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Evidence suggests that untreated obstructive sleep apnea (OSA) is a significant health risk for the development of hypertension, cardiovascular disease, and stroke. OSA is independently associated with obesity, hypertension, and insulin resistance/diabetes mellitus, the three stroke risk factors of the metabolic syndrome. Studies in normal subjects and sleep apneic patients suggest that upper airway occlusion induces arousal from non-rapid eye movement (NREM) sleep once the level of inspiratory effort reaches a certain value, which varies among individuals. During apnea there are several stimuli that are well known to be able to induce arousal, including hypercapnia, hypoxia, and increased airway resistance. Cohort studies have shown OSA to be a risk factor for stroke. OSA is associated with a variety of stroke risk factors that may independently contribute to stroke risk. This suggests the potential for a cause-and-effect relationship between untreated OSA and stroke in some cases.
This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 25-year old patient who was admitted for the evaluation of insomnia. The specialist made a diagnosis of narcolepsy with possible cataplexy and decided not to pursue a CSF hypocretin analysis in light of the diagnostic certainty of the polysomnography (PSG) results. The multiple sleep latency test (MSLT) showed the presence of REM sleep in all four naps with a latency of 5 minutes. He prescribed modafinil 200 mg to be taken in the morning, a dose that could be increased to 400 mg if necessary. Narcolepsy is a life-long disorder presenting with excessive daytime sleepiness (EDS) and, ironically, with fragmented sleep that may lead to an erroneous diagnosis of insomnia. In addition to modafinil, patients may respond favorably to the administration of methylphenidate and dexedrine.
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