Disclosures: Stanley G. Guillaume, MD, MPH: No financial relationships or conflicts of interest

Case Description: The patient had presumed left pontine stroke and was admitted to IRF with tracheostomy due to respiratory failure. Patient initially progressed well in therapy, and underwent decannulation on week 5 of rehabilitation without complication. After decannulation, functional rehabilitation became limited due to multiple transient self-limited episodes of changing mental status, new left lower extremity weakness, and worsening dysarthria. Infectious work-up and repeat brain imaging were negative. Every night, patient had multiple events of hypoxia requiring oxygen supplementation. Thus, the patient fluctuated between maximal assist the prior day and regressed to total assist with activities of daily living (ADLs) the morning after.

Setting: Acute Inpatient Rehabilitation Facility (IRF)

Patient: A 67-year-old male with known history of prior strokes presents with new right-sided weakness and dysarthria.

Assessment/Results: Symptoms remained despite holding sedating medications. Post-decannulation, the patient had loud snoring, gasping arousals, and frequent daytime somnolence. Fiber-optic Evaluation of Swallowing (FEES) showed left vocal cord paralysis and right vocal cord hypomobility. A split-night sleep study with extended montage EEG was performed, showing no seizure activity. However, results showed severe obstructive sleep apnea (OSA) with Apnea-Hypopnea Index of 52/hour (AHI>30) and nadir SpO2 of 55%. With effective CPAP administration and management, his functional mobility, communication and social cognition finally improved suggesting an initial diagnosis of ‘wake-up’ stroke secondary to severe OSA.

Discussion: Wake-up strokes are a phenomenon in which a patient wakes up to stroke symptoms not present prior to falling asleep, highly associated with moderate to severe OSA. Men with respiratory failure and tracheostomy with undiagnosed severe OSA (AHI>30) are likely compensating with the tracheostomy, and at risk for further deterioration after decannulation.

Conclusion: In IRFs, sleep studies should be the standard of care for early screening of OSA in patients with tracheostomy to decrease risk of wake-up strokes and cardiovascular decline.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/wake-up-stroke-symptoms-in-an-individual-with-undiagnosed-obstructive-sleep-apnea-a-case-report/