Obstructive sleep apnea (OSA) is a condition in which airflow is blocked during sleep for longer than 10 seconds at least five times per hour. Risk factors for OSA include genetics, weight, thyroid disorder, issues with adenoids or tonsils, smoking and a thick neck or tissue defect. Complications of OSA include unstable oxygen, increased blood pressure, arrhythmia, stroke and mental changes. However, the association between OSA and cerebral microbleeds (CMBs) had not been previously established. A recent publication in JAMA Neurology therefore sought to establish the relationship between OSA and CMBs in a middle-aged population over eight years.
In the study by Siddiquee and colleagues, 1,441 participants were sourced from the Korean Genome and Epidemiology Study (KoGES). The median age was 57.75 years. The study began with a baseline measurement of OSA using in-home polysomnography and the presence of CMBs using magnetic resonance imaging. The initial measurements were taken from 2011 to 2014, then followed up at four years (between 2015 and 2018) and eight years (between 2019 and 2022).
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Participants were categorised by OSA severity into three groups: non-OSA (n = 812, 56.34%), mild OSA (n = 436, 30.25%) and moderate-to-severe OSA (n = 193, 13.39%). The cumulative incidence of CMBs was measured in these groups at four and eight years. At four years, 1.85% of non-OSA (n=15), 1.61% of mild OSA (n=7), and 4.66% of moderate-to-severe OSA (n=9) participants presented with CMBs. At eight years, these percentages increased to 3.33% of non-OSA (n=27), 3.21% of mild OSA (n=14), and 7.25% of moderate-to-severe OSA (n=14) participants.
The relative risk (RR) of CMBs was calculated using four models. The first model was unadjusted, while subsequent models accounted for age/sex/education, comorbidities and risk factors such as obesity, diabetes, smoking, drinking, exercise and cholesterol level, and changes in apnea-hypopnea and body mass index over time. At four years post-baseline, three models reflected a significantly higher risk of CMBs in the moderate-to-severe OSA group relative to the mild OSA and non-OSA groups: (model 1 RR = 2.52, P = 0.02; model 2 RR = 2.24, P = 0.04; model 3 RR = 2.52, P = 0.03). The exception was the model reflecting change in apnea-hypopnea and BMI (RR = 2.0, P = 0.14). However, by eight years post-baseline, all four models reflected a significantly increased risk of CMBs in the moderate-to-severe OSA group relative to the non-OSA and mild-OSA groups (model 1 RR = 2.18, P = 0.01; model 2 RR = 1.89, P = 0.04; model 3 RR = 2.04, P = 0.03; model 4 RR = 2.14, P = 0.02). Thus, the risk of developing CMBs is correlated with moderate-to-severe OSA over eight years, even accounting for other factors.
GlobalData epidemiologists predict more than three million diagnosed prevalent cases of sleep apnea in South Korea in 2025. This is part of a steady prevalence in men and women of all ages. Because there are treatments and modifiable risk factors for OSA, it may be possible to reduce the burden of OSA and potential downstream effects such as CMBs.
CMBs are also indicative of repeated strokes in patients with a history of acute ischaemic stroke. In South Korea in 2025, GlobalData epidemiologists predict more than 370,000 diagnosed prevalent cases of acute ischaemic stroke. When combined with the burden of OSA and the association with CMBs, this may form a more complete picture of the risk of repeat strokes, especially in people of middle age.
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