The UOEHAssociation The UOEH Association J.UOEH, of ofHealth Health Sciences Sciences l1 (4):38S-391 (1989) 383 [Original) Overnight Recordings of IntracranialPressure and Electroencephalography in Neurosurgical Patients Part II : Changes in IntracranialPressure during Sleep Akira YOKOTA, ShigeakiMATSUOKA, Tadahiro ISHIKAWA, Kiyotaka KOHSHI Hidehiko KfVIWARA and DopartmentofNeurosurgety, Scltool Occtipatienal and Environmental qf tadicine,ehiversity of' Health,Jopan. Kitalpushu 807,Jopan Changes in intracranialpressure (ICP) during sieep were investigatccl in 37 patientswith chronic hydrocephalus, in whom episodic characintracranial hypertension or chronic pressure waves terized by A-waves or episodic B-waveswere seen in Part I of this paper, Thc patientswere Abstract: conscious, sleep and including REM stages 88.9% of A-waves initiation ef REM cpisodic pressure sleep intracranial conditions are Kay known Lo occur ICP, pressurc wave, wordf: and rl'heepisodic waves. many in occasiens, thern. all of and was always During !owerin ICP was sccn in REM sleep. frequent characterized by appcarances of the pressure 95.1% of episodic B-waves appcared during REM The sleep. EEG began 1 to 2 minutes on to er at the onset of the prior scored A observed were in Stage llon sleep, ICP significantly rosc Stage ISfthan in othcr sleep stages. ICP changes during REM sleep were non-REM waves; slccp in REM slccp, markcd elevation of are assumed pressure waves incrcased brainactivity and when to be induced by the sympathctic rcduced tone simultaneously. REM sleep, 15 August <Received I989, accepted IS October 1989) Introduction (ICP) during sleep has been well clocumented in both clinical (Di Rocco et at., l975; Pierre-Kahn et al,, 1976) and ex& Viernstein, 1979; Hirsch et ai., 1978) studies, since Cooper and Hulme perimental (Gilcer rl-his firstdemonstrated it polygraphically in l966. evidence, particularly the episodic appearance called A- and B-waves during rapid ef pressure waves eye movement (REM) sleep, has been applied to reveal occult intracranial hypertensienin normal pressure hydrecephalusand to select candidates for shunting operations Rocco et al., 1976; (Di However, no study has been made Tamaki et at., 1983). regarding the extent of the corThe relation eviclence of that pressure waves intracranial pressure with sleep, and REM and only a few papers have referred te the time & (GUcer Viernstein, 1979;Munari & Calbucci,1981; Pierre-Kahn et at., 1976). The questionwhether REM sleep preccdes the to be importantin determiningthe pathogenesis of the episodic pressurewaves isconsidered In our study, quantativeas well as temporal correlations between epipressure waves. relation between pressure waves REM rises sleep NII-Electronic Library Service The UOEHAssociation The UOEH Association of ofHealth Health Sciences Sciences 384･ A. YoKoTA pressure waves sodic sleep phenomena have two episodic ICP termine REM and sleep stages. study questionwhether was these also & Hulme, (Cooper in their papers but with cliscordant results 1975; Munari & Calbucci,l981). these changes et al., the performed to deA few investigatorshave mentioned 'l-his relationship, during non-REM changes investigated to answer were a causal et al. l966;Di Rocco ClinicalMaterialsand Method Among 85 in whom dilation taneously performed and intracranial hypertension patients with recording of ICP overnight in whom tients, were neurosurgical and characterized pressure waves investi.crated further to analyze ICP episodic observed, were during changes Patients sleep. 15 patientsranging in age from 3 months to 65 years, 10 with brain tumors (7children and 3 adults), 3 with infant or child non-tumorous hydrocephalus, one with adult hydrocephalusdevelopedin the subacute phase of subarachnoid hemorrhage with A-waves simul- was et at., 1989),37 papaper (Yokota by A-waves and episodic B-waves this of ventricular (EEG) electroencephalography I in Part explained and/or consisted of (SAH), one patientswas 20,6years. and firomalert benign intracranialhypertension. with adult Thc consciousness the of The the time of patientsat were or all idiopathic origin, 'l'iheir of conscious. Methods ICP recording Overnight profilesof ICP stages were scored visually waves one Time age these, ranged recording were and sleep stages in ICP concerning relations and in age from 8 to 75 hydrocephalusafi The patients malfbrmation. described in }'art I . EEG diagrammed fbr each patient. Sleep criteria of Rechtschaffen& Kales (l968). sleep stag'es were based on the ICP-sleepstagc were initiationof REM the investigated using data replayed were of 47.8 years. was the I Chiari type with and using Correlations between changes diagrams, and average of age drovv'sy. to slightly Patientswith episodic B-waves consisted of 22 patientsranging communicating years, 9 with postoperative brain tumors, 12 with chronic ter SAH average from a magnetic sleep and pressure episodic tape. Results ICP observed whose during sleop. chatages ICP in patients with A-waves resting pressure was in the lightsleep below the resting than 2, 3a, b). (Figs. normal pressure. subsequent Depcnding in some higherthan high ICP in Stage rv' was ICP with and I, fi)was (Stage Stage M remained as when accordance Ia, b) (Fig. stages M, rv),but ICP in 3b), However, O'ig. 3b), except (Fig. higher in changes always to the on as that case, On were stages patientswith in Stages many that Iand in the pressure waves ICP in non-REM clearly B-waves episodic occasions in the deep slecp lower than episodic the that sleep stages llin other ICP (Stage some cases sleep stages transiently droppcd sleep was both NII-Electronic Library Service The UOEHAssociation The UOEH Association of of Health Health Sciences Sciences OvernightICP EEG Recordii]gsIJ.ICIJ during Slccp and 385 [Fitn.rl V,,,d ft"A,ft nyi 1 R Awake REM tt.Nmao-om I II j i IJI N * 75 -tu=fiE.Ttmv- 'b, "ul 50 1･ 25 ii"tsbalgikk,i3{ )ti )lit-k if t///'.1 - 18 Fig. Ia. 24 1 2 3 4 5 6 7 8 Time {hour} Sleep stage diagrarn {upper column) and overnight ICP profile (lowerco]umn) in a 4-yearold boy with optic-hypothutaniic Episodic repeatediy gliorna. pressurewaves (A-waves) appear coinciding' wit}t REM sleep stage. higherand lower sion concerning REM of than changes 21 20 22 23 ICP in the waking in ICP according ho"'ever, ICP sleep, majority 19 ,,iilA[i ,ikl,,, e rese Ia, 2, 3a). (Figs. state to waking and sleep stage fbrming A-waves abruptly, Thus no be could episodic or definiLe concluIn reached. B-waves in the la, 2,3a). (Figs, cases Correlation waves betweert pressure frequency ef A-waves REAdi and In patients with sleop. A-waves, the average REM stages per night per person were 5.73 and 5.55, respectively. Further, 88.9% of the total numbers of A-waves appcared in accordance with REM s}eep, 7.9% occurrcd duringwakirig and 3.2CZ)occurred in Stage [ . A-waves never occurrcd in Stage M or rv (Fig. Ia,b). On the other hand, REM wcre associatcd A-waves with at a rate and of 91,8%, and group. In patients with 3.15and 4.0 times on waves ll and in Stage at a rate of during 75.0%, while the the interrelationbetween REM data recorder usually ascending occ;urred phase initiation of REM which 1 were stored to 2 minutes of the plateau. slcep, and priorto the only REM without andPressure magnetic and per person. any waves. pressurewaves and on associated B-waves night RErv{occurred 7'imeretation betweenthe initiation ofREM above, were 2, 3a). (Figs, waking other REM episodic pcr duringREM respectively, B-waves occurred percentofepisodic appeared B-waves, episodic averag{,', the other tapes. was also REM B-waxJes in this stages one B-waves episodic B- of episedic accompanied pressure changes. In the subjects investigated based on data replayed from The initiationof REM occurred appeared Ninety-five point 4,9% initiation of A-waves Episodic B-waves with on EEG Ib) or just at (Fig. the i to 2 the minutes after 3b). (Fig. NII-Electronic Library Service The UOEH Association TheUOEHAssociation of ofHealthSciences Health Sciences 386 A. YoKo'r,･1et al. EEG 1 EOG -50"Vlsec EMG EEG -VVpmvafwhVNJN,Ni.-NVVntwtLrwVLJwtth.)V 2 EOG ---･------L------J--･L--･-------･-----J---･-LEMG w EEG tevpmVtwWNWtwVav 3 EOG EMG F･ iit,-,-i;i･gi.{.,ifl--t,L..;Lii. I l-F･.'fi,rnmHgrtr･rtrl,"i -i-i .i4."-il,iil/i,..I-Eli.I' 'ttttttr' T't'ttt'rt :t=.;L-"Ul.=L..ex-Iil.#Ti-t:: 14-1 H.E..::13'-l''"I' i l '/T!t:, --E･ l"･-if-it'I"l1/ E,-+-'ii ifiIEi]. H xt-. i ,.,.-. ipa, ww.1[.-!1Ll.. g-''tr.i t-･. i-". 'L, ;"t' , 'i'-E'l'/'iirili'li -i''t'-1:I i" ±/l//':1/-/t/-li :t,T. :-t'TI"l'su' Y･'rllb. ./i/.';･, .+'t ± /./.ii/fl'i.ri t/1. 1 Fig. 1- Magni{led recording of ICP indicatedby pomt A-(plateau) -vave. REM time of appear rnarkedly at the rninutes priorto 2 abeut W.in and eLectroencephalog'ram real-time LIil'f' 'f'{' (EEG)reeordings il/`l' at the in Fig. Ia. ICP recording shows the initiation ot' stage characterized b},electrooculogram (EOG) discharges (S) plateau of A-wave, howcvcr, REM stage scored on EEG (2)begins the an astcrisk ascending slope Awal{e ofA-wavc (EMG : electromyogram). r REM oberd-utaopt'en I II III N [ ft,=EfiL.moig 30 o 21 Fig. 2. 22 23 24 Sleep stage diagram (upper column) woman who had hccn opcrated Episodic B-waves appear iriREM higher than that in waking. 2 5 3 4 67 Time Chour) and ovcrnighL ICP prufilc(lower column) in 45-ycar-old t'or acoustic on tumor 6 dayssleep. before this recording. sleep stage and in Stage ll ICP in stcep stage$ is 1 NII-Electronic Library Service The UOEHAssociation The UOEH Association of of Health Health Sciences Sciences OvernightICP and il,ICP EEG Recordings during Sleep 387 Awake r-'" REM ji Liny L vaj-smaUgut I ifmu II III rv ' W**V L * i-1 rfli ll*** 75 s=EEvzao:p,o 25 o 2e IY 21 22 24 23 2 1 (hour) Time Fig. 3a. The 5 4 6 7 end Sleep stage diagram (uppcr column) and overnight ICP profilc(lower column} old boy with a pinca[ turnor. Episodic B-wavesappear in REM s}eep and iCP in waking isas high as in sleep stages in thls patient. of remained after occasions or REM did not plateau terminated at necessarily the completion match had been transtbrmed waves disappeared,REM almost 3 the plateauon other into the of plateauwaves; REM pressure levelon some thc resting When oceasions. in a 10-yearin lightslcep. B-waves had episodic remained. Discussion ICP has been found to be higherduringsleep than waking (Cooper & Hulme, 1966;Di Roc(;o et al,, l975; GUcer & Viernstein, 1979), subject to some considerations. ICP is de" initelyhigher in sleep than waking in the REM stage of patientswith cl]isodic pressure waves high (Munari& Calbucci, 1981; Renier et al., 1982) and in patients with continuous altemating lightsleep and waking EEG were observed in accordpressureB-waves in whom ance no & Lundberg, (I'ngvar periodic respiration with elevation of ICP has been observed (Munari& Calbucci, 1981; Yokota sleep was not ICP during that observed or chronic in slow study other significantly non-REM sleep, ICP than in Stage U rose slecp the authors 1989) et ag,, Cooper et al., during sleep in patients with that & sleep hydrocc:phalus,but Di Rocco wave non-REM high¢ r 1961; Yokota the and in waking Hulme of low (1966) ICP during Munari and & pressure non-REM Concerning Calbucci (1981) intracranialhypertension chrenic reported (I975) However, resting in the presentstudy, in patients with et aL elevation 1989). that ICP rose more obviously hydrocephalic patients. In the present in lightsleep in inlantile observed that ICP in Stage ll sleep rose significantly compared with than sleep stages on many occasions. However, on some occasions ICP in NII-Electronic Library Service The UOEHAssociation The UOEH Association of ofHealthSciences Health Sciences 388 A. YoKo･vA EEGiaW" 1 i`,v"p et at. MvN t LA,hV'J/'V",s,NVH-,ptVXx"LJX"VX,1"rtVL,NLfL.rKe EOGEMG -.V-.--.tYrv".W.nydv..J.--...kw...-N- 11 lll Resp 75* ICP o EEG o ･wh"p p m ,-eX:ben.NVvvruvALw--LL.vwY -50ptV lsec EOG'--w""rwh--tw--4 a 'aNre'Uw-, n :l)l･ISwwTiliiiiiliiililii wwtwtsdv･･1･,,, Nfu'wt '' -- -REM Awake ･1 ll ** ' 'i 1･ 75 ICP e EEG wt"ept-vvs,t"v'rtV-"etw. EOG p s.XVv,-tsAJN,s/i"'"uvvv"v"v. ulv..NVLWXvZth7pmX.----k. n t 111 li EMG '. /t t ttilSL ''' Resp* .mmHgve, .tilii tttt ,,,, tttt tt'･ 75**ICP i,j'' "FWZ}･ -･1'･-II･i=･=11･11T.111-;-i-T-I-itil/i,-i''''･'1'･ ･1･/ " i'ti'-/･I:; ,v"wwrwAA"dew-hnvi,w,MtajN-"nvn,"h,in ]vfag'nilied recordings asterisks in Fig.3a arrow) of show high as REM arrow), (third islowerthan and that EEG reai-time upper that B-wgvc$(second arrow) arrow) ICP Thc' as remains colurnns('*) continuc IV ,'g'"', e p･ v Fig. 3b. v d tlt gi`',1,reV' e "va･n,iiVL'v,,wh" that two sleep that in Stage Il sietp stagc appcais at thc an arousal 'I'helova,er patter'non EEG in columns Stage llCfirst arrow) initiation of the (*'*) and 'Fhe middle arrow). (first and two pointsindicatedbv thc ICP in Stuge M sleep (se'eond at thrcc recordings (')show coi"mns appears show whcii that in Stage M ICP cluster or two episod{c episodic B-waves in Stage ]r{third (second arrow), NII-Electronic Library Service The UOEHAssociation The UOEH Association of of Health Health Sciences Sciences Overnight ICP Stage - remained in the other sleep significant high as that in Stage II. ICP in Stage IV was always lower than stages as has been previously described(Rossi et ag., 1975). The most as elevatien ICP is seen of in REM 1975;Munari & Calbucci,1981). ICP changes during REM sleep showed REM REM sleep sleep by Hirsch arc & (Cooper sleep by characterizcd Hulme, 1966; Di Rocco thc frequent appearance et al., of episodic -than by graclualelevation of the resting pressure. The present that 88,9% of A-waves and 95.1% of episodic B-waves were observed in during overnight recording. This high incidenceof episoclic pressurewaves in in clinical cases coineides well with the study in experimental animals conducted pressurewaves, study 389 Recordings J[.ICP during SIeep EEG and et al rather in (1978), 88% which Such high of short-lasting betwccn REM oscillations ICP of werc in REM scen suggests a pressurcwaves causal relationship between them, REM sleep has been reportecl to begin at the onset ol' laterat thc asccnding slope ofICP pressure waves or 40 to 60 seconds (GUcer& Viernstein, 1979; Munari & Calbucci,198I; Pierre-Kahnet at., l976). These reports on the time relation between the initiation of episodic pressurewaves and REM sleep are in close accord with our observation that REM slcep as scored on EEG started 1 to 2 minutes prior to or at the beginningof episodic since electro-oculographic dischargescharacteristic . pressurewaves, of REM usually lag I to 2 minutes behind the initlation of the REM stage on EEG, might The clinical observations statcd above suggest that the episodic pressurewaves be induced by intracranial conditions in the REM stage, when increasedbrain activity and sleep. reduced The correlation tone sympathetic of the cerebral of the blood volume in pressurechange l979). In fact,a rapid demonstratedin REM blood cerebral al., 1968), Meyer in the changes tone and marked cerebral (Katayama et to be caused vasodilatation, waves are augmentation so since the speed the cerebral of control In of blood volume an to occur confirmed 1971). to the tone of the cerebral also 1984). magnitude Viernstein, has been Increase of the increasein cerebral metabolism et (Reivich in REM sleep (Cooper& Hulme, 1966; to this augmented addition and blood volume 1975), al., by the increase (GUcer& pronounced & Ingvar,1973; Seylazet al,, (Risberg & Coote, 1982) are (Futuro-Note increaseof episodic isassumed stage with is postulated due nervous and simultaneously occur pressure episodic has been Toyoda, & associated sleep volumc which to ICP increase in the REM of mechanism known are sleep stage vessels such to play an considered in the REM cerebral metabolic as reduced activity,, sympathetic important role in et al., 1978; Katayama (Hirsch the et al., 1984), References Coopcr,R. & Hulme, A. Intracranial pressure and {1966): Neurosurg. Phychiatry, 29/ 564-570. Di Rocco, C., McLone, D. G., Shimeji, T. pressure 689. recording i'n et aL hydrecepha}icchildren related phenomena cluring steep. Continuous (l975): during wakefulness and J. Neurol. intraventricularcerebrospinal fiuid sleep. Neurosurg., 4･2: 683J. NII-Electronic NII-Electronic Library Service The UOEHAssociation The UOEH Association of ofHealth Health Sciences Sciences 390 A, YOKOTA et ai. Di Rocco,C., Maira, G.,Rossi, G. F. et al. (1976): Cerebraospinal fluidpressure studics hydrocephalus and cerebral atrephy. Eur. Neurol,, 14: 119-128. Futuro-Note, H, A. & Cootc,J. H. (19S2): Changes in sympathetic activity ing desynchronizcd sleep. Brain Res., 252:259-268, GUcer, G. & Viernstein, L, J. (1979): Intracranialpressure in the normal to in normal heartand blood monke>, while awake pressure vessels and dursleep, J.Neurosurg., 51: 206-2]O. }Iirsch,J.C,, Pierre-Kahn, A. & Hirsch, J. F. (1978): Experimentalstudy of intracranial pressure during rapid eye movement sleep in the chronic cat. Neurosci.Lett. 7: 245`249. Ingvar, D, H. & Lundberg, N. (1961): Paroxysmalsymptoms in intracranial hypertension, studied with vcnfluidprcssurerecording and electroencephalography. Brain,84: 446-459. Y., Nakamura, 'IL,Becker D, P, et al. (1984): Intracranialpressure variations associated with activation of the cholinoceptive inhibitory area in the unanesthetizcd drug-free caL. Neuropontine J, tricular Katayama, surg., Meycr, 61:713-724. J. S. & Studies of (1971): Teyoda, M. in cerebral mctabolism during disease. In: Ccrebral Circulation and Stroke, (Zulch, K. J,, ed,), Springer-Verlag, berlinlHciderberg. pp. 156L163. Munari, C. & Calbucci,F. (1981): Correlations betwcen intracranialpressurc and EEG during coma and sleep. Electroencephalogr. CIin. Neurophysiol., 51: 1707176. Pierre-Kahn, A,, Gabersek, V. & }Iirsch, Intracranialprcssurc and rapid eye movemcnt sleep J.F. (1976>: in hyclrocephalus.Child's Brain, 2: l56-166. Rechtschaffen, A. & Kules, A. (ed.) A Manual of Standardized Terminology, Techniques and Scor(1968): ing System fbrSleepStages ofHuman Subjects. U. S. Goverment Printing OMce, Washington D. C. 55 pp. Reivich,M,, Isaacs, G., Evarts, E. et al, (1968): Thc eflbct of slow wave sieep and REM sleep on rcgional cerebral blood flow in cats, J.Ncurochem.,15: 301-306. Renier,D,, Sainte-Rose, C,, Marchac, D. et at. (l982): Intracranialpressure in craniostenosis. J.Neurosurg., 57: 370-S77. Risberg, Incrcasc in regional bloodvolumc duringREM slecp. i}t:Sleep1972. J,& Ingvar,D. H. <I973): Proceedings of the First Europcan Congresson S]ecp Research. (Koella, IV, P, & Levin,P,,ed.). S. Karger,Basel. pp. 384-388. Rossi, G, F,, Maria, G. & Vignati, A. (1975): IntracraniaL in:Sleep 1974. prcssurc cluring' sleep in man, Proceedingsot' the Second European Congress on Sleep Research. <Levin, P, & Kocll, W, P,, ed.). arousal and rapid eye movement sleep rapid in human changcs subjects with circulatien and cerebrovascular S. Kargcr, Basel. pp. 169m180. Seylaz,J., Pinard,E.,Mamo, H. et al. (1975): Human cerebral blood flowduringsleep, in:The Coupling of Function Metabolism and Blood Flow in the Brain. (Ingvar, D. H. & Lassen, N. A., ed.), Munksgard, Copenhagen,pp. 235-252, Tamaki, N., Kusunoki, T., Kose, S. et al. C1983>: Continuous intracranialpressurc monitoring in normal 7 to clinical significancc of B wave and pressurehydrocephalus. NVith special reference prognostic criteria for CSF shunting. Brain and Ncrvc.,35:131-137. (in Japanese) Yokota, A., Matsuoka, S.,Ishikawa, T, et aL (1989): Overnight rccordings ef intracranial pressure and electroencephalography in neurosurgical Part I : Intracranial pressure waves and their clinical patients. correlations. J.UOEH, 11: 371-381. NII-Electronic NII-Electronic Library Service The UOEH The UOEH Assooiation Association of of Health Health Sciences Soienoes Ovcrnight ICP 脳神 経 外 科 疾 患 そ の EEG and Recordings l［．ICP during Sleep 391 け る 睡 眠 時頭 蓋 内圧 波 の 分 析 にお ll． 睡 眠 時 の 頭 蓋 内圧 の 変動 晃 ・松 岡 横田 成 明 ・石 川 忠 廣 ・合 志 清 隆 ・梶 原 秀彦 産業医科 大学脳神経外 科学教室 要 旨： 睡 眠 時 の 頭 蓋 内圧 変動 の を言 羊細 に 検討 す る 37 人 を 対 象 と し た ． れ 患 者 Non ． REM 睡 眠 期 で は ，多 く の 場 合 且期 らの こ い て も 1 期 ，II期 と同様 の 頭 蓋 内圧 の 時期 の 頭 蓋 内圧 記録 で 出現 現 した ．ま た した の 本研究 そ 1で 突発性 圧波が の っ こ と もあ の 上 っ らの 突発 性圧 波 み ら れ た と こ REM B 波 の 95 ， 1％ 睡眠 期 の 開 期 ， ． に お た ， し か し，IV期 で は 常 に 頭 た． 最 も頭 蓋 内 圧 が 上 昇 す る の は お よ び episodic 脳波所 見が 圧波 の 始 ま りに 先行 す る み られ た が 昇が 上 昇 は 突 発 性 に 出現 す る 圧 波 の 形 成 に よ A 波 の 88 ． 9％ ，こ れ ， 有意 な頭蓋 内圧 に 上 昇 をみ る の 蓋 内 圧 は 他 の 睡 眠 段 階 よ り も低 値 で あ こ の た め に は 睡 眠 周 期 お よ び 圧 波 の 変 動 が よ く観 察 さ れ た で が 始時 間 と が 分 か り，圧 波 形 成 に こ を REM 特 徴づ け て っ の REM 期 に 一致 検討 する REM と ， ．今 回 睡 眠期 で られ る ，REM して 出 期の 期の 頭蓋 内 環境 が 関 与 す る もの と推 定 され た ． J．uoEH 〔 産 業 医 大 誌 ），ll （4 ）： 383 一 − 3gl （lg8g） NNII-Electronic 工 工 Eleotronio Library Library Service