Nocturnal Epilepsy and Parasomnias Dr.Ram Sankaraneni 10/02/2020

Home , Nocturnal epilepsy

10/2/2020

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Disclosures

• None

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Epilepsy and Sleep

• 7.5 to 45 percent of people who have epilepsy have seizures mostly during sleep

• Sleep disorders more prevalent in epileptic population

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• Diagnosis of complex nocturnal behaviors is difficult

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Differential Diagnosis

• Nocturnal Seizures

• Non Epileptic Motor Disorders

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Non Epileptic Motor Disorders

• NREM Parasomnias

• REM parasomnias

• Sleep related movement disorders

• Psychogenic

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When to Suspect an Epileptic etiology

• Stereotyped nature

• High frequency/Clusters

• Timing of the events

• Duration

• Age of onset

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Nocturnal Seizures

• Clinical manifestation of seizures vary based on location and involved network

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Seizures in various stages of sleep

70 60 50 40 %seizures 30 %sleep 20 10 0 stage 1 stage 2 SWS REM

Herman et al, Neurology 2001;56:1453-9.

Percentage of partial seizures arising during sleep from various seizure onset zones.

S.T. Herman et al. Neurology 2001;56:1453-1459

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Frontal Lobe Epilepsy

•2nd most common epilepsy ( 18% of adults)

• Often misdiagnosed

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Challenges in Diagnosis

• Dramatic/complex movements

• No postictal state

• Often no Aura

• EEG – excessive artifacts

• EEG – can be normal

• Frequency

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Nocturnal Frontal Lobe Epilepsy

• 90% or more seizures in sleep

• NFLE - sporadic

• ADNFLE – Autosomal dominant

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• Hyper motor movements

• High velocity movements of the trunk and extremity

• Frequent

• Abrupt

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• 34% can have daytime seizures as well

• Episodic Nocturnal Walking ( ENW)

• Mean age of onset – 14

• Only 25% with interictal EEG changes

• Only 12% with MRI abnormalities

CREIGHTON UNIVERSITY Epilepsy Syndromes with Sleep Related Seizures • Nocturnal Frontal Lobe Epilepsy

• Juvenile Myoclonic Epilepsy (JME)

• Benign Childhood epilepsy with centrotemporal spikes (BECTS)

• Electrical Status Epilepticus of Sleep (ESES or CSWS) • Lennox-Gastaut Syndrome

• Landau-Kleffner Syndrome (LKS)

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Psychogenic Non Epileptic Seizures

• Difficult to differentiate from frontal lobe seizures

• Arise from wakefulness – pseudo sleep.

• Have high incidence of sleep related events.

• waxing and waning and long durations.

• Age 5-80 yrs.

• 10% can have co existing epilepsy.

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Parasomnias

• Undesirable physical events that occur during entry, within sleep or during arousals.

• Typically involve complex movements, seemingly purposeful, goal directed behavior's without consciousness.

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Disorders of Arousal / Non-REM

• Confusional Arousal

• Sleep Walking

• Sleep terrors

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Confusional Arousal

• Young children

• Partially awaken from slow wave sleep – sit up.

• Confusion – will lie down and resume sleep

• Typically harmless.

• Treat any underlying condition

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Sleepwalking

• Somnambulism

• Arises from bed and ambulates without full awakening

• Can engage in complex behaviors and the environment

• Difficult to awaken

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• Confused if they wake up

• Best to gently attempt to lead back to bed.

• May react violently

• Peak prevalence age 4-8 yrs.

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• Preventive measures

• Behavioral therapies

• Pharmacotherapy

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Sleep Terrors

• Sudden arousal with intense fearfulness

• Scream or cry

• Unresponsive, if awakened – confused/disoriented.

• Amnesia for the episode.

• may be devoid of images.

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REM Sleep Behavior Disorder

• No Atonia

• Enacts dreams.

• Easy to wake up

• Frequent injuries ( even to bed partner)

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• Treatment

• Clonazepam

• TCI’s

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REM Sleep Behavior Disorder

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Sleep Related Dissociative Disorders

• Disruption in the usually integrated functions of Conciousness, memory, identity or perception of environment.

• History of violence, trauma and/psychiatric disorder.

• Occurs during EEG defined wakefulness – either transition to sleep or after awakening.

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Evaluation

• Polysomnography

• Video EEG

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• Howell, Michael J. • CONTINUUM: Lifelong Learning in Neurology26(4):929-945, August 2020. • doi: 10.1212/CON.0000000000000896 30

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• Howell, Michael J. • CONTINUUM: Lifelong Learning in Neurology26(4):929-945, August 2020. • doi: 10.1212/CON.0000000000000896 31

CREIGHTON UNIVERSITY FLEP Scale ( Frontal lobe epilepsy and Parasomnias scale)

diagnosing bumps in the night. Arch Neurol 2006;63:1037–42. 32

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Nocturnal Frontal lobe Arousal Disorders REM Sleep Behavior Epilepsy (NREM) Disorder

1st -2nd decade of Age 1st decade of life Over 50 yrs life

Non REM, Sleep Stage Non REM REM Transitions

First Third period Timing Anytime Last Third period of sleep

Duration 5-60 sec 2-30 min Seconds to 2 min

Stereotyped Vocalization Semiology Variable Hypermotos Self protection

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Nocturnal Frontal lobe Arousal Disorders REM Sleep Behavior Epilepsy (NREM) Disorder

Sporadic – rare Sporadic – rare Frequency Nightly cluster clusters clusters

Onset/Offset Sudden Gradual Sudden

Injury Low High Moderate

Post –Confusion Absent Present Absent

Slow – wave sleep Epileptic Activity REM sleep without Test Findings arousals, rhythmic on EEG atonia delta pattern

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Seizure - European Journal of Epilepsy 2017 4487-92DOI: (10.1016/j.seizure.2016.11.023)

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Thank You

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