y p p pMeghan Meghan WoughterWoughter, BS, , BS, Amy Perkins, MS, Amy Perkins, MS, Cristina Cristina BaldassariBaldassari, MD, MD

Department of Otolaryngology and Department of Pediatrics, EasteDepartment of Otolaryngology and Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VArn Virginia Medical School, Norfolk, VA

CAI greater than one does not predict CNS pathology on MRI. Thus, the routine use of MRI in the evaluation of pediatric CSA is not recommended. There are certain factors such as abnormal neurologic exam findings and a history of developmental delay that may improve the diagnostic yield of MRI in children with CSA. Further research is necessary to determine if there are other diagnostic tests that can be utilized in the evaluation and management of pediatric CSA.

Patient Demographic InformationTotal number of subjects 36Male, n (%) 16 (44.4)Central Sleep Apnea, n (%) 20 (55.6)Obstructive Sleep Apnea, n (%) 29 (80.6)Chiari Malformation, n (%) 1 (2.8)Abnormal neurologic exam, n (%) 7 (19.4)Developmental delay, n (%) 9 (25)Prematurity, n (%) 11 (30.6)Age in months, mean ± SD 43.2 ± 52.2Mean Central Apnea Index ± SD 2.5 ± 3.8Mean Apnea-Hypopnea Index ± SD 8.1 ± 6.7Mean Obstructive AHI ± SD 5.4 ± 5.9

Pediatric sleep disordered breathing can be divided into two major categories: obstructive sleep apnea (OSA) and central sleep apnea (CSA).1 Pediatric OSA, which is more common, is due to upper airway obstruction, while CSA is characterized by episodes of apnea during sleep in the absence of airway obstruction. Little data exists on the etiology, work-up, and management of pediatric CSA.

Several publications have described an association between CSA and central nervous system (CNS) abnormalities like Arnold-Chiari Malformation (CM).2-5

Thus, Magnetic Resonance Imaging (MRI) is frequently performed when evaluating children with CSA to rule out any brainstem pathology.2,4,5 However, to the authors’knowledge, there have been no prior publications describing the utility of brain MRI in the evaluation of children with CSA.

The objectives were: 1) To determine the incidence of CNS pathology, including CM, identified on MRI scans in children with CSA diagnosed by polysomnogram (PSG); 2) To assess whether certain factors such as developmental delay or neurologic exam abnormalities impact the yield of MRI in the evaluation of CSA.

A retrospective chart review was conducted at a tertiary pediatric hospital. Children between the ages of 3 months and 18 years who had undergone both full-night PSG and a brain MRI over a 10 year period were eligible for inclusion in the study.

Introduction

Methods

Results Results (cont.)

Conclusion

References

The incidence of CNS pathology on MRI in children with a CAI greater than one was 30% (n=6). When children with CSA were compared to those without CSA, there was no significant difference (p=.23) in the rates of abnormal MRI (Figure 1). Furthermore, the presence of OSA on PSG did not predict (p=.54) abnormal findings on MRI (Figure 2).

There were two factors identified in subjects with CSA that improved the diagnostic yield of MRI. These included abnormal neurologic findings on physical exam and a past medical history of developmental delay. The presence of both CSA and an abnormal neurologic exam, increased the likelihood of an abnormal MRI by 8.36 times, while the presence of CSA and developmental delay increased it by 4.47 times.

Key: Apnea-Hypopnea Index – AHI, Standard Deviation – SD, n = number of subjects

Thirty-six children met the inclusion criteria. Demographic data is depicted in Table 1. Fourteen children (38.9%) had evidence of CNS pathology on MRI, with the most common finding (n=5) being arachnoid cyst. Children with a central apnea index (CAI) greater than one were considered to have CSA, while OSA was defined as an obstructive apnea hypopnea index (OAHI) greater than one. There were twenty children diagnosed with CSA on full-night PSG. The presence of CSA was not significantly associated with other co-morbid conditions such as developmental delay, seizures, prematurity, cerebral palsy, or reflux.

1 American Academy of Sleep Medicine. International classification of sleep disorders, 2nd edition: Diagnostic and coding manual. Westchester, Illinois: American Academy of Sleep Medicine, 2005. 2 Dauvilliers Y, Stal V, Aril B, et al. Chiari malformation and sleep related breathing disorders. J Neurol Neurosurg Psychiatry. 2007;78:1344-1343 Hershberger ML, Chidekel A. Arnold-Chiari malformation type I and sleep-disordered breathing: an uncommon manifestation of an important pediatric problem. J Pediatr Health Care. 2003: 17(4): 190-7.4 Spence J, Pasterkamp H, McDonald PJ. Isolated central sleep apnea in type I Chiari malformation: improvement after surgery. Pediatr Pulmonology. 2010:45:1141-4. 5 Zolty P, Sanders MH, Pollack I. Chiari malformation and sleep-distorderedbreathing: a review of diagnostic and management issues. Sleep. 2000: 23(5).6 Van den Broek M, Arbues AS, Chalard F, et al. Chiari type I malforamtion causing central apnoeas in a 4-month-old boy. Official Journal of the European Paediatric Neurology Society. 200p: 13: 463-5.