Seizure 1998; 7: 67-71

CASE REPORT

Episodic nocturnal wandering and complex visual hallucination. A case with long-term follow-up

YING-ZU HUANG & NAI-SHIN CHU

Department of Neurology, Chang Gung Medical College and Memorial Hospital, Taipei, Taiwan

Correspondence to: Nai-Shin Chu, MD, Department of Neurology, Chang Gung Memorial Hospital, 199 Tung-Hwa N Road, Taipei, Taiwan

Episodic nocturnal wandering is rare and thought to be an atypical form of nocturnal epilepsy which is responsive to anticonvulsant therapy. We report a case of adult-onset episodic sleep-walking and daytime complex visual hallucination. Ambulatory EEG recordings suggestedthat both events were ictal phenomenon. Interictal sphenoidal EEG and SPECTstudies revealed an epileptogenic focus in the left anterior temporal lobe. During the nocturnal wanderings, the patient had bizarre but non-violent behaviour, and was at risk of minor or severe injury to himself. Both events were completely controlled by carbamazepine for a follow-up period of 8 years. The present case further supports the notion that episodic nocturnal wandering represents an unusual type of nocturnal complex partial seizures.

Key words: episodic nocturnal wandering; ; ; epilepsy.

INTRODUCTION the first third of the night. On the other hand, episodic nocturnal wander- ings may be a peculiar manifestation of sleep-related Approximately 15% of children aged from 5 to epileptic seizures, characterized by ambulation with 12 years walk in their sleep at least once; in con- screaming, unintelligible vocalization, and complex trast, less than 0.5% of adults sleep-walk’,2. Accord- and often violent automatism73 ‘. Epileptiform abnor- ing to the International Classification of Sleep Disor- malities may be revealed by EEG7-9. Other episodic ders proposed by the Association of Sleep Disorders nocturnal attacks may include nocturnal paroxys- Centers3, paroxysmal motor activity arising during mal dystonia and ”, I’. Those nocturnal sleep is classified into two main categories: the para- episodes often occur in the early morning hours and somnias and the seizures of sleep-related epilepsy. respond to anticonvulant therapy. The nocturnal ambulatory automatisms may include Episodic nocturnal wanderings are rare7-9. Here we simple somnambulism, somnambulism with night ter- report a case of episodic nocturnal wanderings and rors, and somnambulism with other nocturnal mani- daytime complex visual hallucination in a young man. festations such as nightmares, , mastication, Ambulatory sphenoidal EEG recordings and single somniloquy, etc3. photon emission computed tomography (SPECT) pro- share several clinical features with vided evidence that these episodes were of an epilep- epilepsy4. Sleep-walking and night terrors are char- tic nature. acterized by sudden onset, altered consciousness, and retrograde . During nocturnal wanderings, sleep-walkers may exhibit aggressive behaviour and CASE REPORT even injure themselves, sometimes seriously. How- ever, several EEG studies have shown that most para- A 25-year old man visited our hospital in August somniacs are not epileptic 5,6. These nocturnal attacks 1988, complaining of sleep-walking, daytime somno- occur most frequently during stage 4 NREM sleep in lence, and recurring strange visions.

1059-1311/98/010067 + 05 $12.00/O Q 1998 British Epilepsy Association 68 Ying-Zu Huang & Nai-Shin Chu

Fig. 1: SPECT 99mTc-HMPA0 showed an area of hypoperfusion in the left anterior temporal lobe.

The patient had at least six episodes of sleep- devil is chasing after the chicken’; ‘The surroundings walking in 1.5 years. He had no recollection of what become like the fairy tales’ etc. These visual hallu- had happened, and knew of these episodes only later cinations occurred repeatedly when he was working, from his mother, who slept in the next room on the so that he could not concentrate on his job. Although third floor. In the first episode, the patient got up from he was extremely tired or sleepy while working, he his sleep in the early morning, walked toward the win- usually did not fall into sleep. dow, climbed over it, and jumped onto the ground. He The family history was unremarkable except that regained consciousness in an ambulance on the way one of three uncles had enuresis as a child. The pa- to the hospital. He had sustained a bilateral wrist frac- tient had a normal birth and normal motor develop- ture. In the next four episodes, he was found sitting ment. Febrile convulsions were denied. He finished up on the edge of his bed at five to six o’clock in the high school with poor grades. He had suffered from morning, and then walked into the family room and until he was 13 or 14 years old. kitchen. He walked aimlessly with eyes staring and When he was in military service between the ages was totally unresponsive. The episodes lasted about of 20 and 22 years, he had one episode of loss of con- 30-40 minutes. He then went back to his room and sciousness. Although he was hospitalized, the cause slept. When he woke up later, he knew nothing about and the nature were not determined. While on night the spells and denied any nightmares or dreams dur- duty, he often saw some terrible things such as ghosts, ing the previous night. Screaming, yelling, or violent devils, etc. In the past 2 years, his mother had occa- acts were not observed. However, he had broken his sionally noticed that things in the house had been teeth once and broken a table also once during these moved around by someone, but she did not pay at- episodes. He was diagnosed to have somnambulism tention to these strange happenings until the jumping in other hospitals, but treatment was not offered. The episode had occurred. last episode occurred 1 month prior to his visit. He Neurological examination was normal. Routine lab- was found to sit up from sleep, enter the bathroom, oratory tests were also normal. Brain CT with and and attempted to drink the water in the toilet bowl. without enhancement were normal. The SPECT with All these attacks had occurred with no apparent rela- 99mTc-HMPA0 cerebral perfusion revealed an area of tion to emotion, , amount of sleep, drugs, and decreased uptake of radioactivity in the left anterior other physical conditions. temporal region (Fig. 1). The patient also felt tired and was prone to sleep Sphenoidal EEG recordings revealed a focus of when he was performing his job of wrapping the sharp wave activity also in the left anterior tem- dumplings in a food factory. In addition, he was both- poral lobe (Fig. 2). During ambulatory sphenoidal ered by the sudden occurrence of visions, such as: ‘A EEG recordings’* when the patient was writing, Episodic nocturnal wandering 69

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Fig. 2: lnterictal sphenoidal EEG recording showed theta activity and sharp waves in the left anterior temporal lobe (SPl and T3 montages) one episode of visual hallucination occurred at DISCUSSION 20:26 hours which was associated with rhythmic spike-and-wave complexes over the left temporo- Our patient had sleep-related episodic wanderings, occipital montage lasting 15 seconds. Unfortunately, daytime somnolence, and occasional complex visual the site of ictal onset could not be identified due to hallucination. EEG and SPECT findings were con- widespread muscle artefacts. Another similar EEG sistent with an epileptic abnormality in the left tem- event occurred at 04:24 hours while the patient was poral lobe. Furthermore, episodic wanderings and vi- sleeping. sual hallucinations were responsive to carbamazepine. The patient was treated with carbamazepine 200 mg Therefore, the episodic attacks of our patients were three times a day. The nocturnal wanderings and possibly an unusual type of complex partial epilepsy. episodes of visual hallucination stopped, but occa- Most parasomnias are sleep disorders of a non- sionally he would dream throughout the night. How- epileptic nature’.2x4. The typical somnambulism is ever, when the patient forgot to take the anticonvul- automatism that occurs during deep NREM sleep, sant, these episodes would recur. In one episode, the usually in the first third of the night, and is much patient arose with staring eyes and his mouth slightly more common in children than in adults. The sleep- open, tried to place a handbag on his foot, and walked walking lasts only from a few seconds to minutes. On to the back door. In another two episodes, the patient the other hand, episodic nocturnal wandering is rare woke up from sleep and went to the bathroom where and clinically different from the usual sleep-walking he found he had already taken off his underwear. He episode. Nocturnal wandering usually occurs in adults was extremely tired the next day. in the second half of the night or early morning hours The patient and the family emigrated to Canada in during stage 2 NREM sleep7-“‘. During the attacks, 1994. A recent telephone inquiry revealed that the pa- patients are unresponsive to environment and per- tient continued to take carbamazepine. Sleep-walking sons, and have complex violent behaviour associated and visual hallucination would not occur as long as with screaming, incoherent speech or mumbling. The he was taking the anticonvulsant. majority have epileptiform abnormalities on interictal 70 Ying-Zu Huang & Nai-Shin Chu

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EEGs, suggesting that episodic nocturnal wandering EEG and SPECT showed an epileptogenic focus in is an atypical form of sleep-related epilepsy7-lo. This the left anterior temporal lobe. Ambulatory EEG notion is further supported by good responses to car- study suggested that both nocturnal wandering and bamazepine or phenytoin7-lo. Recently, ictal epilep- daytime visual hallucination were ictal events. Our tiform discharges at the onset of sleepwalking were case suggests that episodic nocturnal wanderings in also documented by video-polysomnographic moni- some patients may be associated with daytime ictal toring9. manifestations of different symptomatology. The clinical manifestations of our patient were in general similar to those of previous reports7-9. How- ever, his behaviour during the attacks was bizarre but REFERENCES not violent, and there was no screaming, yelling, and unintelligible vocalization. On the other hand, our pa- 1. Parkes, J.D. Sleep walking. In: Sleep and its Disorders (Ed. J.D. Parkes). London, Saunders, 1985: pp. 205-211. tient also suffered from minor and severe injuries. In 2. Ambrogetti, A., Olson, L.G. and Saunders, N.A. Disorders addition, he had complex visual hallucination which of movement and behaviour during sleep. Medical Journal of had not been reported previously in the literature. Australia 1991; 155: 336-340. Ambulatory EEG study suggests that visual halluci- 3. Therpy, M.J. and the Diagnostic Classification Steering Com- mittee. International classification of sleep disorders: diag- nation was an epileptic event. The complex nature of nostic and coding manual. Rochester, MN, American Sleep the visual hallucination also suggests that it probably Disorders Association, 1990. originated from the temporal lobe rather than from 4. Montplaisir, J., Laverdiere, M. and Saint-Hilaire, J.M. Sleep and epilepsy. In: Long-term Moniforing in Epilepsy (Eds J. the occipital lobe. Gotman, J.R. Ives and P. Gloor.). Electroencephalography Polysomnographic recordings of patients with and Clinical Neurophysiology 1985; Suppl. 37: 215-239. episodic nocturnal wanderings have revealed normal 5. Kales, A., Soldatos, C.R., Cadwell, A.B. et al. Somnambu- waking-sleeping cycles, and two patients with abortic lism: clinical characteristics and personality patterns. Archives of General 1980; 37: 14061410. attacks were not associated with any abnormal elec- 6. Soldatos, C.R., Vela-Bueno, A., Bixler, E.O., Schweitzer, trographic features7-9. In contrast, ambulatory EEG P.K. and Kales, A. Sleepwalking and night terrors in adult- recordings of our patients showed epileptic discharges hood: clinical EEG findings. Clinical Electroencephalography during visual hallucination and nocturnal wandering. 1980; 11: 136-139. 7. Pedley, T.A. and Guilleminault, C. Episodic nocturnal wan- Unfortunately, the entire event of the nocturnal wan- derings responsive to anticonvulsant drug therapy. Annals of dering could not be ascertained due to widespread Neurology 1977; 2: 30-35. muscle artefacts. 8. Guilleminault, C. and Silvers&i, R. Disorders of arousal and epilepsy during sleep. In: Sleep and Epilepsy (Eds M.B. Ster- In conclusion, we present an additional case of man, M.N. Shouse and P. Passouant). New York, Academic episodic nocturnal wandering. Interictal sphenoidal Press, 1982; pp. 513-531. Episodic nocturnal wandering 71

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