Visual Sleep Scoring Research Articles

A Review of Sleep EEG Patterns. Part I: A Compilation of Amended Rules for Their Visual Recognition according to Rechtschaffen and Kales. Eine �bersicht �ber Schlaf-EEG-Muster. Teil I: Eine Zusammenstellung mit erg�nzenden Regeln zu deren visueller Analyse

The reliable evaluation of polysomnographic recordings (PSG) is an essential precondition for good clinical practice in sleep medicine. Although the scoring rules of Rechtschaffen and Kales [86] are internationally well established, they leave some room for different interpretations, and this may contribute to the limited reliability of visual sleep scoring. The German Sleep Society (DGSM) has set up a task force to devise ways to improve scoring reliability in the framework of their quality management programme. The intention was not to revise the rules of Rechtschaffen and Kales (R&K), but to facilitate their reliable application in sleep scoring and to support the development of standardized algorithms for computerized sleep analysis. The task force was formed in September 2004 as a subcommittee of the educational panel of the DGSM: The members of the task force are experienced in sleep scoring and have a background either in physiology, neurology, psychiatry, psychology, or biology. The aim of the task force was to provide interpretation aids and, if needed, specifications or amendments to the R&K rules for the scoring of sleep electroencephalogram (EEG) waveforms and patterns. Decisions were based on the nominal group technique of a nominal panel as the formal consensus-building process. The consensus process was based on scoring and face-to-face discussions of at least 40 examples for each pattern in four 2-day meetings. Relevant EEG patterns for sleep stage scoring are alpha, theta, and delta waves, sleep spindles, K-complexes, vertex sharp waves, and sawtooth waves. If definitions for a given EEG pattern differed in the literature, the nominal group technique resulted in specifications and amended scoring rules for these EEG patterns. A second part including a series of examples with explanatory comments for each of these EEG patterns is under preparation. Amendatory scoring rules of those EEG patterns that are relevant for sleep scoring may contribute to increasing the reliability of visual sleep scoring and to support the development of standardized algorithms for computerized sleep analysis.

Automatic detection of slow wave sleep using two channel electro-oculography

An automatic method was developed for detecting slow wave sleep (SWS). The automatic method is based on a two-channel electro-oculography (EOG) with left mastoid (M1) as reference. Synchronous electroencephalographic (EEG) activity was detected by calculating cross-correlation between the two EOG channels by using 0.5–6 Hz band. An amplitude criterion was used for detecting slow waves and beta power 18–30 Hz was used to exclude artefacts. The automatic scoring was compared to a standard visual sleep scoring based on EOG, central EEG and submental EMG. Sleep EEG and EOG were recorded from 265 subjects. The optimal cross-correlation, amplitude and beta thresholds were derived using data from 133 training subjects and then applied to the data from different 132 validation subjects. Results were most sensitive to the changes in the amplitude criteria. Cohen's Kappa between the visual and the new developed automatic scoring in separating non-SWS and SWS was substantial (0.70) with epoch-by-epoch agreement of 93%. SWS epoch detection sensitivity was 75% and specificity was 96%. Also the total amount of slow waves, slow wave time (SWT), was estimated. The advantage of the automatic method is that it could be applied during online recordings using only four disposable self-adhesive electrodes.

Pergolide restores sleep maintenance but impairs sleep EEG synchronization in patients with restless legs syndrome

Background: The treatment with the long-acting dopamine D1/D2 receptor agonist pergolide has been proven as very effective in lowering the frequency of periodic leg movements (PLM) in patients with restless legs syndrome (RLS). To further investigate the influence of this potent dopaminergic drug on the microstructure of rapid eye movement (REM) and non-REM sleep EEG we established a quantitative analysis of the EEG data. Methods: The study group consisted of 15 patients with primary RLS (mean age 57.1±10.1 years) who were a subgroup of patients within a double-blind randomized crossover treatment study with pergolide versus placebo. The polysomnographic recordings were analyzed visually and submitted to a quantitative EEG analysis (fast Fourier transformation). Results: The pergolide treatment induced a significant reduction of the spectral power in the delta range (0.78–3.9 Hz; P<0.05; t-test) during SWS, as well as a significant reduction of PLMs. In addition, we observed a decrease in the sigma EEG activity (12.1–14.8 Hz; P<0.03) during non-REM sleep and stage 2 sleep. The visual sleep scoring revealed a significant increase in stage 2 sleep ( P<0.005), whereas wakefulness was markedly diminished ( P<0.001). The REM sleep parameters including the EEG power spectrum remained unchanged. Conclusions: The treatment with pergolide markedly improved the sleep quality in RLS patients but did not restore SWS including the spectral power in the lower frequencies. Our results suggest that the dopamine agonist pergolide interferes with the subcortical mechanisms regulating the process of EEG synchronization during non-REM sleep.

Variability of respiratory effort in relation to sleep stages in normal controls and upper airway resistance syndrome patients

Objective: Investigation of the role of sleep states on the respiratory effort of controls and subjects with upper airway resistance syndrome (UARS) using nasal cannula/pressure transducer system and esophageal manometry. Patients and methods: One night's monitoring of sleep and breathing, including the determination of peak end inspiratory esophageal pressure (respiratory effort) with esophageal manometry and flow limitation with nasal cannula. Analysis of the data, breath-by-breath, using visual inspection and a computerized program. Setting – a university sleep laboratory. Patients were nine men with UARS and nine control men matched for age, ethnicity, and body mass index. Results: A modulation of respiratory effort by sleep state and stages is seen in all subjects, the lowest noted during REM sleep and the highest associated with Slow Wave Sleep. When total nocturnal breaths are investigated, a significant difference between peak end inspiratory esophageal pressure [(Pes)-considered as an index of respiratory effort] is noted between normal subjects and UARS. Two specific breathing patterns, seen primarily in UARS patients, are NREM sleep stage dependent. Crescendos (defined as more negative peak end inspiratory Pes with each successive abnormal breath) occur mostly during stages 1–2 NREM sleep, while segments consisting of regular and continuous, breath-after-breath, high respiratory efforts are associated with Slow Wave Sleep. Depending on sleep stage, visually scored arousal response displays differences in Pes negativity. The termination of the abnormal breathing pattern, always well defined with Pes, is not necessarily associated with a pattern of ‘flow limitation’ at the nasal cannula tracing, even when a visually scored EEG arousal is present. Conclusions: UARS patients have significantly more breaths, with more negative peak end inspiratory Pes, than do control subjects. The modulation of peak end inspiratory Pes (an index of respiratory effort) by sleep stage and state differs in UARS patients and control subjects. The nasal cannula/pressure transducer system may not detect all abnormal breathing pattern during sleep. As indicated by the visual sleep scoring, repetitive arousals may lead to more or less severe sleep fragmentation.

Changes in EEG power density during sleep laboratory adaptation in depressed inpatients

Background: The aim of the present study was to evaluate the first-night effect in depressed inpatients, using standard sleep measures as well as all-night spectral analysis of the sleep electroencephalogram (EEG). Methods: Eighteen drug-free, depressed inpatients were studied for 3 consecutive nights in the hospital sleep laboratory. Results: Visual sleep scoring results showed a slight but measurable first-night effect, characterized by a reduction of rapid eye movement (REM) sleep amount and increased wakefulness. Sleep EEG spectral analysis showed significantly reduced delta ( p < .01) and theta ( p < .05) power density in non-REM (NREM) sleep of the first night compared with that of the second and third nights. These differences were limited to the early part of the sleep period, a time during the night that is particularly vulnerable to the effects of depressive disorder. In contrast to the NREM sleep findings, spectral REM variables studied did not significantly vary across the three nights. Conclusions: The results obtained suggest that first-night data should not be simply discarded but could be used in subsequent analyses and could be considered useful in the evaluation of the sleep of depressed patients.

Interictal spiking increases with sleep depth in temporal lobe epilepsy.

To test the hypothesis that deepening sleep activates focal interictal epileptiform discharges (IEDs), we performed EEG-polysomnography in 21 subjects with medically refractory temporal lobe epilepsy. At the time of study, subjects were seizure-free for > or =24 h and were taking stable doses of antiepileptic medications (AEDs). Sleep depth was measured by log delta power (LDP). Visual sleep scoring and visual detection of IEDs also were performed. Logistic-regression analyses of IED occurrence in relation to LDP were carried out for two groups of subjects, nine with frequent IEDs (group 1) and 12 with rare IEDs (group 2). The LDP differentiated visually scored non-rapid eye movement (NREM) sleep stages (p = 0.0001). The IEDs were most frequent in NREM stages 3/4 and least frequent in REM sleep. Within NREM sleep, in both groups, IEDs were more frequent at higher levels of LDP (p < 0.05). In group 1, after accounting for the level of LDP, IEDs were more frequent (a) on the ascending limb of LDP and with more rapid increases in LDP (p = 0.007), (b) in NREM than in REM sleep (p = 0.002), and (c) closer to sleep onset (p < 0.0001). Fewer than 1% of IEDs occurred within 10 s of an EEG arousal. Processes underlying the deepening of NREM sleep, including progressive hyperpolarization in thalamocortical projection neurons, may contribute to IED activation in partial epilepsy. Time from sleep onset and NREM versus REM sleep also influence IED occurrence.

Changes in EEG power density during sleep laboratory adaptation.

First- and second-night effects on the electroencephalogram (EEG) were investigated by means of polygraphic sleep recordings and all-night spectral analysis. Eighteen normal subjects were studied for three consecutive nights in a hospital sleep laboratory. Visual sleep scoring showed that there was a first-night effect in normal subjects similar to that reported previously [increased wakefulness; decreased total sleep time, sleep efficiency, and rapid eye movement (REM) sleep]. Spectral analysis of the sleep EEG revealed important changes, most of which occurred in REM sleep. Increased delta, theta, and beta1 power densities accompanied by decreased mean frequency were seen in REM sleep in the second night. On the basis of REM sleep deprivation results previously published, our data suggest that the second night could be affected by partial REM sleep deprivation that occurred in the first night. Delta and theta power density values decreased in the first non-rapid eye movement episode of nights 1 and 2; this could result from increased REM sleep pressure. The overall consistency of spectral data in the first and second night with REM sleep findings derived from visual scoring in the first night lends further support to this hypothesis. The sleep disturbance experienced during the first night in a sleep laboratory may be a useful and valid model of transient insomnia. Therefore, we conclude that data from all nights recorded should be included in assessing a subject's sleep.

EEG Slow Wave Activity, REM Sleep, and Rectal Temperature During Night and Day Sleep in Morning‐Type and Evening‐Type Subjects

During 3 baseline nights (2 for adaptation) and during 3 days of a sleep-wake reversal, electrophysiological characteristics of sleep and rectal temperature were recorded in 8 morning-type (M-type) and 8 evening-type (E-type) subjects, living in a quiet sleep laboratory. Outcomes of visual sleep scoring revealed the following general tendencies for day-sleep as compared to night-sleep: shorter sleep latencies, shorter REM (rapid eye movement sleep) latencies, advance of the time of maximum REM duration, increased duration of slow wave sleep, more intermittent wakefulness, and decreased subjective sleep quality. Furthermore, for the M-types consistently shorter sleep latencies and--for day-sleep--longer REM latencies were observed than those for the E-types. With regard to the parabolic time course of REM duration, M-types appeared to be relatively phase advanced, in particular for their day-sleep. In addition, subjective sleep quality was consistently higher for the M-types, with the exception of the first day-sleep. The temporal distributions of EEG delta (0.5-3.5 Hz) energy over the first four NREM/REM cycles of day-sleep all deviated from a monotonically decreasing trend. Compared to night-sleep the M-types showed a relative increase of delta energy for Cycle 2, whereas for the E-types a relative increase for Cycles 3 and 4 was observed. An analysis of delta energy, employing a pattern-recognition technique independently from visual sleep scoring, revealed an overall faster rate of accumulation for the M-types. Following sleep onset, rectal temperature showed a decrement, which was larger for the M-types. Moreover, rectal temperature and delta energy were negatively related, as indicated by a negative mean intra-individual correlation. These results are discussed in relation to the characteristic sleep-wake behavior of M-types and E-types.

Differences between morning-types and evening-types in the dynamics of EEG slow wave activity during night sleep

During baseline nights in a sleep laboratory electrophysiological sleep records were made for 8 morning-type subjects (M-types) and 8 evening-type subjects (E-types). As compared with the E-types, the M-types were relatively advanced with respect to the times of maximum and minimum rectal temperature and sleep times. Also, the M-types showed a larger initial temperature drop after sleep onset. Comparisons of the outcomes of visual sleep scoring revealed for the M-types a shorter sleep latency and a longer sleep duration. In addition, the M-types reported a higher subjective sleep quality than the E-types. For the M-types sleep stages 3+4 and EEG delta (0.5–3.5 Hz) energy declined monotonically across the first 4 NREM/REM cycles. For the E-types, however, no decrement was observed over the first 2 cycles. Analysis of the wave forms of delta energy, emploring a pattern recognition technique independent of visual sleep scoring, substantiated this finding. These results are discussed in relation to the differences in circadian characteristics between M-types and E-types.

Modulation of delta activity by hypnotics in middle-aged subjects: studies with a benzodiazepine (flurazepam) and a cyclopyrrolone (zopiclone).

Period crossing analysis was used to study the effects of flurazepam (30 mg) and zopiclone (5, 7.5, and 10 mg) on delta wave activity (0.5-2.0 Hz) during the first 4 h of sleep in middle-aged subjects. The drugs do not affect the visual scoring of slow wave sleep in middle age, but modification of delta activity does occur. Mean amplitude of delta wave activity over the 4-h period was reduced by both drugs, while the total number of delta waves and their mean period increased. The number of high-amplitude delta waves (greater than 60 microV) was decreased by the drugs, and those of low amplitude (10-60 microV) increased. Power in the frequency band 1.2-2.0 Hz was reduced.