Acute lacunar infarct in an obese adolescent with obstructive sleep apnea

Abstract

Obstructive sleep apnea is associated with an increased risk of acute ischemic cerebrovascular accidents in adults. However, this association has not been well established in the pediatric population. We report a case of acute right internal capsule lacunar infarct manifesting as left-sided hemiplegia in an adolescent with severe obesity. Severe untreated obstructive sleep apnea was identified during the hospital stay. Positive airway pressure therapy, weight loss, and tonsillectomy eventually normalized sleep-disordered breathing. The patient recovered completely without any residual neurological deficits with multidisciplinary care. Lacunar infarcts due to hypertension-related cerebral vasculopathy are a well-known cause of stroke in adults. Untreated obstructive sleep apnea may cause hypertension and potentially predispose even the pediatric population to develop lacunar infarcts. Polysomnography needs to be considered as a part of the diagnostic algorithm in pediatric patients with stroke.

Citation: Chen B, Gorantla S, Shah V. Acute lacunar infarct in an obese adolescent with obstructive sleep apnea. J Clin Sleep Med. 2021;17(8):1743-1747.

Keywords: ischemic stroke; obstructive sleep apnea; pediatric obesity.

Figure 1. MRI of the brain without contrast showing restricted diffusion lesion in the posterior limb of the internal capsule on the right side.

(A) Hyperintense lesion on DWI. (B) Lesion with corresponding hypointensity on ADC sequence. ADC = apparent diffusion coefficient, DWI = diffusion weighted imaging, MRI = magnetic resonance imaging.

Figure 2. Hypnogram of the initial split-night study and representative epochs.

(continued on following page) (A) Hypnogram of the initial split night study showing severe OSA and severe nocturnal hypoxemia. (B) Two representative epochs of (epoch 1) the severe OSA and (epoch 2) PAP and positional therapy that normalized AHI at a bilevel PAP setting of 19/12 cm of H₂O. ADI = apnea disturbance index, AHI = apnea-hypopnea index, APN = apnea, CA = central apnea, CPAP = continuous positive airway pressure, DX = desaturation time, EPAP = expiratory positive airway pressure, act, HDI = hypopnea disturbance index, HYP = hypopnea, IDX = desaturation index, IPAP = inspiratory positive airway pressure, MA = mixed apnea, OA/OSA = obstructive sleep apnea, PAP = positive airway pressure, PS = pressure support.

Figure 2. Hypnogram of the initial split-night study and representative epochs.

(continued on following page) (A) Hypnogram of the initial split night study showing severe OSA and severe nocturnal hypoxemia. (B) Two representative epochs of (epoch 1) the severe OSA and (epoch 2) PAP and positional therapy that normalized AHI at a bilevel PAP setting of 19/12 cm of H₂O. ADI = apnea disturbance index, AHI = apnea-hypopnea index, APN = apnea, CA = central apnea, CPAP = continuous positive airway pressure, DX = desaturation time, EPAP = expiratory positive airway pressure, act, HDI = hypopnea disturbance index, HYP = hypopnea, IDX = desaturation index, IPAP = inspiratory positive airway pressure, MA = mixed apnea, OA/OSA = obstructive sleep apnea, PAP = positive airway pressure, PS = pressure support.