Serie FLENI / e-Sleep

Transcripción

Del síntoma al diagnóstico en los
trastornos del sueño. Claudio Podestá
Director de e-Sleep Centro de Medicina del Sueño
Subjefe del Laboratorio de Sueño de FLENI
e-Sleep
THE
INTERNATIONAL CLASSIFICATION
OF
SLEEP DISORDERS, REVISED
(2005)
Diagnostic and Coding Manual
Produced by the
American Academy of Sleep Medicine
in association with the:
EUROPEAN SLEEP RESEARCH SOCIETY
JAPANESE SOCIETY OF SLEEP RESEARCH
LATIN AMERICAN SLEEP SOCIETY
Claudio Podestá FLENI / e-Sleep
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INSOMNIOS e-Sleep
CLINILABS (New York)
Certified site
Lunes
Martes
Miércoles
Jueves Viernes
Sábado
Domingo
Ayer, hizo siestas? Indique cuanto tiempo (aunque haya
reposado sin haber dormido).
Anoche tomó algún medicamento o bebida alcohólica para conciliar el sueño?
Anoche a qué hora comenzó a tratar de
dormir ?
Anoche cuánto tiempo CREE que tardó en dormirse ?
Durante la noche cuántas veces CREE haberse
despertado?
Durante la noche cuánto tiempo CREE que durmió en
total ?
Esta mañana a que hora se despertó por última vez ?
Esta mañana a qué hora se levantó ?
De 1 punto (mala) a 10 (excelente), otorgue una
calificación a la noche pasada
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Medical Disorders
N  Respiratory disorders (COPD, Asthma).
N  Gastroesophageal reflux.
N  Fibromyalgia, other rheumatological
diseases.
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Neurological Disorders
N  Parkinsonism and other movement
disorders.
N  Dementia, degenerative diseases.
N  Cerebrovascular disease.
N  Epilepsy.
N  Headache and other pain syndromes.
N  Fatal familial insomnia.
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Circadian Rhythm Disorders
N  Time change zone syndrome.
N  Shift work sleep disorder.
N  Delayed or advance sleep phase
syndrome.
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Jet-Lag
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Trabajo en turnos rotativos
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Síndrome de Retardo de Fase
Adolescentes y
adultos jóvenes.
Insomnio de
conciliación.
Dificultoso despertar.
Hipersomnia matinal.
Alerta vespertina.
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Síndrome de Avance de Fase.
Gerontes.
Insomnio de precoz
despertar matinal.
Hipersomnia
vespertina.
Precoz conciliación
del sueño nocturno.
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Behavioral Disorders
N  Psychophysiological insomnia.
N  Inadequate sleep hygiene.
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Psychiatric Disorders
N  Alcoholism, alcohol-dependent sleep
disorder.
N  Drug-dependent sleep disorder.
N  Mood disorders.
N  Psychoses.
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Primary Sleep Disorders
N 
N 
N 
N 
Sleep state misperception.
Primary insomnia.
Sleep apnea.
Restless legs syndrome and periodic limb
movements.
N  Parasomnias.
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HIPERSOMNIAS Exploración diurna Test subjetivos:
Escala de somnolencia de Epworth (ESS)
Test objetivos:
Test Múltiple de Latencias del Sueño (MSLT)
Test de Mantenimiento de la Vigilia (MWT)
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e-Sleep
CLINILABS (New York)
Certified site
ESCALA DE EPWORTH
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Prevalencia
 Mc Ghie/Russell (1962) * 2466 (0.5%)
  Bixler (1969)
* 1066 (4.2%)
  Lavie (1981)
* 1052 (4.9%)
  Franceschi (1982)
* 2518 (3.4%)
  Lugaressi (1983)
* 5173 (8.7%)
  Billiard (1987)
* 58162 (4.9%)
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Fisiológica
N  Circadiana.
N  Ligada al embarazo.
Patológica 1° y 2°
N  Narcolepsia.
N  Sindrome de Apneas del
Sueño (OSAS).
N  Sindrome de piernas sin
reposo (RLS).
N  Hipersomnia Idiopática.
N  Hipersomnias
Recurrentes.
Patológica Inducida
N  Medicación.
N  Alcohol.
N  Trabajos rotativos.
N  Jet-Lag.
N  Sueño insuficiente.
Patológica Circadiana
N  Retardo de fase.
N  Avance de fase.
N  Sindrome
Hipernictameral.
Billiard M., 2003 (adaptado)
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Sindrome de Insuficiencia de sueño
I  2% de consultas generales.
I  6% de consultas por ESD.
I  63% sexo masculino.
I  Edad media 40 años.
I  Horas de sueño: 5.9.
I  PSG: normal (> IE / >SWS)
I  MSLT: latencia media 5-8’.
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Recurrent hypersomnia a�er trauma�c brain injury Michel Billiard and Claudio Podestá (in press) N  Abstract N  Recurrent hypersomnia (RH) following a trauma�c brain injury (TBI) is a rare form of RH. According to ICSD-‐2, it must be considered as a differen�al diagnosis of RH secondary to an organic insult of the central nervous system, not as a clinical subtype of RH. Thirteen cases of RH developed a�er TBI were collected and analyzed in terms of circumstance at onset, severity of trauma�c brain injury (TBI), delay between TBI and occurrence of first episode of RH, symptoms of RH, dura�on and cycle length of episodes of hypersomnia, physical signs and brain imaging at �mes of episodes of hypersomnia. Based on the delay between TBI and the first episode of RH, on the presence of other triggering factors or gene�c factors, on the degree of severity of TBI, on the presence or absence of any consistent imaging abnormality, it is concluded that some of these cases may be considered as symptoma�c of the underlying brain process, some others are only triggered by TBI in pa�ents at risk, and some are neither symptoma�c nor triggered by TBI in view of the long delay between TBI and occurrence of symptoms. Claudio Podestá FLENI / e-Sleep
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Recurrent hypersomnia a�er trauma�c brain injury Michel Billiard and Claudio Podestá (in press) N 
N 
Abstract Recurrent hypersomnia (RH) following a trauma�c brain injury (TBI) is a rare form of RH. According to ICSD-‐2, it must be considered as a differen�al diagnosis of RH secondary to an organic insult of the central nervous system, not as a clinical subtype of RH. Thirteen cases of RH developed a�er TBI were collected and analyzed in terms of circumstance at onset, severity of trauma�c brain injury (TBI), delay between TBI and occurrence of first episode of RH, symptoms of RH, dura�on and cycle length of episodes of hypersomnia, physical signs and brain imaging at �mes of episodes of hypersomnia. Based on the delay between TBI and the first episode of RH, on the presence of other triggering factors or gene�c factors, on the degree of severity of TBI, on the presence or absence of any consistent imaging abnormality, it is concluded that some of these cases may be considered as symptoma�c of the underlying brain process, some others are only triggered by TBI in pa�ents at risk, and some are neither symptoma�c nor triggered by TBI in view of the long delay between TBI and occurrence of symptoms. Claudio Podestá FLENI / e-Sleep
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Narcolepsia con cataplexia
Narcolepsia sin cataplexia
Narcolepsia sintomática y/o asociada
Treatment of narcolepsy and other hypersomnias of
central origen. An American Academy of Sleep Medicine
review. Wise M, Arand D et al. Sleep, Vol 30, N°12,
2007 Dec, 1712-25.
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Narcolepsia
Parkinson
Esclerosis Múltiple
Narcolepsia
Corea de Huntington
ELA
Miastenia Gravis
0
50
100
150
200
250
Prevalencia comparada 1/00000.(Billiard M, 1998).
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ICSD Review 2005. Narcolepsia.
N  Narcolepsia con Cataplexia
(347.01;G47.41)
N  Narcolepsia sin Cataplexia
(347.00;G47.42)
N  Narcolepsia Sintomática
(341.1;G47.49)
  Prevalencia 0.56 -1.37/mil. (Sleep 2002,Vol. 25, N°2, 197-202).
  Sexo 1:1. (1.72 / 1.05).
  Excesiva somnolencia diurna y ataques irresistibles de sueño.
  Cataplexia parcial o generalizada.
  Alucinaciones hipnagógicas / hipnopómpicas.
  Parálisis del sueño.
  Trastornos comportamentales durante SREM (RSBD).
  Fragmentación del sueño nocturno.
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% sobre total PSG (e-Sleep / FLENI)
201
(1.2 %)
nº 17100
Distribución por sexo
40%
60%
“Narcolepsia Sintomática”.
Podestá C, Fridman E, Carrara G, Calderón C. Actas del 1er. Congreso
Argentino de Medicina del Sueño, Buenos Aires, 1998.
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Reduced Number of Hypocretin Neurons in Human Narcolepsy.
Thannickal T, Aldrich M, Siegel J et al. Neuron 2000, Vol. 27, 469–474.
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diagnostic latency
(mean: 15.9 years / range: 4 m – 63 y)
70
60
age
50
40
30
20
10
0
1
11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 171 181 191 201 211 221 231
Nº 253
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Edad de inicio de síntomas
70 60 50 40 30 20 10 0 1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 The narcolep�c borderland: a mul�modal diagnos�c approach including cerebrospinal fluid levels of hypocre�n-‐1 (orexin A). Bassetti C, Gugger M, Bischof M, Mathis J, Sturzenegger C, Werth E, Radanov B, Ripley B, Nishino S,
Mignot E. Sleep Med. 2003 Jan;4(1):3-‐4. N  Hypocre�n-‐1 was undetectable in three pa�ents with classic narcolepsy and detectable in the remaining 24 pa�ents. N  ESS>14 (78% of 27 pa�ents) N  REM symptoms (30%) N  Sleep latencies on MSLT<5 min (41%) N  >/=2 SOREM (30%) N  DQB1*0602 posi�vity (52%) N  BMI>25 (52%) N  Increased CSF lep�n (48%) N  Overlapping clinical and electrophysiological findings were seen mostly in pa�ents with narcolepsy without cataplexy, idiopathic hypersomnia, and psychiatric hypersomnia. “VI° Congreso Argentino de Medicina del Sueño”
13 y 14 de Mayo de 2011
Unexpected complaints in narcolepsy
Claudio Podestá
e-Sleep
age at onset
60
50
age
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
Nº 81
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Narcolepsy with cataplexy
16%
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ADHD
N s/ Cx
F
MDF
200
HYPERSOMNIA
N s/ Cx
E
MDF
200
ADHD
N s/ Cx
E
MDF
200
INSOMNIA
N + Cx
E
MDF
100
HYPERSOMNIA
N s/ Cx
E
MDF
200
INSOMNIA
N s/ Cx
E
MDF
200
HYPERSOMNIA
N s/ Cx
E
MDF
100
HYPERSOMNIA
N s/ Cx
E
MDF
100
HYPERSOMNIA
N s/ Cx
E
MDF
100
INSOMNIA
N s/ Cx
F
MDF
100
HYPERSOMNIA
N s/ Cx
E
MDF
300
HYPERSOMNIA
N s/ Cx
F
MTF
30
SLEEP PARALISYS
N s/ Cx
E
MDF
200
FIBROMYALGIA
N s/ Cx
E
MDF
200
INSOMNIA
N s/ Cx
E
MDF
200
HYPERSOMNIA
N s/ Cx
E
MDF
200
CATAPLEXY
N + Cx
E
MDF
200
HYPERSOMNIA
N s/ Cx
F
MTF
30
HYPERSOMNIA
N + Cx
E
MDF
200
HYPERSOMNIA
N s/ Cx
E
MDF
200
HYPERSOMNIA
N s/ Cx
F
MTF
30
NIGHTMARES
N s/ Cx
E
MDF
200
BIPOLAR DISORDER
N s/ Cx
E
MDF
200
SLEEP DRUNKENNESS
N + Cx
E
MDF
200
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22%
unexpected
symptoms
12%
66%
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Hipersomnia
Tratamiento no farmacológico N  Higiene de sueño y siestas breves Tratamiento farmacológico N  Modafinil N  Armodafinil N  Me�lfenidato N  Oxybato de Sodio (GHB) N  Selegilina (IMAO-‐B) N  Reboxe�na (IRNORA) N  Ritanserina (5-‐HT2 ant) N  Pemolina (?) 54
Serie FLENI / e-Sleep
92
186
Total
Modafinil
Metilfenidato
6
0
20
40
60
80
100
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Cataplexia y manifestaciones de SREM N  Inhibidores recaptación NORA/SER Venlafaxina (37.5-‐300 mg/d) N  Inhibidores recaptación NORA Viloxazina (100-‐300 mg/d) N  An�depresivos tricíclicos Clomipramina (25-‐75 mg/d) N  Oxybato de Sodio (GHB) (4.5-‐9 g/noche) 56
Estabilizadores del sueño nocturno N  Benzodiacepínicos
Alprazolam
Clonazepam
N  No Benzodiacepínicos
Zolpidem
Zopiclona
Eszopiclona
Zaleplón
Oxibato de Sodio (GHB)
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Tratamientos futuros Terapia Hipocre�nica N  Hcrt-‐1 intranasal. N  Transplantes neuronales. N  Ingeniería gené�ca de Stem-‐cells. 58
SARVAS
OSAS
RONQUIDO
HVO
OS
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<  4% población general.
<  ( 3:1 >SM)
<  > 6° década de la vida.
<  Hipersomnia diurna.
<  Roncopatía.
<  Nicturia.
<  Cefalea matinal.
<  Déficit de memoria.
<  < líbido.
<  > irritabilidad.
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 Ocurrencia en cualquier grupo etáreo.
 Incremento de severidad sin tratamiento.
 HTA / IAM.
 Hipertensión pulmonar.
 Arritmias cardíacas.
 Stroke.
 Depresión.
 Accidentes ligados a la hipersomnia diurna.
ICSD Review 2004
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Sleep apnea in acute cerebrovascular diseases: final report on
128 patients.
Aldrich M, Basetti C. Sleep 22: 217-222,1999.
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Central nuclear Three Mile Island
3/1979
4-6 AM
Central nuclear Oak-Harbor
6/1985
1:35 AM
Central nuclear Rancho Seco
2/1985
4:14 AM
Central nuclear Chernobyl
4/1986
1:23 AM
Transbordador Columbia
06/1/86
(LANZAMIENTO
ABORTADO)
Transbordador Challenger
27/1/86
Buque petrolero Exxon-Valdez
3/1989
0:04 am
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Serie FLENI / e-Sleep

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