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

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Nocturnal Epilepsy and Parasomnias Dr.Ram Sankaraneni 10/02/2020 10/2/2020 Nocturnal Epilepsy and Parasomnias Dr.Ram Sankaraneni 10/02/2020 1 CREIGHTON UNIVERSITY Disclosures • None 2 1 10/2/2020 CREIGHTON UNIVERSITY 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 3 CREIGHTON UNIVERSITY • Diagnosis of complex nocturnal behaviors is difficult 4 2 10/2/2020 CREIGHTON UNIVERSITY Differential Diagnosis • Nocturnal Seizures • Non Epileptic Motor Disorders 5 CREIGHTON UNIVERSITY Non Epileptic Motor Disorders • NREM Parasomnias • REM parasomnias • Sleep related movement disorders • Psychogenic 6 3 10/2/2020 CREIGHTON UNIVERSITY When to Suspect an Epileptic etiology • Stereotyped nature • High frequency/Clusters • Timing of the events • Duration • Age of onset 7 CREIGHTON UNIVERSITY Nocturnal Seizures • Clinical manifestation of seizures vary based on location and involved network 8 4 10/2/2020 CREIGHTON UNIVERSITY 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. 9 Percentage of partial seizures arising during sleep from various seizure onset zones. S.T. Herman et al. Neurology 2001;56:1453-1459 ©2001 by Lippincott Williams & Wilkins 10 5 10/2/2020 CREIGHTON UNIVERSITY Frontal Lobe Epilepsy •2nd most common epilepsy ( 18% of adults) • Often misdiagnosed 11 CREIGHTON UNIVERSITY Challenges in Diagnosis • Dramatic/complex movements • No postictal state • Often no Aura • EEG – excessive artifacts • EEG – can be normal • Frequency 12 6 10/2/2020 CREIGHTON UNIVERSITY Nocturnal Frontal Lobe Epilepsy • 90% or more seizures in sleep • NFLE - sporadic • ADNFLE – Autosomal dominant 13 CREIGHTON UNIVERSITY • Hyper motor movements • High velocity movements of the trunk and extremity • Frequent • Abrupt 14 7 10/2/2020 CREIGHTON UNIVERSITY • 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 15 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) 16 8 10/2/2020 CREIGHTON UNIVERSITY 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. 17 CREIGHTON UNIVERSITY 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. 18 9 10/2/2020 CREIGHTON UNIVERSITY Disorders of Arousal / Non-REM • Confusional Arousal • Sleep Walking • Sleep terrors 19 CREIGHTON UNIVERSITY 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 20 10 10/2/2020 CREIGHTON UNIVERSITY Sleepwalking • Somnambulism • Arises from bed and ambulates without full awakening • Can engage in complex behaviors and the environment • Difficult to awaken 21 CREIGHTON UNIVERSITY • Confused if they wake up • Best to gently attempt to lead back to bed. • May react violently • Peak prevalence age 4-8 yrs. 22 11 10/2/2020 CREIGHTON UNIVERSITY • Preventive measures • Behavioral therapies • Pharmacotherapy 23 CREIGHTON UNIVERSITY Sleep Terrors • Sudden arousal with intense fearfulness • Scream or cry • Unresponsive, if awakened – confused/disoriented. • Amnesia for the episode. • may be devoid of images. 24 12 10/2/2020 CREIGHTON UNIVERSITY REM Sleep Behavior Disorder • No Atonia • Enacts dreams. • Easy to wake up • Frequent injuries ( even to bed partner) 25 CREIGHTON UNIVERSITY • Treatment • Clonazepam • TCI’s 26 13 10/2/2020 CREIGHTON UNIVERSITY REM Sleep Behavior Disorder 27 CREIGHTON UNIVERSITY 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. 28 14 10/2/2020 CREIGHTON UNIVERSITY Evaluation • Polysomnography • Video EEG 29 CREIGHTON UNIVERSITY • Howell, Michael J. • CONTINUUM: Lifelong Learning in Neurology26(4):929-945, August 2020. • doi: 10.1212/CON.0000000000000896 30 15 10/2/2020 CREIGHTON UNIVERSITY • 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 16 10/2/2020 CREIGHTON UNIVERSITY 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 33 CREIGHTON UNIVERSITY 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 34 17 10/2/2020 CREIGHTON UNIVERSITY 35 CREIGHTON UNIVERSITY 36 18 10/2/2020 CREIGHTON UNIVERSITY 37 CREIGHTON UNIVERSITY 38 19 10/2/2020 Seizure - European Journal of Epilepsy 2017 4487-92DOI: (10.1016/j.seizure.2016.11.023) 39 CREIGHTON UNIVERSITY Thank You 40 20 10/2/2020 41 21.
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