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Seizure 1997; 6: 145-149

Nocturnal in adults

BASIM A YAQUB, GHAZALA WAHEED & MOHAMMAD MU KABIRAJ

Division of Neurology and Neurophysiology, King Khalid University Hospital, PO Box 7805, Riyadh 11472, Saudi Arabia

Correspondence to: Dr. Basim A. Yaqub, Consultant Neurologist, Department of Clinical Neurosciences. Armed Forces Hospital, P.O. Box 7897 (X1006), Riyadh 11159, Kingdom of Saudi Arabia

We evaluated the clinical characteristics and the electroencephalographic (EEG) findings by long video-EEG monitoring in 64 successive patients with definite nocturnal . Mental state, neurological examination, neuroimaging and EEG background were normal in all patients. Classification of epilepsies was possible in 42 out of 64 (66%) patients according to the revised Classification of Epilepsies and Epileptic Syndromes by the Commission on Classification and Terminology of International League Against (1989). Out of those 42 patients, 33 (79%) had partial epilepsies, while 9 (21%) had generalized epilepsies. Response to antiepileptic drugs was excellent and only 4 (6%) patients had one attack per year, two of them were on two antiepileptic drugs while the others were free of seizure on a single drug during the 2 years of follow-up. It seems that nocturnal seizuresin adults form a new distinctive partial epileptic syndrome of a benign entity.

Key words: nocturnal seizures: epileptic syndromes: video-EEG monitoring: benign childhood epilepsy with centro-temporal spikes:antiepileptic drugs.

INTRODUCTION EEG (VEEG) monitoring, has become an essential technique in most sleep laboratories, The pattern of seizure occurrence in most also it is an important technique for the epileptics is random without cycling or clustering identification and classification of unusual sei- so they can occur during the daytime or sleep’. zures and to assess seizure control in intractable However, some seizures occur mainly during epilepsy I’. The aim of our study is to utilize long sleep2, such as seizures in benign childhood video EEG monitoring to study the clinical and epilepsy with centro-temporal spikes (BCECI’S). electrical characteristic of nocturnal seizures, and Other nocturnal seizures are difficult to classify to classify them into different syndromes accord- into epileptic syndromes according to the revised ing to the recent ILAE c1assification3, which will classification of epilepsies and epileptic syndr- be important for the management and prognosis. omes by the Commission on Classification and Terminology of the International League Against Epilepsy (ILAE)3. They are considered under PATIENTS AND METHODS ‘Epilepsies and syndromes undetermined whether focal or generalized’ due to lack of We studied 64 successive patients with unclas- unequivocal generalized or focal features. As sified nocturnal seizures, 39 males, mean age 21 they only occur during sleep, the onset of seizures years (range, 13-38), and 25 females, mean age is not always recognized by the patient or 20 years (range, 14-36). Age of onset, clinical witnessed by their relatives, also the interictal description of the seizures, family history of EEG is usually normal. seizure disorder, past history of trauma and Some of the nocturnal seizures are overlooked febrile were recorded in all patients. or misdiagnosed as different sleep disorders such All patients have a thorough clinical examination as terrors and somnambulism, nocturnal paroxys- and computerized tomography (CT) of brain with mal dystonia and benign physiological hypnic contrast. Electrical studies included conventional jerks and twitches&“. (EEG) with hyperven- Neurodiagnostic monitoring, especially video tilation up to 180 seconds and intermittent photic

1059-131 l/97/020145 + 05 $12.00/O 0 1997 British Epilepsy Association 146 B. A. Yaqub et al stimulation (IPS) of 5-25 Hz, sleep-deprived one seizure per 6 months, a score of (4) if the EEG, and long VEEG. Video EEG was patient had one seizure per 3 months, and a score performed by telefactor to display the patient of (5) if the patient had more than one seizure in 3 image on one half of the screen and 16 channel months. The letter A was attached to the score if EEG data on the other half. All were recorded the patient was on a single AED, the letter B if by video tapes. The recordings were initially the patient was on 2 AEDs, and the letter C if he made for 24 hours including natural sleep for one was on more than 2 AEDs. night. In patients with initially normal VEEG, 24-hour recording was repeated on two occasions. All cassettes, with or without events, were RESULTS reviewed by one of us. Following the completion of neurophysiological studies (EEG, sleep- Mental state, systemic and neurological examina- deprived EEG, and VEEG), the records and tion was normal in all patients. Computerized cassettes were assessed for the presence of tomography (CT) of brain was normal in all electroclinical seizures, organization of EEG except one patient with a porencephalic cyst. background, and epileptiform discharges of gen- None of the patients had a family history of eralized spike wave or isolated unilateral or epilepsies. bilateral synchronous or independent spikes. The EEG background was organized with They were assessed independently by two of us, posterior symmetrical alpha rhythm in the awake in case of disagreement, the cassettes were state in all patients. Epileptiform discharges in reviewed by a third investigator. Seizures in all different neurophysiological procedures are patients were classified into generalized, partial shown in Table 1. Electroclinical seizures complex, partial simple, or secondary generalized occurred only in nine patients. All were difficult according to revised clinical and electro- to diagnosis without VEEG. In 29 (69%) out of encephalographic classification of epileptic sei- 42 patients, the discharges occurred in stage II zures by the Commission on Classification and and/or stage III of nonREM (NREM) sleep, Terminology of the ILAE’-‘. After completion of while in the remaining 13 (31%) the discharges clinical and electrical studies, all cases were occurred in all stages of REM and NREM sleep. classified into epileptic syndromes according to All the electroclinical seizures occurred in stage II recent classification of ILAE. or III of NREM sleep. The patients were included if all their seizures Classification of seizures was not feasible in 22 occurred only during sleep, and the age at the patients, because electrical studies were all onset of seizure was 12 years old or more. All had normal, and the patients had convulsive seizures, either (1) more than one definite convulsive which could be generalized or secondary general- seizure witnessed by the patient’s relatives, (55 ized. Seizures in the remaining patients were patients) or (2) suspected to have nocturnal classified, as shown in Table 2. seizures clinically, and during VEEG recording, Classification into epileptic syndromes is shown had either electroclinical seizures or a definite in Table 3. In partial epilepsies, the seizure type EEG epileptiform discharges and responded was that of partial complex in 16 (25%) [ll (17%) favourably to AED (antiepileptic drug, 9 pati- had temporal and five (8%) had frontal focus], ents). We excluded patients with nocturnal and partial simple in three (5%) [two with frontal and daytime seizures, BCECTS, those with psychiat- one with parietal focus], and secondary general- ric disorders and alcohol abuse. ized in 14 (22%) [lo (16%) had temporal, three The period of follow-up was 2 years; the (5%) had frontal and one (1%) parietal focus]. control of seizures and response to therapy was Sixty patients (94%) were seizure free on assessed according to the following scores: a score of (1) if the patient had no seizures during the follow-up, a score of (2) if the patient had one Table 2: Classification of seizures in 64 patients with seizure per year, a score of (3) if the patient had nocturnal epilepsy Seizure type No. of patients %

Table 1: Neuroohvsiolooical abnormalities in 64 oatients Unclassified 22 34 Test No. of patients % Generalized 9 14 Partial complex 16 25 Awake EEG 11 17 Partial simple 3 5 Sleep-deprived EEG 13 20 Secondary generalized 14 22 Video-EEG 42 66 Total 64 loo Nocturnal seizures in adults 147

Table 3: Epileptic syndromes of 64 patients with nocturnal seizures showing also seizure type, neurophysiological findings and seizure control Epileptic syndrome Seizure type No. EEG/video EEG Seizure Control (%I discharges score no. (%)

1. Unclassified 22(34) Convulsive seizure 22(34) None 1A 21 undetermined generalized or SG 2A 1 Il. Generalized Grand Mal 9(14) Generalized tonic-clonic 9(14) Generalized spike waves 1A 9 Tonic-clonic seizures III. Partial 33(52) Cryptogenic temporal 21(33) (i) Partial complex ll(17) Unilateral or bilateral 1A 19 epilepsies with/without SG synchronous or independent 1B 1 (ii) SG lO(16) spikes in the temporal 2A 1 regions Cryptogenic frontal lO(16) (i) Partial complex seizure 5(g) Unilateral or independent 1A 9 epilepsies (ii) Partial simple seizure 2(3) bilateral spikes in the 1B 1 (iii) SG 3(5) frontal regions Cryptogenic parietal 2(3) (i) Parrtial simple l(1.5) Unilateral spikes in the 1A 2 epilepsies (ii) SG l( 1.5) parietal regions monotherapy, four (6%) had one seizure each VEEG was unable to classify the nocturnal during the 2-year period of follow-up, and two of seizures; this might be due to the fact that them were on two AEDs (see Table 3). nocturnal seizures are infrequent. Despite some of the disadvantages of VEEG such as hos- pitalization, restriction of normal activities and CASE ILLUSTRATION expensei4, it has an important clinical implication in nocturnal seizures, especially those of bizarre A 13-year-old girl seen in the Epilepsy Clinic nature; Such seizures, without simultaneous because she had repeated ‘terror’ attacks at night. EEG discharges, can be overlooked or misdiag- She had no previous or family history of seizure nosed as nonepileptic seizures, as illustrated in disorder, and she was doing well at school. She one of our patients. The high diagnostic yield of had a stable personality, and her mental state was VEEG overweighs other disadvantages’2”5-‘n. normal. Systemic and neurological examination In our patients, sleep was the only activating was normal. Awake and sleep-deprived EEG factor for seizure occurrence. Sleep is recognized was within normal limits. CT brain with contrast to facilitate the occurrence of some epileptic was normal. Video EEG showed two stereotyped seizures, especially partial seizures’9-2’. This has seizures (Fig. 1). She was diagnosed to have been observed previously by Gibbs and Gibbs22. nocturnal partial seizures and was treated suc- The cause of this is uncertain, but it can be cessfully with 200 mg. b.i.d. and explained by the fact that synchronization of the did well with no further seizures in the 2 years of cortical activity during early stages (stage II-III) follow up. of NREM sleep provokes epileptiform discharges in these patients as none of the discharges or electroclinical seizures occurred in REM sleep or DISCUSSION the awake state alone23 . None of our patients had family history of epilepsy, so they cannot be Video EEG is utilized to identify the nature of similar to those described by Scheffer ef al as paroxysmal events such as seizure disorders, autosomal dominant nocturnal frontal lobe syncope, psychogenic seizure or sleep disorders, epilepsy2”2”. to recognize the type of seizure, to localize the Of the 42 patients in whom the seizures could part of the brain from which the seizure begins, be classified, 79% had partial epilepsies. The and to quantify the seizures in intractable most common seizure type was either partial epilepsy”. Our study succeeded in classifying complex or secondary generalized, while the seizures into different syndromes in 66%. This is partial simple type was the least common. superior to the yield of conventional EEG, the Nocturnal epilepsies occurred more in males than latter being positive in 17%, and in sleep- in females and more in adolescence or early deprived EEG being positive in 20%. In 34%, adulthood. Although they are heterogenous B. A. Yaqub et al

groups and are different, they still have the characteristic of benign epilepsies. They all had normal, mental state, neurological ex- amination, neuroimaging, EEG background and excellent response to AED therapy. Ninety-four per cent were seizure free on a single AED during the period of follow up. Therefore, they consti- tute epilepsy of special entity and ought to be considered as such in any future revised classification.

ACKNOWLEDGEMENTS

We are grateful to Ms. Miguela dela Fuente, Ms. Evangeline Dela Rosa and Ms. Teresita Manluc- tao for performing EEG and VEEG; Mr. V. Salvador from Medical Illustration; and Mr. Mohammad Hasoon from the Medical Photog- raphy Department. We also thank Ms. Lydia Gallardo, Ms. Divina Nojadera, and Ms. Clarina De Venancio for their excellent secretarial assistance.

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Fig. 1. Secondary generalized seizure mimicking a hysterical seizure, careful observation of the cassette replay showed two stereotypes seizures, one of them is shown, the seizure starts by awakening of the patient from sleep (B), followed by tonic movement of the right side of the face with closure of the right eye (C), followed by movements of the right upper limb, see arrows to indicate abduction of the right upper limb (D), this is followed by movement of the right lower limb (E), and then the other limbs and later arrest of the seizure (F,G,H). In the corresponding EEG discharges, the arrow shows eye movements when the patient wakes up, followed by flattening of the record followed later by build up of sharp waves and then spike waves starting probably in the right frontal regions at a frequency of 4-5 Hz and later spreading to the other side and becoming generalized but still with higher amplitude in the frontal regions. The discharges terminate gradually. Nocturnal seizures in adults 149

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