Imaging
Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.
The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.
Medical Image of the Week: DBS Polysomnogram Artifact
Safal Shetty, MD
Kenneth S. Knox, MD
Pulmonary, Allergy, Critical Care & Sleep Medicine
Banner University Medical Center
Tucson, AZ
Figure 1. Thirty second epoch showing DBS artifact obscuring all recording channels except flow, efforts belts and the EKG channels.
Figure 2. Ten second epoch showing the electrical artifact due to DBS.
A 79-year-old man with known Parkinson’s disease and status post deep brain stimulator (DBS) implantation underwent an overnight polysomnogram for clinical suspicion of obstructive sleep apnea. Artifact was seen on the polysomnogram recording (Figures 1 & 2).
Patient-related electrical artifacts may be seen from devices such as pacemakers, deep brain stimulators and vagal nerve simulators. Abrupt discontinuation of DBS is associated with a high likelihood of worsening of symptoms in patients with Parkinson’s disease (1). Patients with DBS are most commonly programmed in monopolar mode. Bipolar configuration, forms a short electrical dipole that affects a relatively smaller volume of tissue and generates far less artifact, suggesting that this may be an effective option in a Parkinsonian patient with indications for polysomnography (2).
References
- Chou KL, Siderowf AD, Jaggi JL, Liang GS, Baltuch GH. Unilateral battery depletion in Parkinson's disease patients treated with bilateral subthalamic nucleus deep brain stimulation may require urgent surgical replacement. Stereotact Funct Neurosurg. 2004;82(4):153-5. [CrossRef] [PubMed]
- Frysinger RC, Quigg M, Elias WJ. Bipolar deep brain stimulation permits routine EKG, EEG, and polysomnography. Neurology. 2006;66(2):268-70. [CrossRef] [PubMed]
Cite as: Shetty S, Knox KS. Medical image of the week: DBS polysomnogram artifact. Southwest J Pulm Crit Care. 2015;11(4):151-2. doi: http://dx.doi.org/10.13175/swjpcc096-15 PDF
Medical Image of the Week: REM without Atonia
Figure 1. Polysomnogram with thirty-second epoch showing leg movements and relative increase in chin tone during REM sleep.
Figure 2. Polysomnogram with thirty-second epoch demonstrating similar interval of REM without atonia with the addition of sleep-talking.
A 78 year-old man with a past medical history of Parkinson’s disease (PD) presented to the sleep medicine clinic for evaluation of obstructive sleep apnea (OSA). An overnight polysomnogram (PSG) study was consistent with sleep apnea and revealed frequent leg and arm movements and sleep-talking during rapid eye movement (REM) sleep.
REM sleep behavior disorder (RBD) is a parasomnia characterized by repeated episodes of abnormal behavior occurring during REM sleep (1,2). On PSG, REM sleep without atonia is seen while features of “normal REM” such as number of REM periods and REM cycling remain intact (2). RBD emerges most often in the context of alpha-synucleinopathies, and occurs in up to 60% of PD patients (3). The presence of RBD may be an important preclinical symptom prior to the onset of PD. Cases of PD with RBD are associated with a unique phenotype with an older age of onset, longer disease duration, more profound motor disability, and greater degrees of hallucinations and cognitive dysfunction (3). Establishing a safe sleep environment can be of primary importance in patients with RBD as REM without atonia is associated with injurious behavior. Melatonin is effective as a first-line agent in patients with dementia. In non-demented patients without OSA, low-dose clonazepam is the first line intervention and is rarely associated with withdrawal or need for dose escalation (1). Treating concomitant OSA is important adjunctive therapy.
Jared Bartell, Safal Shetty MD, and Kenneth S. Knox MD
University of Arizona Medical Center
Tucson, AZ
References
- Aurora RN, Zak RS, Maganti RK, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Ramar K, Kristo DA, Morgenthaler TI; Standards of Practice Committee; American Academy of Sleep Medicine. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010;6(1):85-95. [PubMed]
- Schenck CH, Mahowald MW. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep. 2002;25(2):120-38. [PubMed]
- Kim YE, Jeon BS. Clinical implication of REM sleep behavior disorder in Parkinson's disease. Parkinsons Dis. 2014;4(2):237-44. [CrossRef] [PubMed]
Reference as: Bartell J, Shetty S, Knox KS. Medical image of the week: REM without atonia. Southwest J Pulm Crit Care. 2015;10(3):147-8. doi: http://dx.doi.org/10.13175/swjpcc022-15 PDF