alpha band 7.8- /2 .1 Hz. Calc ulated AAC were 4.0 ± 2. 1 and 6.8 ± 4.7 (P < 0.0014), respectively, indicating a correlation betwee n AAT and MWT. Our data shows the feasibilit y of easi ly administere d AAT in screening daytime somnolence.
S77
Posters
Ip17-os I
Electrophysiological study of priming effect during sleep
F. Perrin'", L. Garcia-Larrea'", F. Mauguiere'", H, Bastuji'"; "Sleep Disorders Unit, Neurological Hospital; bUPRES EA 1880, University Claude Bernard; 'Human Neurophysiology, CERMEP, Lyon, France
While sleeping persons, in sleep stage II and paradoxical sleep can discriminate deviant tones in a series of monotone tones (Bastuji and Garcia-Larrea, 1999) as well as their own name in a series of other names (Perrin et aI., 1999), the question whether a strictly semantic discrimination is possible during sleep remains open. To further investigate the extent to which sleeping subjects can process the meaning of external stimuli, we recorded auditory evoked potentials, from 10 normal adults, in response to semantically related and unrelated pairs of words, during both waking (passive listening) and all night sleep. Six lists of 72 stimuli were elaborated: all were monosyllables and presented with a fixed 1200 ms interval. One third of stimuli were pseudo-words and were intermingled between either semantically related or unrelated pairs of words. During passive waking, a higher N400 potential was elicited in response to unrelated words relative to related words. This effect was also observed in response to pseudo-words which evoked a higher N400 wave than related words. During sleep stage II, a more negative potential, was observed to unrelated words and to pseudo-words relative to related words. AEP morphology during paradoxical sleep was similar to that observed in the waking state and a N400-like potential appeared in response to incongruous words. These results suggest that semantic priming effects are still operative during paradoxical sleep and sleep stage II.
Ip17-06
Consensus recommendation for the diagnosis and management of upper airway obstruction in South West Finland
M. Erkinjuntti, 1. Antila, B. Falck, P. Kangasniemi, I. Kantola, J. Karrnakoski, R. Kokkala, H. Korvenranta, O. Polo, E.-R. Salomaa, A.-L. Tamminen, K Vahatalo. Consensus Group of Upper Airway Obstruction, Hospital District of South-Western Finland, Turku, Finland The prevalence of obstructive sleep apnea syndrome is about 4% among men and 2% among women. Partial upper airway obstruction is almost as common as sleep apnea. There are around 20 000 patients with upper airway obstruction in our hospital district with a population of 450 000. The available resources for the diagnosis and management are limited; therefore the multidisciplinary team responsible for these patients has reached a common consensus recommendation. The Department of Clinical Neurophysiology at the University Hospital is responsible for the diagnostic network. Several recording units will be set up in the hospitals in the district. The primary care doctors refer patients directly for sleep studies either to local hospitals or to the university hospital. Patients with mild sleep apnea or partial upper airway obstruction arc treated conservatively within the primary health care by weight reduction and/or position treatment. If conservative treatment does not give results the patients are referred to university hospital in which patients with mild apnea without overweight will be candidates for surgery, while patients with moderate or severe apnea and/or obesity will primarily be treated with nasal-CPAP. With this model we achieve more effective diagnostic and treatment for this common disease.
Ip17-o7
Sleep in female alcoholics
W. Jernajczyk, B. Woronowicz, I. Musinska, J. Antczak, A. Wierzbicka. Institute of Psychiatry and Neurology, Warsaw, Poland Sleep in alcoholics during the abstinence characterized by shortening of sleep, fragmentation of sleep and reduction of delta sleep. There is no study about sleep pattern in female alcoholics. Polysomnographic sleep recordings were obtained from 45 untreated physically sound female alcoholics
(mean 39.0) with minimum 2 weeks period of sober and 45 age-matched normal female controls (mean 39.6). The technique of EEG sleep recording and sleep stage scoring was determined by visual examination using standard criteria. The following 14 parameters were analysed: total sleep time (TST), awaking time (AT), number of awaking (AN), sleep efficiency (SE), sleep maintenance (SM.), sleep latency (SL), REM latency (RL), percentage of stages I NREM (lNREM%), 2 NREM (2 NREM%),), delta sleep (DS%), REM sleep (REM%), latency of eye movement in each sleep cycles (LEM), mean latency of eye movement (M-LEM) and REM density (RD). In 8 conventional parameters of sleep pattern we obtained significant differences between female alcoholics and normal controls. The differences between female alcoholics and controls were: reduction of TST, increase of AT and NA, decrease of SE, shortening of RL, increasing of stage lNREM% and stage REM%, decrease of DS%. We found the significant longer LEM I and MLEM in female alcoholics then in female controls. Biological value of sleep in female alcoholics is dramatically worse then in controls.
Ip17-o8 I
Density of REM sleep in narcolepsy-cataplexy and polysymptomatic form of idiopathic hypersomnia
1. Vankova, S. Nevsimalova, KSonka. Department of Neurology, 1st Medical Faculty, Charles Univesity, Prague. Czech Republic
In the present work we focused on density of REM sleep in patients with primary hypersomnias in comparison with nonhypersomnolent subjects. Sixteen unmedicated patients with narcolepsy-cataplexy (NC), 10 unmedicated patients suffering from polysymptornatic form of idiopathic hypersomnia (lH) and their age- and sex-matched controls were included in the study. The clinical diagnosis was confirmed by MSLT, nocturnal PSG as well as by actigraphic monitoring. Polygraphical recordings were visually scored with special interest devoted to two most characteristic phasic features of REM sleep: number of rapid eye movements (EMs) and chin muscle twitches (Tws) per minute. These events were evaluated according to recognized criteria; we looked more closely at the frequency and their distribution across all the REM periods (REMPs) of the night. Our results show two main differences between hypersomniacs and controls concerning phasic activity: (l) REM density (expressed by number of EMs/min and Tws/min) is significantly increased in the hypersomniac patients (for EMs/ min P < 0.0 I in IH patients and P < 0.05 in NC, for Tws/min P < 0.05 in both groups of patients), with maximal values reached in idiopathic hypersomnia patients. (2) The intra-night distribution of phasic activity show more considerable rising in hypersomniac patients than in control group.
IP17-09 I
Melatonin as a sleep inducer for EEG in children
E. Wassmer?". E. Quinn'", P. Carter', N. Bonick c , P. Mocroft", W. Whitehouse":", S. Seri a.h. Departments of "Neurology and "Clinical Neurophysiology, Birmingham Children's Hospital, Birmingham, UK; "Department of Community Paediatrics, Walsall Community NHS Trust, Walsall, UK Aims: To determine the efficacy, safety and practicality of melatonin when used to induce sleep for EEG. Methods: One hundred children, aged 2-17 years, referred to two Clinical Neurophysiology Departments for sleep EEG were recruited. 48/100 had disordered behaviour. Informed consent was obtained and 2.5 or 5 mg of melatonin administered immediately prior to the EEG recording. Data was obtained from a detailed request form, the technical EEG report and, in 30, a follow-up telephone interview. Results: Eighty-four out of 100 fell asleep - average latency 30 min (:!::2 min 95% Cl). Sixty of the 84 attained stage 3 sleep. Seven of the 84 complained of feeling tired on waking up but there were no other adverse effects. All had normal looking sleep macro-structure. Epileptiform activity was seen in 40% of the sleep recordings. Conclusions: Melatonin induces sleep reliably and safely in children
S78
Posters
undergoin g EEG. It is a practical alternative to sleep deprivation when the specific activating effect of the latter is not need ed.
Ip 17-10
Central sleep apneas during fast nCPAP titration in patients with obstructive sleep apnea (OSA) syndrome
K. I1cheva. MANA Medical Center, Sofia, Bulgaria Severe obstructive sleep apnea (OSA) syndrome needs ultimatel y nCPAP treatment. The nCPAP titration process aims fully restoration of the patency of upper airways, compen sation of the obstructions and normalization of breathing patterns. A rapid increase in the nCPAP pressure compensates the obstructi ve sleep apneas, but frequently leads to occurrence of excessive repetiti ve central apneas. The latter breathing pattern is explained with the rapid normali zation of Sa02, increase in the pCOr wakening threshold, due to relati ve temporary hypocarbia . CO 2 and O2 sensors reset varies (minutes duration). A reduction of the nCPAP pressure level and slowly return of the titrati on process is recommended. The reported facts relate closely to the new technology for the automatic titration of nCPAP, which does not compens ate central apnea episodes.
IP17-11
Twenty-four hour EEG in Smith Magenis syndrome: EEG morphology and sleep studies in 9 cases
A.L. Frenkel ' , F. Salefranque", H. Deleersnyder'', aEFSN, Necker Enfants Malades, Paris, France; bUnite de Genetique Clinique, Necker Enfants Malades, Paris, France Sleep abnormalities, hyperactivity and self injuries are major issues in SMS caused by a chromosome deletion disorder (l7pI1.2). We investigated cyclic organization of slow wave sleep-REM sleep and the relation ship between melatonin wakefulness and sleep stages. 9 children (5 boys and 4 girls aged 4-1 8 years) were recorded with an ambulato ry system (Medilog 9000): 6 EEG, 1 electro -oculogram and I electromyogram of the trapezius. Serum melatonin level was determined every hour. We identified cyclic organization of SWS -REM Sleep. EEG showed particular aspects with humps, rapid activit y and elevated number of spikes and spikes-waves during sleep and wakefulness. We recorded sleep attacks in daytime showing the perturbation of circadian organization . Plasmatic and urinary melatonin was drastically low among each child. What can be the relationship between EEG modification and plasmatic melatonin? We need more investigations to understand physiopathology of SMS but it seemed important to point out these particul ar EEG features in diagnostic orientation of mental retardation and sleep disturbances.
IP17·12
I
Fatal familiar insomnia in a new Spanish family
S. Gimenez, M.D. de la Calzada , C. Nos', J. Yague", R. Rovira, C. Borras",
J. Castell, A. Sainz ", A. Rovira, 1. Casas, X. Montalban" "Hospital Universitari Vall d' Hebron , Unitat de Neuroinmunologia Clinica, Barcelona, Spain; "Hospital CLInic i Provincial, Barcelona, Spain Fatal familiar insomnia (FFI) is an autosomal dominant prion disease linked to the GAC-l-AAS mutati on in the codon 178 of the prion protein (PrP) gene (PRNP), resulting in the substitution of aspartic acid by a~par agine, coupled with a methion ine coding triplet in the mutant allele at polymorphic codon 129 . Clinicall y, it is characterized by progressive loss of the ability to sleep, dysautonomi a, endocrine and motor disturbanc es. The neuropathologic hallmarks are severe neuronal loss and astroglio sis of the thalamus. Phenot ypic variability has been linked at PRNP codon on the normal allele which determines homo and heterozygosity, modulating the age of onset and duration and the severity. According to this, we describe 2 new patients from the same famil y, with the clinical and pathologic featu res of FFY. A 48-year-old man, heterozy got Met/Val with an onset of depression, severe insomnia and ataxia and his cousine, a 55-year-old woman, homozigot MetlMet,with severe sleep and autonomic disturbances.
IP17-13
I
Is there an influence of repetitive transcranial magnetic stimulation on frontal EEG-asynunetl1' in depressive patients?
J. Heppne r", K. Bollow ' , J. Buchmann", J. Richter", G. Irmisch ", D. Schliifke' . "Department of Psychiatry and Psychotherapy; "Department of Child and Adolescent Neuropsychiatry, Centre of Nervous Disease. University of Rostock, Germany There is some evidence of relationship between asymmetri c anterior brain activation and affective style. An increa sed left frontal EEG-po wer in alpha band was reported in acute depressives in rest suggesting a left anterior hypoacti vation (Henriques and Davidson. 1991). Repetitive transcranial magnetic stimulation (rTMS) is a procedure in which regional electri cal brain activity is influenced by a pulsed magnet ic field. Some studies lent support for an antidepressant effect of high-frequency stimulation over the left dorsolateral prefrontal cortex (DLPFC) (Pascual-Leone et al., 1996;, Figiel et al., 1998; Triggs et al., 1999), whereas other authors reported an antidepressant effect of low-frequency stimulation of the right DLPFC (Klein et al., 1999; Feinsod et al., 1998). The aim of our investig ation is to study the influence of rTMS frequency and localisation on the baseline anterior alpha asymmetry in patient s with major depression. Preliminary we report about 10 patients, fitting DSM-lll-R criter ia for major depression. Four of the patients were treated with 20 Hz rTMS over the left DLPFC, 3 were stimulated with I Hz over the right DLPFC and 3 patients received a sham stimulati on. EEG data were recorded from 19 scalp electrodes during 10 min resting periods before and after the first. fifth and last rTMS-session and after 2 weeks (follow-up period). The alpha asymme try index (AI) for homologou s leads was calculated by the formu la: power (right minus left)/(right plus left). We could not find consistent changes of AI. In comparison to I Hz - and sham stimulation, 20 H7. rTMS, however, seems to have higher influence on a defined global EEG-p arameter (quantitative electroenceph alographi c ipsative difference assessment) describing spectral variations.
Ip17-14
I
Left frontal lobe high frequency repetitive transcranial magnetic stimulation in patients affected by depression: a case control pilot study on short- and long-term effect
M. Bortolomasi, P. Manganotti, G.M. Giacopuzzi, A. Fiaschi. Sezione di Neurologia Riabilitativa, Cam di Cura Villa S. Chiara, Universita' di Verona, Italy The effect of repetitive transcranial magnetic stimulation has been recently used as potential treatment on depression . Based on the hypoth esis that major depression may result from decreased activity on the left frontal function, high frequency rTMS has been applied to the left frontal lobe producing a mild but significantly clinical impro vement in the mood of depressed patients after the period o f stimulation. No information exists on the long-term effect of the high frequency rTMS on the patients affected by major depression. The aim of this study was to study the short- and longterm effect of rTMS on depressed patients. We performed the protocol of high frequency rTMS performed by George (1995). We admini stered rTMS each morning for 1 week (5 days) to the left frontal cortex in 16 patients (mean age 48 years) with primary mood disorders (8 bipolar disorders, 6 unipolar disorder ). Each morning subjects received 202 s train of rTMS at 20 Hz at 80% of motor threshold in muscles of right Thenar eminenc e (TE ). Repetitive TMS was applied to the left frontal hemisphere using a circ ular coil. On 16 patient s II patients were stimulated using the real rTMS, while 5 patients were stimulated using a placebo stimulation. Hamilton D and Beck inventory scales were performed before (T I) and after (T2) the treatment protocol and after I month (T3) from the rTMS. No adverse outcomes were noted in either groups. Significant antidepressant effect was noted in 9/1 1 treated patients on Hamilton and Beck depression rating scale (P < 0.05) immediately after the treatmen t. While no significant changes were noted in two treated patients . No significant changes on Hamilton and
Posters
Beck depression rating scale were noted in patients treated by a placebo stimulation. In 4/9 patients the antidepressant effect lasted less then 30 days. In 5 patients significant changes on Hamilton and Beck depression rating scale were present after I month (T3). In conclusion rTMS in psychiatric disorders seems to produce long-lasting effect on mood with deserves further investigation. Ip17.15
1
One case of paroxysmal arousals
M.e. Moja, L. Ambrogio, P.C. Gerbino PrOIniS, U. Dimanico, C. La Piana, G.P. Pellegrino, B. Picasso, E. Grasso. Department of Neurology, S Croce Hospital, Cuneo, Italy We present the case of one man aged 51 with no anamnestic relevant pathology. Since he was a child sleep disorders characterized by sudden arousals with vivid dreaming and nightmares are described. In the last 10 years sleep movements are described, starting after I h of quiet sleep, with
S79 abrupt muscle contractions, sometimes more complex, making the patient getting off the bed. These movements are stereotyped, last some seconds and are remembered by the patient himself. These symptoms are not described in the latter part of the night or in afternoon naps and when the patients falls asleep again after one episode, these arousals appear again. Due to these symptoms nocturnal sleep is disturbed but with no daytime somnolence. Multiple sleep Latency Test was normal with a medium latency of 17 min. Video-polisomnography showed 5 episodes in sleep phase 11 with abduction of the right upper limb, tremor and distonic posture of the hand which awake the patient with controlateral distonic posture and voluntary movements trying to stop it. These attacks last 30 s about and are always identical during each night recording. Electroencephalography disclosed a K complex followed by marked vegetative symptoms, muscle activity and arousal. Neuroimaging scans are normal. We conclude that this case can be diagnosed as complex motor attacks as paroxysmal arousals. Therapy by Carbamazepine 400 mg led to symptoms resolution.
Sleep and psychiatric disorders Ip 17.01
The effects of temazepam on sleep quality, EEG slow waves and sleep spindles are correlated
Ip17-03
I
The value of ambulatory poly somnography in th e diagnosis of excessive da ytime sleepiness
B. Kemp , K. Zwinderman . Center for Sleep and Wake Disorders, MCHwesteinde Hospital, Den Haag, The Netherlands
RJ . Schirnsheimer , M.M.R. Verhelst Center fur Sleep and Wake Disorders, MCH, Westeinde Hospital, The Hague , The Netherlands
Benzodiazepines such as temazepam enhance sleep spindle activity, reduce EEG slow-w ave activity and improve slee p qualit y. We have analyzed these effects by accurate automatic quantification of EEG slowwave time, spindle time and subjectively assessed sleep quality. In 22 subjects, PzOz EEG was recorded during 2 nig hts that were at least I week apart. Each subject took 20 mg of temazepam on one of the two nights. Temazepam enhanced spindle time by (on average, per night) 90 min (P < 0.00 1), reduced slow-wave time by 70 min (P < 0.001), and improved sleep quality by 4 on a scale of 16 (P < 0.002). Despite the tem azepam -induced reduction of slow-wave time, we found a significant (P < 0.03) pos itive correlation (r = 0.48) between sleep quality and slowwave time and also a significant (P < 0.03) positive correlation (r = 0.52) betwee n spindle time and slow-wave time. Apparently, more improved slee p quality and more enhan ced spindle time correspo nd to less decreased slow-wave time. This ca n be ex plained by assuming that the spindle generator exe rts a direct influence on the slow-wave generator. Tn that case, regression analysis shows that the 90-min increase of spindle time causes a l OO-min increase of slow-wave time. Without this effect, temaz epam would have reduc ed slow-wave time by 170 min. Partial correlation analysis showed that both spindle time and slow-wave time are positively corre lated (P = 0.05 and P = 0.05, r = 0.36 and r = 0.37, respectively) to sleep quality. In this view, sleep qu ality dete riorates by the direct temazepaminduced slow-wave red uction, but both the direct increase of spindle time and the resulting compe nsatory increase in slow-w ave time improve sleep quality more.
Background: Tn our sleep cen ter ambulatory polyso mnography (APSG) is used the day and night before the MSLT to survey the quality of the night before the MSLT . Hence the question is raised if APSG can be used to diagnose excessive daytime sleepiness (EDS). To answer this question we retrosp ectively studied the result of the APSG the day and night before the MSLT. Method s: APSGs and MSLT s of 23 patients were reviewed - 12 men, II women, varying from 18 to 66 years of age. APSG is started in the afternoon of the day precedin g the MSLT . The mean registration duration during the day and evening, excluding night sleep, was 09.08 h. Results: MSLTwas positi ve in II patients, 6 patients showed REM sleep onset in one or more test periods. Nine out of these I I showed one or more naps during the APSG. MSLT was negative in 12, 6 out of these 12 showe d naps during the APSG. If we use MSLT as the go ld standa rd and classify APSG positive if there are 3 or more naps than the positive predicti ve value of the polysomnography is 80% and the negative predictive value 6 1% with a sensitivity of 36% and a specificity of 91%. From 6 patient s with REM periods in their MSLT 3 showed REM periods in thei r naps and polyso mnograph y and 3 did not. Concl usion: APSG can be used in the diagnosis of EDS. The positive predictive value is moderate. It can be optimize d when AP is performed the whole day under standardised conditio ns.
jP17.02
I
FFT analysis of MSLT recordings classified by visual adaptive scoring
S.-L. Himanen", J. Virkkala", A. Saastamoinen", M. Oksanen", J. Hasan", "Depart ment of Clinical Neurophysiology, Tampere University Hospital; "Institute of Occupational Health, Helsinki; ' Digiral Media Institute , Tampere University of Technology, Finland The scoring system of Rechtschaffen and Kales (RKS, 1968) is characterized by fixed, long epoc hs and insufficient number of sleep stages . In order to overcome these limitations we de veloped a method of visual adaptive scoring (VASS). Epochs of variable length and more stage catego ries than in RKS are used. The purpose is to obtain electro physiologicaJIy more stationary epochs . Multiple sleep latency test (MSLT) record ings from 6 apnea patients and 4 healthy volunteers were performed by recording of EEG, EOG. and EMG. The recordings were visually scored by RKS and VASS. The following VASS stages were defined by morphology: 3 stages of wakefulness, two drowsy stages , 4 arousal types. two light sleep stages and Stage 2. Mean frequen cy spectra of each RK S and VASS stage were calcu lated by FFr. FFr analysis of VASS segments resulted in improved distinction between wakefulness and light sleep as com pared to analysis of RKS epoc hs. Differences in spectra l characteristics of VASS stages were found (Friedman and Wilcoxon tests, P < 0.05). The results are in agreement with the idea that more distinctive resu lts in analysis of especially the sleep onse t period can be obtained with shorter, preferably adaptive segments as com pared to the use of 30 s epochs.
Ip 17. 04
I
Comparison of th e alpha attenuation test with the maintenance of wakefulness test
J. Virkkala, S. Pihl, M. Harma, K. Muller. BrainWork Laboratory, Finnish Institute of Occupation al Health, Helsinki, Finland There is a clear need for sim ple objective sleepiness tests to evalu ate, e.g. daytime somnolence. Most commonly used tests arc multiple sleep latency test (MSLT) and maintenance of wakefulness test (MWT). One of the other tests is the alpha attenuati on test (AAT) where the ratio of alpha power is calcu lated between eyes closed and eyes open. A smaller alph a attenuation coefficient (AAC) ratio indicates greater sleepiness. We measured AAT and MWT from 79 traffic safety workers after a baseline night by using the Somnologica software. AAT was admi nistered at 13:30 and MWT at 14:00. Subjects were instructed by a handheld co mputer to close and open eyes in I min periods during the 6 min AAT test. 02-A I channel was analyzed in 2.56 s artifact free epochs with the custom Matlab program . For both eyes closed and eyes open the mean, standard devia tion and median of power spectrum epochs were calc ulated . We compare d the spectrum of groups having at least a single sleep epoch in MWT to a group with no sleep epochs in MWT. Six subjects were excluded because their eyes closed alpha power was above 80%. From the remaining 73 subjec ts, there were 24 males and 6 females who had at least a single sleep epoc h. Th irty-seven males and 6 females had no slee p epochs . The spectrum of eyes closed and eyes open was different betwee n these groups. The main effect was seen in alpha band 7.8- /2 .1 Hz. Calc ulated AAC were 4.0 ± 2. 1 and 6.8 ± 4.7 (P < 0.0014), respectively, indicating a correlation betwee n AAT and MWT. Our data shows the feasibilit y of easi ly administere d AAT in screening daytime somnolence.
S77
Posters
Ip17-os I
Electrophysiological study of priming effect during sleep
F. Perrin'", L. Garcia-Larrea'", F. Mauguiere'", H, Bastuji'"; "Sleep Disorders Unit, Neurological Hospital; bUPRES EA 1880, University Claude Bernard; 'Human Neurophysiology, CERMEP, Lyon, France
While sleeping persons, in sleep stage II and paradoxical sleep can discriminate deviant tones in a series of monotone tones (Bastuji and Garcia-Larrea, 1999) as well as their own name in a series of other names (Perrin et aI., 1999), the question whether a strictly semantic discrimination is possible during sleep remains open. To further investigate the extent to which sleeping subjects can process the meaning of external stimuli, we recorded auditory evoked potentials, from 10 normal adults, in response to semantically related and unrelated pairs of words, during both waking (passive listening) and all night sleep. Six lists of 72 stimuli were elaborated: all were monosyllables and presented with a fixed 1200 ms interval. One third of stimuli were pseudo-words and were intermingled between either semantically related or unrelated pairs of words. During passive waking, a higher N400 potential was elicited in response to unrelated words relative to related words. This effect was also observed in response to pseudo-words which evoked a higher N400 wave than related words. During sleep stage II, a more negative potential, was observed to unrelated words and to pseudo-words relative to related words. AEP morphology during paradoxical sleep was similar to that observed in the waking state and a N400-like potential appeared in response to incongruous words. These results suggest that semantic priming effects are still operative during paradoxical sleep and sleep stage II.
Ip17-06
Consensus recommendation for the diagnosis and management of upper airway obstruction in South West Finland
M. Erkinjuntti, 1. Antila, B. Falck, P. Kangasniemi, I. Kantola, J. Karrnakoski, R. Kokkala, H. Korvenranta, O. Polo, E.-R. Salomaa, A.-L. Tamminen, K Vahatalo. Consensus Group of Upper Airway Obstruction, Hospital District of South-Western Finland, Turku, Finland The prevalence of obstructive sleep apnea syndrome is about 4% among men and 2% among women. Partial upper airway obstruction is almost as common as sleep apnea. There are around 20 000 patients with upper airway obstruction in our hospital district with a population of 450 000. The available resources for the diagnosis and management are limited; therefore the multidisciplinary team responsible for these patients has reached a common consensus recommendation. The Department of Clinical Neurophysiology at the University Hospital is responsible for the diagnostic network. Several recording units will be set up in the hospitals in the district. The primary care doctors refer patients directly for sleep studies either to local hospitals or to the university hospital. Patients with mild sleep apnea or partial upper airway obstruction arc treated conservatively within the primary health care by weight reduction and/or position treatment. If conservative treatment does not give results the patients are referred to university hospital in which patients with mild apnea without overweight will be candidates for surgery, while patients with moderate or severe apnea and/or obesity will primarily be treated with nasal-CPAP. With this model we achieve more effective diagnostic and treatment for this common disease.
Ip17-o7
Sleep in female alcoholics
W. Jernajczyk, B. Woronowicz, I. Musinska, J. Antczak, A. Wierzbicka. Institute of Psychiatry and Neurology, Warsaw, Poland Sleep in alcoholics during the abstinence characterized by shortening of sleep, fragmentation of sleep and reduction of delta sleep. There is no study about sleep pattern in female alcoholics. Polysomnographic sleep recordings were obtained from 45 untreated physically sound female alcoholics
(mean 39.0) with minimum 2 weeks period of sober and 45 age-matched normal female controls (mean 39.6). The technique of EEG sleep recording and sleep stage scoring was determined by visual examination using standard criteria. The following 14 parameters were analysed: total sleep time (TST), awaking time (AT), number of awaking (AN), sleep efficiency (SE), sleep maintenance (SM.), sleep latency (SL), REM latency (RL), percentage of stages I NREM (lNREM%), 2 NREM (2 NREM%),), delta sleep (DS%), REM sleep (REM%), latency of eye movement in each sleep cycles (LEM), mean latency of eye movement (M-LEM) and REM density (RD). In 8 conventional parameters of sleep pattern we obtained significant differences between female alcoholics and normal controls. The differences between female alcoholics and controls were: reduction of TST, increase of AT and NA, decrease of SE, shortening of RL, increasing of stage lNREM% and stage REM%, decrease of DS%. We found the significant longer LEM I and MLEM in female alcoholics then in female controls. Biological value of sleep in female alcoholics is dramatically worse then in controls.
Ip17-o8 I
Density of REM sleep in narcolepsy-cataplexy and polysymptomatic form of idiopathic hypersomnia
1. Vankova, S. Nevsimalova, KSonka. Department of Neurology, 1st Medical Faculty, Charles Univesity, Prague. Czech Republic
In the present work we focused on density of REM sleep in patients with primary hypersomnias in comparison with nonhypersomnolent subjects. Sixteen unmedicated patients with narcolepsy-cataplexy (NC), 10 unmedicated patients suffering from polysymptornatic form of idiopathic hypersomnia (lH) and their age- and sex-matched controls were included in the study. The clinical diagnosis was confirmed by MSLT, nocturnal PSG as well as by actigraphic monitoring. Polygraphical recordings were visually scored with special interest devoted to two most characteristic phasic features of REM sleep: number of rapid eye movements (EMs) and chin muscle twitches (Tws) per minute. These events were evaluated according to recognized criteria; we looked more closely at the frequency and their distribution across all the REM periods (REMPs) of the night. Our results show two main differences between hypersomniacs and controls concerning phasic activity: (l) REM density (expressed by number of EMs/min and Tws/min) is significantly increased in the hypersomniac patients (for EMs/ min P < 0.0 I in IH patients and P < 0.05 in NC, for Tws/min P < 0.05 in both groups of patients), with maximal values reached in idiopathic hypersomnia patients. (2) The intra-night distribution of phasic activity show more considerable rising in hypersomniac patients than in control group.
IP17-09 I
Melatonin as a sleep inducer for EEG in children
E. Wassmer?". E. Quinn'", P. Carter', N. Bonick c , P. Mocroft", W. Whitehouse":", S. Seri a.h. Departments of "Neurology and "Clinical Neurophysiology, Birmingham Children's Hospital, Birmingham, UK; "Department of Community Paediatrics, Walsall Community NHS Trust, Walsall, UK Aims: To determine the efficacy, safety and practicality of melatonin when used to induce sleep for EEG. Methods: One hundred children, aged 2-17 years, referred to two Clinical Neurophysiology Departments for sleep EEG were recruited. 48/100 had disordered behaviour. Informed consent was obtained and 2.5 or 5 mg of melatonin administered immediately prior to the EEG recording. Data was obtained from a detailed request form, the technical EEG report and, in 30, a follow-up telephone interview. Results: Eighty-four out of 100 fell asleep - average latency 30 min (:!::2 min 95% Cl). Sixty of the 84 attained stage 3 sleep. Seven of the 84 complained of feeling tired on waking up but there were no other adverse effects. All had normal looking sleep macro-structure. Epileptiform activity was seen in 40% of the sleep recordings. Conclusions: Melatonin induces sleep reliably and safely in children
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undergoin g EEG. It is a practical alternative to sleep deprivation when the specific activating effect of the latter is not need ed.
Ip 17-10
Central sleep apneas during fast nCPAP titration in patients with obstructive sleep apnea (OSA) syndrome
K. I1cheva. MANA Medical Center, Sofia, Bulgaria Severe obstructive sleep apnea (OSA) syndrome needs ultimatel y nCPAP treatment. The nCPAP titration process aims fully restoration of the patency of upper airways, compen sation of the obstructions and normalization of breathing patterns. A rapid increase in the nCPAP pressure compensates the obstructi ve sleep apneas, but frequently leads to occurrence of excessive repetiti ve central apneas. The latter breathing pattern is explained with the rapid normali zation of Sa02, increase in the pCOr wakening threshold, due to relati ve temporary hypocarbia . CO 2 and O2 sensors reset varies (minutes duration). A reduction of the nCPAP pressure level and slowly return of the titrati on process is recommended. The reported facts relate closely to the new technology for the automatic titration of nCPAP, which does not compens ate central apnea episodes.
IP17-11
Twenty-four hour EEG in Smith Magenis syndrome: EEG morphology and sleep studies in 9 cases
A.L. Frenkel ' , F. Salefranque", H. Deleersnyder'', aEFSN, Necker Enfants Malades, Paris, France; bUnite de Genetique Clinique, Necker Enfants Malades, Paris, France Sleep abnormalities, hyperactivity and self injuries are major issues in SMS caused by a chromosome deletion disorder (l7pI1.2). We investigated cyclic organization of slow wave sleep-REM sleep and the relation ship between melatonin wakefulness and sleep stages. 9 children (5 boys and 4 girls aged 4-1 8 years) were recorded with an ambulato ry system (Medilog 9000): 6 EEG, 1 electro -oculogram and I electromyogram of the trapezius. Serum melatonin level was determined every hour. We identified cyclic organization of SWS -REM Sleep. EEG showed particular aspects with humps, rapid activit y and elevated number of spikes and spikes-waves during sleep and wakefulness. We recorded sleep attacks in daytime showing the perturbation of circadian organization . Plasmatic and urinary melatonin was drastically low among each child. What can be the relationship between EEG modification and plasmatic melatonin? We need more investigations to understand physiopathology of SMS but it seemed important to point out these particul ar EEG features in diagnostic orientation of mental retardation and sleep disturbances.
IP17·12
I
Fatal familiar insomnia in a new Spanish family
S. Gimenez, M.D. de la Calzada , C. Nos', J. Yague", R. Rovira, C. Borras",
J. Castell, A. Sainz ", A. Rovira, 1. Casas, X. Montalban" "Hospital Universitari Vall d' Hebron , Unitat de Neuroinmunologia Clinica, Barcelona, Spain; "Hospital CLInic i Provincial, Barcelona, Spain Fatal familiar insomnia (FFI) is an autosomal dominant prion disease linked to the GAC-l-AAS mutati on in the codon 178 of the prion protein (PrP) gene (PRNP), resulting in the substitution of aspartic acid by a~par agine, coupled with a methion ine coding triplet in the mutant allele at polymorphic codon 129 . Clinicall y, it is characterized by progressive loss of the ability to sleep, dysautonomi a, endocrine and motor disturbanc es. The neuropathologic hallmarks are severe neuronal loss and astroglio sis of the thalamus. Phenot ypic variability has been linked at PRNP codon on the normal allele which determines homo and heterozygosity, modulating the age of onset and duration and the severity. According to this, we describe 2 new patients from the same famil y, with the clinical and pathologic featu res of FFY. A 48-year-old man, heterozy got Met/Val with an onset of depression, severe insomnia and ataxia and his cousine, a 55-year-old woman, homozigot MetlMet,with severe sleep and autonomic disturbances.
IP17-13
I
Is there an influence of repetitive transcranial magnetic stimulation on frontal EEG-asynunetl1' in depressive patients?
J. Heppne r", K. Bollow ' , J. Buchmann", J. Richter", G. Irmisch ", D. Schliifke' . "Department of Psychiatry and Psychotherapy; "Department of Child and Adolescent Neuropsychiatry, Centre of Nervous Disease. University of Rostock, Germany There is some evidence of relationship between asymmetri c anterior brain activation and affective style. An increa sed left frontal EEG-po wer in alpha band was reported in acute depressives in rest suggesting a left anterior hypoacti vation (Henriques and Davidson. 1991). Repetitive transcranial magnetic stimulation (rTMS) is a procedure in which regional electri cal brain activity is influenced by a pulsed magnet ic field. Some studies lent support for an antidepressant effect of high-frequency stimulation over the left dorsolateral prefrontal cortex (DLPFC) (Pascual-Leone et al., 1996;, Figiel et al., 1998; Triggs et al., 1999), whereas other authors reported an antidepressant effect of low-frequency stimulation of the right DLPFC (Klein et al., 1999; Feinsod et al., 1998). The aim of our investig ation is to study the influence of rTMS frequency and localisation on the baseline anterior alpha asymmetry in patient s with major depression. Preliminary we report about 10 patients, fitting DSM-lll-R criter ia for major depression. Four of the patients were treated with 20 Hz rTMS over the left DLPFC, 3 were stimulated with I Hz over the right DLPFC and 3 patients received a sham stimulati on. EEG data were recorded from 19 scalp electrodes during 10 min resting periods before and after the first. fifth and last rTMS-session and after 2 weeks (follow-up period). The alpha asymme try index (AI) for homologou s leads was calculated by the formu la: power (right minus left)/(right plus left). We could not find consistent changes of AI. In comparison to I Hz - and sham stimulation, 20 H7. rTMS, however, seems to have higher influence on a defined global EEG-p arameter (quantitative electroenceph alographi c ipsative difference assessment) describing spectral variations.
Ip17-14
I
Left frontal lobe high frequency repetitive transcranial magnetic stimulation in patients affected by depression: a case control pilot study on short- and long-term effect
M. Bortolomasi, P. Manganotti, G.M. Giacopuzzi, A. Fiaschi. Sezione di Neurologia Riabilitativa, Cam di Cura Villa S. Chiara, Universita' di Verona, Italy The effect of repetitive transcranial magnetic stimulation has been recently used as potential treatment on depression . Based on the hypoth esis that major depression may result from decreased activity on the left frontal function, high frequency rTMS has been applied to the left frontal lobe producing a mild but significantly clinical impro vement in the mood of depressed patients after the period o f stimulation. No information exists on the long-term effect of the high frequency rTMS on the patients affected by major depression. The aim of this study was to study the short- and longterm effect of rTMS on depressed patients. We performed the protocol of high frequency rTMS performed by George (1995). We admini stered rTMS each morning for 1 week (5 days) to the left frontal cortex in 16 patients (mean age 48 years) with primary mood disorders (8 bipolar disorders, 6 unipolar disorder ). Each morning subjects received 202 s train of rTMS at 20 Hz at 80% of motor threshold in muscles of right Thenar eminenc e (TE ). Repetitive TMS was applied to the left frontal hemisphere using a circ ular coil. On 16 patient s II patients were stimulated using the real rTMS, while 5 patients were stimulated using a placebo stimulation. Hamilton D and Beck inventory scales were performed before (T I) and after (T2) the treatment protocol and after I month (T3) from the rTMS. No adverse outcomes were noted in either groups. Significant antidepressant effect was noted in 9/1 1 treated patients on Hamilton and Beck depression rating scale (P < 0.05) immediately after the treatmen t. While no significant changes were noted in two treated patients . No significant changes on Hamilton and
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Beck depression rating scale were noted in patients treated by a placebo stimulation. In 4/9 patients the antidepressant effect lasted less then 30 days. In 5 patients significant changes on Hamilton and Beck depression rating scale were present after I month (T3). In conclusion rTMS in psychiatric disorders seems to produce long-lasting effect on mood with deserves further investigation. Ip17.15
1
One case of paroxysmal arousals
M.e. Moja, L. Ambrogio, P.C. Gerbino PrOIniS, U. Dimanico, C. La Piana, G.P. Pellegrino, B. Picasso, E. Grasso. Department of Neurology, S Croce Hospital, Cuneo, Italy We present the case of one man aged 51 with no anamnestic relevant pathology. Since he was a child sleep disorders characterized by sudden arousals with vivid dreaming and nightmares are described. In the last 10 years sleep movements are described, starting after I h of quiet sleep, with
S79 abrupt muscle contractions, sometimes more complex, making the patient getting off the bed. These movements are stereotyped, last some seconds and are remembered by the patient himself. These symptoms are not described in the latter part of the night or in afternoon naps and when the patients falls asleep again after one episode, these arousals appear again. Due to these symptoms nocturnal sleep is disturbed but with no daytime somnolence. Multiple sleep Latency Test was normal with a medium latency of 17 min. Video-polisomnography showed 5 episodes in sleep phase 11 with abduction of the right upper limb, tremor and distonic posture of the hand which awake the patient with controlateral distonic posture and voluntary movements trying to stop it. These attacks last 30 s about and are always identical during each night recording. Electroencephalography disclosed a K complex followed by marked vegetative symptoms, muscle activity and arousal. Neuroimaging scans are normal. We conclude that this case can be diagnosed as complex motor attacks as paroxysmal arousals. Therapy by Carbamazepine 400 mg led to symptoms resolution.