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Published on: July 30, 2009
Polysomnographic predictors of abnormal brainstem imaging in children
Robert C Stowe1, Monica Miranda-Schaeubinger2, Savvas Andronikou2,3
1Department of Neurology, Boston Children's Hospital and Harvard School of Medicine, Boston, Massachusetts.
Insights
Pediatric central sleep apnea patients with a central apnea-hypopnea index (CAHI) of ≥ 9.5 events/h and specific CO₂ levels may indicate brainstem pathology. These polysomnography findings can help optimize neuroimaging in children with central sleep apnea.
Area of Science:
- Pediatric Sleep Medicine
- Neuroimaging in Sleep Disorders
- Respiratory Physiology
Background:
- Elevated central apnea-hypopnea index (CAHI) in children often prompts neuroimaging to rule out brainstem pathology.
- Evidence is limited on polysomnography (PSG) thresholds that predict abnormal brainstem imaging.
- This study aimed to identify PSG variables that predict brainstem abnormalities in pediatric patients.
Purpose of the Study:
- To evaluate if specific polysomnography variables can predict brainstem pathology in pediatric patients with central sleep apnea.
- To determine thresholds for CAHI and end-tidal CO₂ that correlate with abnormal brainstem imaging.
- To assess the utility of prolonged central apneas in predicting brainstem abnormalities.
Main Methods:
- Retrospective review of 65 pediatric patients (ages 1-18) who underwent brain MRI for central sleep apnea diagnosis.
- Comparison of demographics, medical history, PSG variables, and MRI results.
- Analysis using receiver operating characteristic (ROC) curves to identify predictive thresholds.
Main Results:
- 69.2% of patients had normal MRIs; 30.8% had abnormal MRIs.
- Seven patients (10.8%) showed brainstem pathology, with a median CAHI of 10.8 events/h and higher rates of hypoventilation.
- A CAHI ≥ 9.5 events/h and ≥ 6.4% of total sleep time with end-tidal CO₂ ≥ 50 mm Hg predicted abnormal brainstem imaging.
- Prolonged central apneas did not predict brainstem abnormalities.
Conclusions:
- Most pediatric central sleep apnea patients do not have brainstem structural abnormalities on MRI.
- Specific CAHI (≥ 9.5 events/h), end-tidal CO₂ (≥ 6.4% TST with ≥ 50 mm Hg), and hypoventilation thresholds may optimize MRI use.
- Clinical history alongside these PSG parameters can aid in judicious MRI utilization for central sleep apnea evaluation.
Study Objectives:
Evaluation of elevated central apnea-hypopnea index (CAHI) or prolonged central apneas in pediatric patients typically includes neuroimaging with a focus on brainstem pathology. There is little evidence guiding thresholds of polysomnographic variables that accurately predict abnormal neuroimaging. We sought to evaluate whether additional polysomnographic variables may help predict brainstem pathology.
Methods:
A 10-year retrospective review of patients ages 1-18 years who received a brain magnetic resonance imaging (MRI) for an indication of central sleep apnea diagnosed via polysomnography was performed. Demographics, medical history, polysomnogram variables, and MRI results were compared.
Results:
This study included 65 patients (69.2% male). The median age was 5.8 years (interquartile range, 3.0-8.3). Most patients had negative (normal or nonsignificant) MRIs (n = 45, 69.2%); 20 (30.8%) had abnormal MRIs. Of the patients with abnormal MRIs, 13 (20.0%) had abnormalities unrelated to the brainstem. Seven patients (10.8%) were found to have brainstem pathology and had a median CAHI of 10.8 events/h (interquartile range, 6.5-21.9), and three of seven (42.9%) had hypoventilation and were more likely to have developmental delay, abnormal neurological examinations, and reflux. Other patients (n = 58) had a median CAHI of 5.6 events/h (interquartile range, 3.1-9.1), and seven (12.1%) had hypoventilation. Area under the curve and receiver operating characteristic curves showed a CAHI ≥ 9.5 events/h and ≥ 6.4% of total sleep time with end-tidal CO₂ ≥ 50 mm Hg predicted abnormal brainstem imaging. Prolonged central apneas did not predict abnormal brainstem imaging.
Conclusions:
Most patients with central sleep apnea do not have MRIs implicating structurally abnormal brainstems. Utilizing a cutoff of CAHI of ≥ 9.5 events/h, ≥ 6.4% total sleep time with end-tidal CO₂ ≥ 50 mm Hg and/or frank hypoventilation, and additional clinical history may optimize MRI utilization in patients with central sleep apnea.
