Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
 
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
 
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
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mystery of yawning 

 

 

 

 

mise à jour du
31 octobre2019
Balkan Med J.
2019 Oct 9.

Pathological Yawning in Patients with Acute Middle Cerebral Artery Infarction: Prognostic Significance and Association with the Infarct Location

Aksoy Gündo¤du A, Özdemir AÖ, Özkan S.

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Insular and caudate lesions release
abnormal yawning in stroke patients
Krestel H, Weisstanner C, Hess CW, Bassetti CL, Nirkko A, Wiest R.
 
Yawning and Stroke Bâillements et AVC
Pathological yawning (PY) is a compulsive, frequent, repetetive yawning triggered by a specific reason besides fatigue or boredom. It may be related to iatrogenic, neurologic, psychiatric, gastrointestinal or metabolic disorders. PY could also be seen in the course of ischemic stroke. The authors aimed to determine whether PY is a prognostic marker of middle cerebral artery (MCA) stroke and evaluate its relationship with the infarct location.
 
They examined 161 patients with acute middle cerebral artery stroke who were consecutively admitted to emergency department. Demographic information, stroke risk factors, stroke type according to Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, blood oxygen saturation, body temperature, blood pressure, heart rate, glucose levels, daytime of stroke onset, National Institutes of Health Stroke Scale (NIHSS, at admission and 24 h), modified Rankin Scale (mRS, at 3 m) and infarct locations were documented. PY was defined as ³3 yawns/15 min. All patients were observed for 6 hours to detect PY. NIHSS>10 was determined as severe stroke. The correlation between the presence of PY and stroke severity, infarct location and the short and long term outcomes of the patients were evaluated.
 
Sixty-nine (42.9%) patients had PY and 112 (69.6%) patients had cortical infarcts. Insular and opercular infarcts were detected in 65 (40.4%) and 54 (33.5%) patients respectively. PY was more frequently observed in patients with cortical, insular and opercular infarcts (p<0,05). PY was related to higher NIHSS scores. Patients with severe stroke (NIHSS³10) presented with more PY than mild to moderate strokes (p<0.05).

Le bâillement pathologique (BP) est un bâillement compulsif, fréquent et répétitif, déclenché par une raison spécifique, autre que la fatigue ou l'ennui. Il peut être lié à des causes iatrogènes, neurologiques, psychiatriques, gastro-intestinaux ou métaboliques.Un BP peut également être observée au cours d'un AVC ischémique.
 
Les auteurs ont cherché à déterminer si BP est un marqueur pronostique de l'AVC de l'artère cérébrale moyenne (MCA ou sylvien) et à évaluer sa relation avec l'emplacement de l'infarctus. Dans les accidents vasculaires cérébraux, le BP est correlé à la gravité de l'AVC, à la présence d'une atteinte corticale, aux infarctus insulaire et operculaire. Cependant, aucune association n'a été trouvée concernant l'état fonctionnel à long terme et la mortalité.

PY in MCA stroke is associated with stroke severity, presence of cortical involvement, insular and opercular infarcts. However no association was found regarding long term outcome and mortality.
 
Stroke is a common neurological disease which is the major cause of disability and mortality in both genders and has an accelerating frequency due to the increase in life expectancy in adult age group. (1, 2) A variety of factors influence the outcome of stroke including age, gender, stroke severity, early rehabilitation, stroke etiology, infarct location, rehabilitation, cognitive decline, aphasia, depression and comorbid diseases. (3) Being able to predict the prognosis of stroke makes length of stay in the hospital or long- term costs manageable and may reduce the economic burden of stroke. Studies providing and comparing prognosis, survival and recurrence data in stroke allows clinicians to identify high-risk patients for stroke recurrence and stroke-related death, researchers to plan clinical trials to develop new strategies, and provide public health policy-makers with a clearer picture of the social impact of ischemic stroke.
 
Yawning is a very common stereotyped motor behavior which is physiologically observed in humans, other mammals and numerous animal species. (4, 5) Healthy humans may yawn 0-28/day and this frequency of physiological yawning may vary according to the age, circadian rhythm, arousal, decreased attention, boredom, fatigue, hunger, satiety, before and after sleep episodes. (6, 7) Former studies revealed that, paraventricular nucleus of the hypothalamus, hypocampus, reticular activating system in the brainstem, cervical spinal cord (phrenic nerve C1&endash;4), intercostal muscles, oxytocin, acetylcholine, dopamine, glutamate, serotonin, GABA, adrenergics, ACTH, and ·MSH are involved in the occurrence and the mediation of yawning. (6-8) Cortical involvement of yawning has been defined by recent studies but not fully demonstrated yet. (5, 7) Frequent, repetetive and compulsive yawning episodes are termed as excessive, abnormal or pathological.
 
Besides the physiological factors such as fatigue, boredom or contagion, pathological yawning (PY) is found to be triggered by various cases, iatrogenic causes, and several metabolic, gastrointestinal, psychiatric, or neurological diseases. (9-12)
PY has been reported in numerous neurological conditions including parkinsonism, Parkinson's disease, progressive supranuclear palsy, Huntington disease, myasthenia gravis, bulbar amyotrophic lateral sclerosis, multiple sclerosis, neuromyelitis optica spectrum disorders, migraine aura, vasovagal syncope, narcolepsy, brain tumor, encephalitis, intracranial hypertension, stroke, Chiari malformation type I, epilepsy, stress and anxiety disorders. (6, 9-25)
Although PY in brainstem and anterior circulation (AC) ischemic stroke has been previously reported in the literature; to date, the exact mechanism of cortical network remains to be established by functional neuroimaging studies. Some recent studies concluded that ischemic lesions of the posterior insula and caudate nucleus induces PY. Still there is no sufficient clinical data in humans regarding PY in AC stroke and no data regarding the frequency or prognostic effect of PY on long-term prognosis and mortality rates of middle cerebral artery (MCA) strokes.
 
This observational study investigates whether PY affects the clinical outcome and mortality of the patients with acute MCA stroke. We hypothesised that certain infarct locations in the AC system may facilitate PY and the presence of PY may be considered as a prognostic factor of MCA strokes. Among our cohort of 161 patients, PY was observed in 69 (42.9%) patients and likely to occur in patients with higher NIHSS scores. The equal distribution of gender is a strong aspect of our study. We found PY to be related with cortical involvement, insular and opercular infarcts. Our study revealed that, PY is a common phenomenon among patients with MCA stroke and seems to be associated with stroke severity. However, no relationship was found regarding its effect on long term outcome or mortality rates of the patients.
 
The evidence of former case reports and studies suggests that PY occurs frequently in the course of many neurological diseases. (6, 9-25) A limited number studies have been reported PY in acute ischemic stroke. (9, 23, 24) Bauer et al. stated that, the patients with locked-in syndrome can elicit yawning movements involuntarily despite the total paralysis of the volunteer bulbar muscles. (27) Cattaneo et al. published a case report of two patients with brainstem stroke who were presented with PY. (9) To date, only 2 studies have provided data concerning PY in AC stroke. The pivot study of Singer et al. revealed that PY can be a sign of AC lesions. They observed PY in 7 patients with AC strokes in MCA territory and hypothesized that PY occurs due to supratentorial lesions releasing the hypothalamic PVN from neocortical control mechanisms and increasing activity of hippocampus and periamygdalar regions. (24) A more recent study of Krestel et al. investigated PY in 10 patients with acute AC.
 
Infarct regions and volumes of the patients were evaluated using MRI lesion maps, diffusion weighted (DWI) and apparent diffusion coefficient (ADC) images. Intensity of the infarcts were found to be correlated with the period of abnormal yawning They proposed that insular and caudate nucleus infarcts are responsible for PY. (25) The use of dopaminergic D2 agonists, imipramine, selective serotonin reuptake inhibitor (SSRI) agents, morphine withdrawal, valproate overdose and oestrogen substitution may induce PY. Anesthetic agents are leading drowsiness and loss of consciousness. (28) None of our patients were using these agents. Intravenous thrombolytic therapy has a positive impact on prognosis. However, we found no significant relationship between the patients who received thrombolytic therapy and the occurrence of PY.
 
It has been noted that PY is primarily triggered by low vigilance. However, PY can be seen even there is no change in consciousness level during stroke attacks. This may be as a result of the increased intracranial pressure secondary to stroke or the damage of the particular cortico-subcortical circuits and the disruption of theconnections between the reticular formation that regulates alertness in the brain stem. As the clinical severity of stroke increases, PY is observed more frequently.
 
Krestel et al. found a significant correlation between the period of PY and stroke severity. (25) Factors such as low vigilance, increased brain temperature, intracranial hypertension, deterioration of homeostasis and damage of more neuroanatomical structures including cortico-subcortical circuits may be the possible causes of PY. (5-7)
This study has several limitations. First of all, during observation period we could not video-record the patients. Thus, the duration or the distinctive features of yawning attacks could not be measured quantitatively. Moreover, despite the cut-off yawning count for PY (³3/15 min) was determined after two previous studies (24, 25), physiological yawning may also occur at the same frequency. And finally sleepiness scale tests could not be performed to the aphasic or clinically severe patients. This situation has led us insufficient data regarding increased sleepiness or drowsiness of the patients.
Further studies measuring the neurotransmitter and neurohormone levels released during PY attacks in acute stroke or using improved neuroradiological tools such as tractography are required to discover the exact pathophysiological mechanism and neural pathways responsible for PY. The causative factors that triggers PY in acute stroke, involving cortical brain areas and clinical significance of PY still remains to be clarified.
 
To the best of our knowledge, the present study is the first one analyzing the clinical and radiologic findings of PY in acute MCA stroke with larger human cohort including findings regarding long- term outcome and mortality rates of the patients with PY. Consistent with the existing evidence, our study revealed that cortical involvement, opercular and insular infarcts trigger PY. Supporting statistically, we established the clinical significance of PY and could evaluate its prognostic role in MCA stroke. Notwithstanding its connection with the clinical severity, PY reveals no significant predictive value for clinical outcome of patients with MCA stroke.