Stroke during sleep and obstructive sleep apnea: there is a link

  • Yousef MohammadEmail author
  • Ahmed Almutlaq
  • Abdullah Al-Ruwaita
  • Amjad Aldrees
  • Abdulaziz Alsubaie
  • Fawaz Al-Hussain
Original Article



The onset of ischemic stroke symptoms has been established to have a diurnal variation, with a sizeable proportion (8–28%) occurring during sleep. Obstructive sleep apnea (OSA) has been established as an important risk factor for ischemic stroke. However, data on the relationship between OSA and wake-up stroke (WUS) has been scarce. The aim of our study is to determine the relationship between OSA and WUS.


This is a case-control study conducted on acute stroke patients who presented to one of two major medical centers in Riyadh of Saudi Arabia. Those who woke up with the symptoms were labeled as WUS, and those whose stroke occurred while awake were labeled as non wake-up stroke (NWUS). The Berlin Questionnaire, which was submitted to either the patient or his/her partner, was used to determine the frequency of OSA in the two groups.


One hundred seven patients (60% males) with acute stroke were admitted between March 2016 and March 2017. Of the 40 patients with WUS, 29 (72.5%) had underlying OSA based on the Berlin Questionnaire, whereas only 30 (45%) of the 67 patients with NWUS have underlying OSA. Logistic regression analysis showed OSA is highly prevalent in the patients with WUS (OR = 3.25; 95% CI = 1.397–8.38; p = 0.0053).


OSA is an important risk factor for ischemic stroke during sleep. Health care providers must be vigilant in inquiring about symptoms suggestive of OSA in every ischemic stroke patient, especially the patient whose stroke occurred during sleep.


Stroke Wake-up Obstructive sleep apnea Berlin Questionnaire 


Funding information

The authors extend their appreciation to the Deanship of Scientific Research at King Saud University for funding this work through research group NO (RGP-1438-008).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Warlow CP (1998) Epidemiology of stroke. Lancet 352(Suppl 3):Slll1–Slll4CrossRefGoogle Scholar
  2. 2.
    Murray CJ, Lopez AD (1997) Mortality by cause for eight regions of the world: global burden of disease study. Lancet 349(9061):1269–1276CrossRefGoogle Scholar
  3. 3.
    Chapman SN, Mehndiratta P, Johansen MC, McMurry TL, Johnston KC, Southerland AM (2014) Current perspective on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Vasc Health Risk Manag 10:75–87Google Scholar
  4. 4.
    Parker S, Ali Y (2015) Changing contraindications for t-PA in acute stroke: review of 20 years since NINDS. Curr Cardiol Rep 17(10):81CrossRefGoogle Scholar
  5. 5.
    Gerber J, Puetz V, Bodechtel U, Kitzler H, von Kummer R, Linn J (2016) Endovascular treatment of ischemic stroke patients- new evidence and old challenges. Vasa 45(4):267–274CrossRefGoogle Scholar
  6. 6.
    Young T, Peppard PE, Gottlieb DJ (2002) Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 165(9):1217–1239CrossRefGoogle Scholar
  7. 7.
    Drager LF, Polotsky VY, Lorenzi-Filho G (2011) Obstructive sleep apnea: an emerging risk factor for atherosclerosis. Chest 140(2):534–542CrossRefGoogle Scholar
  8. 8.
    Tosun A, Köktürk O, Karataş GK, Ciftçi TU et al (2008) Obstructive sleep apnea in ischemic stroke patients. Clinics 63:625–630CrossRefGoogle Scholar
  9. 9.
    Redline S, Yenokyan G, Gottlieb DJ, Shahar E, O'Connor GT, Resnick HE, Diener-West M, Sanders MH, Wolf PA, Geraghty EM, Ali T, Lebowitz M, Punjabi NM (2010) Obstructive sleep apnea-hypopnea and incident stroke: the sleep heart health study. Am J Respir Crit Care Med 182:269–277CrossRefGoogle Scholar
  10. 10.
    Ifergane G, Ovanyan A, Toledano R, Goldbart A, Abu-Salame I, Tal A, Stavsky M, Novack V (2016) Obstructive sleep apnea in acute stroke: a role for systemic inflammation. Stroke 47(5):1207–1212CrossRefGoogle Scholar
  11. 11.
    Siarnik P, Kollar B, Carnicka Z, Surda P et al (2016) Association of sleep disordered breathing with wake-up acute ischemic stroke: a full polysomnographic study. J Clin Sleep Med 12(4):549–554CrossRefGoogle Scholar
  12. 12.
    Lago A, Geffner D, Tembl J, Landete L, Valero C, Baquero M (1998) Circadian variation in acute ischemic stroke: a hospital based study. Stroke 29:1873–1875CrossRefGoogle Scholar
  13. 13.
    Chaturvedi S, Adams HP Jr, Woolson RF (1999) Circadian variation in ischemic stroke subtypes. Stroke 30:1792–1795CrossRefGoogle Scholar
  14. 14.
    Bornstein NM, Gur AY, Fainshtein P, Korczyn AD (1999) Stroke during sleep: epidemiological and clinical features. Cerebrovasc Dis 9:320–322CrossRefGoogle Scholar
  15. 15.
    Fink JN, Kumar S, Horkan C, Linfante I, Selim MH, Caplan LR, Schlaug G (2002) The stroke patient who woke up: clinical and radiological features, including diffusion and perfusion MRI. Stroke 33:988–993CrossRefGoogle Scholar
  16. 16.
    Berlin questionnaire (2000) Sleep Breath 44:187–192Google Scholar
  17. 17.
    Netzer NC, Stoohs RA, Netzer CM, Clark K et al (1999) Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 31(7):485–491CrossRefGoogle Scholar
  18. 18.
    Hiestand DM, Britz P, Goldman M, Phillips B (2006) Prevalence of symptoms and risk of sleep apnea in the US population: results from the national sleep foundation sleep in America 2005 poll. Chest 130(3):780–786CrossRefGoogle Scholar
  19. 19.
    Kapsimalis F, Kryger M (2009) Sleep breathing disorders in the U.S. female population. J Women's Health (Larchmt) 18(8):1211–1219CrossRefGoogle Scholar
  20. 20.
    Hrubos-Strom H, Randby A, Namtvedt SK, Kristiansen HA et al (2011) A Norwegian population-based study on the risk and prevalence of obstructive sleep apnea. The Akershus Sleep Apnea Project (ASAP). J Sleep Res 20(1 Pt 2):162–170CrossRefGoogle Scholar
  21. 21.
    Poli M, Philip P, Taillard J, Debruxelles S, Renou P, Orgogozo JM, Rouanet F, Sibon I (2017 Feb) Atrial fibrillation is a major cause of stroke in apneic patients: a prospective study. Sleep Med 30:251–254. CrossRefGoogle Scholar
  22. 22.
    Ciccone A, Proserpio P, Roccatagliata DV, Nichelatti M, Gigli GL, Parati G, Lombardi C, Pizza F, Cirignotta F, Santilli IM, Silani V, Sterzi R, Nobili L (2013) DARIA (detection of sleep apnea as risk factor in acute stroke) investigators. Thorax 68(1):97–104CrossRefGoogle Scholar
  23. 23.
    Ozdemir O, Beletsky V, Hachinski V, Spence JD (2008) Cerebrovascular events on awakening, patent foramen ovale and obstructive sleep apnea syndrome. J Neurol Sci 268(1–2):193–194CrossRefGoogle Scholar
  24. 24.
    Budhiraja R, Parthasarathy S, Quan SF (2007) Endothelial dysfunction in obstructive sleep apnea. J Clin Sleep Med 3(4):409–415Google Scholar
  25. 25.
    Hsieh SW, Lai CL, Liu CK, Hsieh CF, Hsu CY (2012) Obstructive sleep apnea linked to wake-up stroke. J Neurol 259(7):1433–1439CrossRefGoogle Scholar
  26. 26.
    Koo BB, Bravata DM, Tobias LA, Mackey JS, Miech EJ, Matthias MS, Stahl SM, Sico JJ, Vaz Fragoso CA, Williams LS, Lampert R, Qin L, Yaggi HK (2016) Observational study of obstructive sleep apnea in wake-up stroke: the SLEEP TIGHT study. Cerebrovasc Dis 41(5–6):233–241CrossRefGoogle Scholar
  27. 27.
    Saleh AB, Ahmad MA, Awadalla NJ (2011) Development of Arabic version of Berlin questionnaire to identify obstructive sleep apnea at risk patients. Ann Thorac Med 6(4):212–216CrossRefGoogle Scholar
  28. 28.
    Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 31(8):1071–1078Google Scholar

Copyright information

© Fondazione Società Italiana di Neurologia 2019

Authors and Affiliations

  1. 1.Department of Internal MedicineKing Saud UniversityRiyadhSaudi Arabia

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