Research of Sleep Disorders in Patients with Acute

Cerebral Infarction

Xiaofang Chen, MM,* Hongye Bi, BM,* Meiyun Zhang, MD,* Haiyan Liu, MM,†
Xueying Wang, BM,‡ and Ruonan Zu, BMx

Background: The purpose of this study is to investigate the incidence of sleep disor-
ders (SD), characteristic of cerebral infarction patients with different parts affected.
Methods: The research selected 101 patients with a first occurrence of acute cerebral
infarction as the experimental group, and 86 patients without cerebral infarction as
controls. Polysomnography, Pittsburgh Sleep Quality Index, Epworth Sleepiness
Scale, and US National Stroke Scale were assessed. Results: Compared with control
group, the incidence of SD was higher in experimental group (P , .05), and the inci-
dence of SD in women was more frequent in experimental group (P ,.05). There was
no significant difference in the types of SD patients with acute cerebral infarction. In
addition, the sleep quality of cerebral infarction patients with different parts affected
was different: the sleep quality of left hemisphere infarction patients was poor
compared with the right one, and the sleep quality of anterior circulation patients
was poor compared with posterior circulation patients. Patients with thalamus
infarction had a longer sleep time and a shorter sleep latency and stage 2 of non–
rapid eye movement sleep compared with non–thalamus infarction group. Conclu-
sions: The prevalence of SD was relatively high in acute cerebral infarction patients,
and the detailed classification of acute cerebral infarction may provide a more effec-
tive therapeutic method and therefore relieve patients’ pain and supply a better
quality of sleep. Key Words: Acute cerebral infarction—sleep disorders—sleep
quality—excessive daytime sleep.
Ó 2015 by National Stroke Association

Acute cerebral infarction is a major cause of disability

From the *Department of Neurology, Tianjin Union Medicine
Centre, Tianjin; †Department of Rheumatology, Second Affiliated
Hospital of Dalian Medical University, Dalian; ‡Department of Reha-
bilitation, Dalian Shipbuilding Sanatorium, Dalian; and xDepartment
of Rehabilitation, Dalian Port Hospital, Dalian, China.
Received February 16, 2015; revision received June 10, 2015;
accepted June 25, 2015.
The research is supported by projects in Tianjin Health Bureau
(No.2010KZ47).
The authors declare that they have no conflict of interest.
The article is approved by all the authors for publication.
Address correspondence to Xiaofang Chen, MM, Department of
Neurology, Tianjin Union Medicine Centre, No. 190 Jieyuan Road,
Hongqiao district, Tianjin 300121, China. E-mail: xiaofangchen766@
163.com.
1052-3057/$ - see front matter
Ó 2015 by National Stroke Association
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.06.033
and the second leading cause of death; there is still no
effective method to reduce acute cerebral infarction mor-
tality.1 Sleep disorders (SD) of acute cerebral infarction are
related to many risk factors leading to acute cerebral
infarction, and SD may be exacerbated by acute cerebral
infarction or caused by acute cerebral infarction.2 Some
reports showed that SD is one serious complication in
acute cerebral infarction patients, which is characterized
by insomnia, hypersomnia, sleep-disordered breathing,
excessive daytime sleep (EDS) and depression, restless
legs syndrome, or anxiety.3-6 Some reports showed that
SD can not only affect the cognitive function, life
quality, physical and mental health, and recovery of
patients’ physiological functions, but also aggravate the
risk of acute cerebral infarction, and at worst, induce
the recurrence of acute cerebral infarction.7 At present,
the relationship between SD and cerebral infarction has

Journal of Stroke and Cerebrovascular Diseases, Vol. -, No. - (---), 2015: pp 1-6 1
2 X. CHEN ET AL.

been well described, but still not fully understood. Table 1. The incidence of SD
Limited data are available in related research of the
detailed classification in patients with both SD and acute Groups SD (%) Non-SD (%) Total
cerebral infarction. In addition, unrecognized and un-
Experimental group 78 (77.23%) 23 (22.77%) 101
treated SD may influence the rehabilitation and function
Control group 24 (27.91%) 62 (72.09%) 86
following acute cerebral infarction and increase the risk
of acute cerebral infarction recurrence. Therefore, this Abbreviation: SD, sleep disorders.
study provides a detailed classification of acute cerebral Statistical significance was set at P 5 .00.
infarction to clarify the characteristics of different types
of patients with acute cerebral infarction, and conse- Statistical Analysis
quently to provide clinical evidence or a method for
further relieving and treating patients’ symptoms to All measurement data were analyzed by SAS 9.3 statis-
improve the quality of their life. tical software (SAS Institute Inc., Cary, NC). Qualitative
data of both the groups were compared by c2 test. Re-
searchers used the unpaired t test for quantitative data.
Materials and Methods Statistical significance was set at P less than .05.
Patients
The experimental group included 101 patients (65 men
Results
and 36 women with a mean 6 standard deviation age of
56.67 6 12.4 years) with acute cerebral infarction, who Incidence of Sleep Disorders
were recruited from the Department of Neurology, Tianjin
The results of Table 1 showed that SD were found in 78
Union Medicine Centre, from July 1, 2010, to December 31,
(77.23%) of 101 patients with acute cerebral infarction and
2011. Normal controls consisted of 86 patients (50 men and
24 (27.91%) of 86 controls. There was a significant differ-
36 women aged 64.69 6 11.67 years) without cerebral
ence between the 2 groups. In the 101 patients with acute
infarction, who were recruited from the physical examina-
cerebral infarction, significant differences were found
tion center of our hospital. There was no significant differ-
between SD group and non–SD group in National Insti-
ence between the 2 groups in terms of age (P . .05).
tutes of Health Stroke Scale, Hamilton depression, and
The diagnostic criteria should meet the revised stan-
Hamilton anxiety scores (Table 2). Our results suggested
dards of the Fourth National Cerebrovascular Disease
that cerebral infarction patients with low neurologic func-
Conference in 1995: aged 40-80 years, and the course of
tion, depression, or anxiety were more tend to have SD.
disease was within 2 weeks, diagnosed by brain magnetic
resonance imaging scan. Patients were excluded from the
study if they meet any of the following criteria: (1) with
Incidence of Different Types of Sleep Disorders
serious condition who cannot cooperate with the inspec-
tion; (2) with mental disorder or family history; (3) with As shown in Table 3, the incidence of EDS was 11.9%
severe sleeping disorder; (4) with drug and alcohol abuse; (12) in experimental group, whereas 1.2% in control
(5) with cerebral infarction combined with other serious group; difficulty falling asleep was 44.6% in experimental
physical diseases; and (6) with dementia. Informed group and 18.6% in control group; early awakening was
consent was obtained from all patients. The study was 24.8% in experimental group and 7% in control group;
approved by the Ethics Committee of Tianjin Union snoring was 9.9% and 3.5%, and nocturia was 15.8%
Medicine Centre. Face-to-face questionnaires were and 7%, respectively, in experimental and control groups.
carried out by 2 professional neurology specialists. The results demonstrated that there was no distinct differ-
ence between the 2 groups (P . .05).

Methods
Table 2. Difference in NIHSS, HAMD, and HAMA scores in
The National Institutes of Health Stroke Scale (NIHSS) was patients with acute cerebral infarction
used to assess patients’ neurologic function. The
psychological symptoms such as depression and anxiety Parameters SD (n 5 78) Non-SD (n 5 23)
were evaluated using the Hamilton depression and the Ham-
ilton anxiety rating scores, respectively. Pittsburgh Sleep NIHSS 7.9362.28 4.0162.63*
Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) HAMD 31.5565.64 5.963.2*
HAMA 19.4964.46 5.464.55*
were applied to assess the quality of sleep and excessive day-
time sleepiness, respectively. The whole process of objective Abbreviations: HAMA, Hamilton anxiety; HAMD, Hamilton
sleep examination was monitored with EmblaN7000 (Embla, depression; NIHSS, National Institutes of Health Stroke Scale;
Broomfield, CO) under 20 C for at least 8 hours. Significant SD, sleep disorders.
*
difference was indicated by P less than .05. Represents P , .05 compared with the SD group.
SD IN PATIENTS WITH ACUTE CEREBRAL INFARCTION 3

Table 3. Types of SD shown in Table 4. Compared with the anterior circulation

group, S31S4 and REM increased dramatically (P , .05)
Experimental Control P in the posterior circulation group.
Type of SD group group t value value
Sleep Monitoring between Thalamic and Non–
EDS 12 1
thalamic Infarction
Non-EDS 66 23 .1114 .2910
Difficulty falling 45 16 Relative reports8 showed thalamic infarction may
asleep course amnesia and linguistic disorders in various types
Non–difficulty 33 8 .6149 .4330 of acute cerebral infarction. So researchers divided the
falling asleep experimental group into thalamic infarction group and
DMS 32 5
non–thalamic infarction group (Table 4). Compared with
Non-DMS 46 19 3.24 .07
the non–thalamic infarction, S2 and SL reduced signifi-
Early awaking 25 6
Non–early 53 18 .34 .56 cantly (P , .05), whereas SL increased significantly in
awaking the thalamic infarction group (P , .05).
Snoring 10 3
Non-snoring 68 21 .27 1.00 Sleep Monitoring of Different Parts of Cerebral
Nocturia 16 6 Infarction
Non-nocturia 52 18 .021 .88
As shown in Table 5, compared with the other 3 groups,
Abbreviations: DMS, difficulty maintaining sleep; EDS, exces- TST, sleep efficiency (SE), S31S4, REM, and RL decreased
sive daytime sleepiness; SD, sleep disorders. significantly, and S1, SL, and WASO increased markedly
in the cerebral infarction group (P , .05). The results
Sleep Monitoring indicated that patients with cerebral infarction had poor
quality sleep when compared with the other 3 groups as
Sleep Monitoring between Experimental and Control
in Table 5.
Groups
Compared with the control group, total sleep time
(TST), stage 1 (S1) of non-rapid eye movement (NREM) Discussion
sleep, stage 3 and 4 of NREM sleep (S31S4), and PSQI More attention has been focused on the research of SD
reduced significantly (P , .05), whereas wake time after in patients with cerebral infarction. At present, many
sleep onset (WASO), ESS, rapid eye movement (REM), studies have suggested that SD may increase the inci-
sleep latency (SL), and REM latency (RL) increased signif- dence and risk of hypertension, cardiovascular disease,
icantly (P , .05) in the experimental group (Table 4). and cerebral infarction.9-11 S Claiborne12 reported that
types of SD in patients with cerebral infarction varied;
Sleep Monitoring between Men and Women main symptoms of SD were sleep-disordered breathing
As shown in Table 4, compared with men in the exper- (SDB) and sleep–wake disorders, both of them were com-
imental group, TST, REM, and SL of women in experi- plications of cerebral infarction and the factors of its prog-
mental group reduced significantly, whereas S1 and RL nosis.13,14 Reports showed the incidence of SD in normal
increased significantly. The differences were significant population was 1 in 5, that is, up to 80% in patients with
(P ,.05), indicating that SD in patients with acute cerebral cerebral infarction. The research showed that SD was
infarction was associated with gender. found in 78 (77.23%) of 101 patients with acute cerebral
infarction and 24 (27.91%) of 86 controls, which
Sleep Monitoring between Left and Right Hemi- demonstrated that the incidence of SD in patients with
spheres acute cerebral infarction was higher than in controls,
indicating that SD in patients with acute cerebral
As shown in Table 4, patients in the experimental group
infarction is a common phenomenon and a frequent
were divided into patients with left side cerebral infarc-
complication of acute cerebral infarction (Table 1).
tion and patients with right side cerebral infarction. Our
Related reports showed the incidence of SD in patients
results found that compared with the right hemisphere
with acute cerebral infarction was inconsistent in
(RH), S1 and ESS increased dramatically in the left hemi-
different countries: the incidence in China is 18.75%-
sphere (LH; P , .05).
77.25%9,10 and almost up to 78% in other countries.
Some researchers found that the incidence of SD in
Sleep Monitoring between Anterior and Posterior
patients with acute cerebral infarction was highly
Circulation
associated with age and gender, and the incidence of SD
Researchers divided the experimental group into 2 in women with acute cerebral infarction was higher
groups according to the blood resources of brain, as than men. TST and SL of women were less than those of
 4
Table 4. Sleep monitoring

Experimental Control Anterior Posterior Thalamic Non–thalamic

group group Women Men LH RH circulation circulation infarction infarction
Parameters (n 5 101) (n 5 86) (n 5 36) (n 5 65) (n 5 39) (n 5 34) (n 5 20) (n 5 22) (n 5 17) (n 5 84)

TST (min) 31.07 6 91.33* 421 6 100.7 262.50 6 87y 328.00 6 104.8 288.8 6 97.05 297 6 111.2 301.5 6 101.2 308.8 6 21.76 32.59 6 102.2 294.4 6 100.4
SE (%) 79.84 6 17.72 84.3 6 15.2 82 6 16.82 86 6 19.23 81.23 6 15.27 82.02 6 16.67 83.4 6 13.58 82.86 6 10.87 76.27 6 21.48 80.56 6 16.92
S1 (%) 14.7 6 14.59* 24.07 6 19.12 15.7 6 13.7y 7.9 6 9.3 16.8 6 16.44z 10.29 6 9.39 64.87 6 57.29 76.02 6 60.27 18.97 6 22.7 13.8 6 12.35
S2 (%) 39.07 6 15.03 41.67 6 18.62 38.85 6 17.44 42 6 13.61 37.86 6 15.20 43.06 6 12.68 40.77 6 13.6 43.08 6 11.66 32.56 6 18.70k 40.39 6 13.94
S31S4 (%) 10.3 6 7.3* 11.4 6 6.7 55.4 6 12.3 43.1 6 10.5 45.1 6 13.2 48.3 6 17.6 32.11 6 17.89x 17.36 6 14.57 46.03 6 27.01k 41.25 6 17.61
REM (%) 59.51 6 49.31* 38.39 6 52.02 11.9 6 12.07y 13.6 6 10.06 15.58 6 12.97 11.86 6 8.51 16.36 6 13.66x 9.22 6 1.68 11.46 6 11.03 13.38 6 12.27
WASO (%) 19.55 6 22.96* 6.92 6 14.05 22.43 6 18.9 17.95 6 16.20 18.35 6 15.50 17.48 6 16.26 15.84 6 12.74 16.61 6 10.66 23.17 6 20.75 18.81 6 16.52
SL (min) 46.8 6 34.6* 31.3 6 30.6 11 6 5.3y 35 6 11.2 20 6 5.7 21 6 8.6 22.3 6 6.36 21.66 6 9.73 10.30 6 4.98k 23.76 6 10.73
RL (min) 136 6 87.3* 114 6 75.3 83 6 12.6y 22 6 7.9 78 6 12.6 72 6 17.5 88 6 17.6 10.53 61.30 6 13.33 70.60 6 17.5
PSQI 9.1 6 4.8* 14.7 6 5.9 10.3 6 5.24 8.5 6 4.44 9 6 4.55 9.8 6 5.46 8.5 6 3.35 10.5 6 5.35 9.71 6 4.27 9.08 6 4.91
ESS 6.3 6 5.2* 1.0 6 1.6 7.25 6 5.13 5.83 6 7.15 7.41 6 6.50z 4.85 6 4.09 7.95 6 7.33x 4.54 6 4.85 8.12 6 5.63 5.97 6 5.19

Abbreviations: ESS, Epworth Sleepiness Scale; LH, left hemisphere; NREM, non–rapid eye movement; PSQI, Pittsburgh sleep quality index; REM, rapid eye movement; RH, right hemisphere; RL,
REM latency; SE, sleep efficiency; SL, sleep latency; S1, stage 1 of NREM sleep; S2, stage 2 of NREM sleep; S31S4, stage 3 and 4 of NREM sleep; TST, total sleep time; WASO, wake time after sleep
onset.
*Represents P , .05 compared with control group.
yRepresents P , .05 compared with male group.
zRepresents P , .05 as compared with RH in experimental group.
xRepresents P , .05 compared with posterior circulation.
kRepresents P , .05 compared with non–thalamic infarction.

X. CHEN ET AL.
SD IN PATIENTS WITH ACUTE CEREBRAL INFARCTION 5

Table 5. Sleep monitoring of cerebral infarction patients with different parts affected

Cerebral infarction Subcortical infarctions Brainstem infarctions Cerebellum infarctions

Parameters (n 5 27) (n 5 32) (n 5 18) (n 5 6)

TST (min) 178.4 6 97.6* 314 6 79.3 306.4 6 110.8 334.9 6 97.4
SE (%) 50.4 6 11.5* 65.0 6 11.9 61.2 6 19.3 60.5 6 25.3
S1 (%) 86.6 6 19.8* 35.3 6 18.9 31.3 6 19.9 31.6 6 25.4
S2 (%) 10.3 6 11.4 14.6 6 11.2 21.6 6 12.1 23.4 6 19.7
S31S4 (%) 10.9 6 11.7* 15.4 6 12.5 21.6 6 10.8 23.6 6 17.8
REM (%) 10.7 6 8.6* 12.7 6 9.3 12.4 6 6.8 15.1 6 13.9
WASO (%) 23.4 6 11.9* 18.5 6 13 20.3 6 11.4 23.8 6 16.5
SL (min) 50.3 6 39.8* 27.6 6 20.3 38.7 6 50.3 34.6 6 31.4
RL (min) 99.6 6 89.5* 136.8 6 117.6 121.3 6 97.7 130.8 6 95.7
PSQI 9.9 6 6.3 9.3 6 6.8 8.9 6 7.6 8.6 6 7.4
ESS 6.9 6 5.4 6.4 6 6.8 7.2 6 6.8 6.8 6 7.1

Abbreviations: ESS, Epworth Sleepiness Scale; NREM, non–rapid eye movement; PSQI, Pittsburgh sleep quality index; REM, rapid eye
movement; RL, REM latency; SE, sleep efficiency; SL, sleep latency; S2, stage 2 of NREM sleep; S31S4, stage 3 and 4 of NREM sleep;
TST, total sleep time; WASO, wake time after sleep onset.
*Represents P , .05 compared with the other 3 groups.

men.14-16 Similarly, the present study showed a similar
result: the incidence of SD in women is higher than in
men, and both sleep time and SE were shorter in
women than in men, which may be related to
physiological state, mental state, and the severity of the
disease.
Various types of SD are extremely common in cerebral
infarction patients. Frequent SD in patients with
cerebral infarction include insomnia, EDS, SDB, and pain-
ful SD.13, 17 Relative literature reported the incidence of
different types of SD, namely difficulty falling asleep,
difficulty maintaining sleep, and structure of SD and
EDS (high to low). Similarly, the present study found
that the prevalence of difficulty falling asleep in the
patients was 44.6%, the incidence of early awaking was
24.8%, and EDS was 11.9%. There were 66 (65.35%)
cases experiencing both cerebral infarction and SDB,
and there were no significant differences among
nightmares, snoring, nocturia, hallucinations, body
cramps, and restless legs syndrome (P . .05).
Recently, objective sleep was more concerned; relative
reports showed TST and SE reduced, whereas WASO
increased significantly in patients with cerebral infarc-
tion.14,18-20 Our results showed TST, S1, S31S4, and
PSQI reduced significantly (P , .05) in the experimental
group, whereas WASO, ESS, REM, SL, and RL increased
significantly (P , .05), indicating less sleep time.
Structure of SD and lower SE may course excessive sleep.
It is evident that cerebral infarction patients with
different parts affected were highly correlated with SD.
As shown in Table 4, when compared with RH, S1 and
ESS increased dramatically (P , .05) in the LH, indicating
the appearance of sleep quality. These results are consis-
tent with those of previous reviews.15, 20 Compared
with the anterior circulation group, S31S4 and REM
increased significantly in the posterior circulation
group. Researchers further divided the experimental
group into 4 groups as in Table 5: when compared with
the other 3 groups, sleep quality of the cerebral infarction
group was the most poor (P , .05). TST, SE, S31S4, REM,
and RL decreased significantly, and S1, SL, and WASO
increased markedly in the cerebral infarction group
(P , .05); however, there still exist some opposite
views.21,22 These results may be related to experimental
surroundings, physical condition, mood, and so forth.
SD could affect the treatment and recovery of patients
with acute cerebral infarction. Seriously, SD may be
related to the mechanisms of sleep-related structural
damage, abnormal secretion of neurotransmitters,
mood, and environment-related interference, and there
is still no effective treatment. Therefore, people need to
pay much more attention to SD after cerebral infarction
because of different reasons for SD and because different
parts are affected in cerebral infarction to perform appro-
priate treatment, improve patients’ quality of sleep, and
then promote rehabilitation of patients.
Conclusion
The research clarified sleep monitoring indicators for
different parts of cerebral infarction. It also demonstrated
that the sleep quality of patients with LH infarction was
poor compared with that of patients with RH infarction;
the sleep quality of patients with anterior circulation
was poor compared with that of patients with posterior
circulation; patients with thalamus infarction had a
longer sleep time and a shorter SL and S2 compared
with non–thalamus infarction group. This study lays a
foundation for further understanding the mechanism of
SD in patients with acute cerebral infarction and finding
better therapeutic methods, therefore alleviating patients’
pain and supplying a better quality of sleep.
6 X. CHEN ET AL.
Acknowledgments: The authors would like to thank all
study participants, physicians, and coworkers for their help
in the preparation and process of this study.
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