at Shirley Ryan Ability Lab, and this is my presentation that is labeled Wake Up Stroke Symptoms in an Individual with Undiagnosed Obstructive Sleep Apnea, the case report. To start off, this is a 67-year-old male with no history of prior strokes, presenting with right-sided weakness and dysarthria. So this all happened in an acute care setting. This was worked up, and he was found to have lesions on the left side of his brain that resulted in him having the right-sided weakness and the dysarthria. He had many complications, and these complications are listed in the timeline here. I won't read every word on this poster, but essentially, complications included tracheostomy, gastric tube, he had a stage four sacral wound, which was complicated by osteomyelitis, multidrug-resistant, so that was a issue, an active issue, even after being discharged from acute and patient rehab. He had certain precautions that limited his therapies. So essentially, he came into inpatient rehab with no function in any of his ADLs due to all the complications. So the reason why I wanted to do this presentation is because I feel like it's really important to understand the symptoms and etiology of wake-up strokes, especially in patients like my own who go undiagnosed with OSA and Obstructive Sleep Apnea, which with him is very interesting because with the tracheostomy that he had in, he had that in for the first month, as you can see in the timeline. So in the first month, he had the tracheostomy and he showed improvement. He went from not being able to perform those ADLs with bio to doing self-care with max assist, transfers with total assist, and social cognition with moderate assist. We take out the tracheostomy tube, he gets decannulated, and three days later, rounding in the morning, we realize he has altermental status, worsening slurred speech with new left lower extremity weakness, and he cannot participate in therapies. All right, so to backtrack a little bit, wake-up strokes are essentially a situation where the patient awakens in the morning with new stroke symptoms that weren't present the night prior or the day prior. And about 50 to 70% of patients with acute ischemic stroke, or TIA, actually have Obstructive Sleep Apnea. And searching for sleep disorders for patients who have acute ischemic stroke is actually very important in this population. And actually, in 2014, the AHA actually put that in their guidelines to essentially look for sleep disorders for these patients because of such a high prevalence. So for our guy, we did the CT scan for that concern of the new acute stroke, given that he had a left-sided weakness and the worsening dysarthria, but nothing was found acute. We did infectious workup, we did med workup, we took out some meds that were possibly sedating him, some meds that possibly could be dehydrating him, especially in the setting of AKI. But in the afternoon, he returned to his baseline. He was no longer as dysarthric, his left side wasn't as weak, and he would be somewhat to his baseline as the day before. And this would happen multiple times, and it would be a recent repeat, until eventually we got a sleep-night study with extended EEG and found with no seizures, but he was found to have severe OSA. And finally, he was discharged in a mod to max assist. And this is important because, especially with a patient like him, things like this, when the OSA gets undiagnosed and it affects him functionally, this prolongs his acute inpatient stay. So had this OSA been found earlier, especially in the setting of him being decannulated, he possibly could have had a shorter stay. And there's multiple reasons why this pathophysiology is the way it is. There's a lot of research being looked into that. Some theories stating that one factor called plasminogen activator inhibitor, PAI-1, is actually upregulated at night. So it's a prothrombotic that may actually cause these wake-up strokes to occur, but by the afternoon, for them to resolve. So other papers showing that even sleep-disordered breathing in the setting of a wake-up stroke could actually cause large decreases in perfusion on the unaffected side of the brain in patients who have acute ischemic strokes that affect one side of the brain, which is like our guy here, who came in with right-sided weakness, and that was improved, but when he had these wake-up strokes, he was starting to have left-sided weakness as the presentation on that side that wasn't affected initially. So interesting case in the setting of a guy who was decannulated to have undiagnosed OSA, important to note.

wake-up stroke

67-year-old male

right-sided weakness

dysarthria

severe obstructive sleep apnea