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Perivascular space imaging marker and glymphatic function in obstructive sleep apnea: A systematic review and
Pongsakorn Tanayapong1, Pawin Numthavaj2, Gareth McKay3
1Division of Sleep Medicine, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
Background And Objectives:
Obstructive sleep apnea (OSA) is a recognized cardiovascular and dementia risk factor that has been previously reported in association with enlarged cerebral perivascular spaces (PVS) indicative of cerebral small vessel disease (CSVD) and impaired glymphatic function. We aimed to evaluate associations between OSA and neuroimaging-visible PVS and Diffusion Tensor Imaging Analysis Along the Perivascular Space (DTI-ALPS), as a surrogate marker of glymphatic function.
Methods:
A systematic search of MEDLINE, Scopus, and Embase was conducted through Oct 11, 2026. The meta-analysis included observational studies exploring associations between OSA severity and PVS burden and DTI-ALPS. Reported effect estimates for PVS or glymphatic parameters across OSA disease severity were pooled using a random-effect model.
Results:
Sixteen studies (N = 2618) met the inclusion criteria. Results showed that patients with OSA had a significantly higher odds of documented PVS compared to those without OSA (OR = 4.97, 95% CI 2.51 to 9.82). Each per unit increase in apnea-hypopnea index corresponded to a 3% increase in the odds of PVS (OR = 1.03, 95% CI 1.01 to 1.04). OSA was linked to a significant decrease in glymphatic-related diffusion as indicated by DTI-ALPS index (mean difference = -0.2, 95% CI -0.35 to -0.06). This reduction persisted across all OSA severities, including mild (mean difference = -0.17, 95% CI -0.32 to -0.02), and moderate-to-severe (mean difference = -0.10, 95% CI -0.17 to -0.04) OSA.
Conclusions:
Our meta-analysis demonstrated a strong link between OSA and both increased PVS burden and impaired surrogate of glymphatic function, potentially implicating OSA in the pathogenesis of both CSVD and dementia. Further prospective studies are necessary to confirm causality and direction of effect of the observed association. Registration PROSPERO registration number, CRD420261279540. ABBREVIATIONS AND ACRONYMS.
