LGS and Sleep
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Lennox-Gastaut syndrome is a severe childhood epilepsy syndrome characterized by multiple seizure types, cognitive impairment, and a specific EEG pattern of slow spike-and-wave discharges. It commonly causes seizures, especially during sleep, and is associated with high mortality. Polysomnography can identify comorbid sleep disorders like sleep apnea and assess seizure activity during sleep. Treatment involves antiepileptic drugs and management of sleep issues and comorbidities.
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LGS and Sleep
- 1. Lennox-Gastaut syndrome (LGS) and Sleep Sagarika Nallu, M.D. Assistant professor Pediatric Neurology, Epilepsy & Sleep Medicine Chief of Pediatric Neurology Director of Pediatric Sleep Medicine University of South Florida Morsani College of Medicine
- 2. Lennox-Gastaut syndrome (LGS) Severe form of childhood-onset epilepsy associated with high morbidity and mortality Peak period between ages 3 and 5 years More common in males Annual prevalence of 0.26 per 1000 at age 10 years Comprises ~4% of childhood epilepsy cases High mortality rates-Sudden unexpected death in epilepsy (SUDEP) is the most frequent cause of death among patients with Lennox-Gastaut syndrome Status epilepticus
- 3. Classic Lennox-Gastaut syndrome triad Multiple seizure types Cognitive impairment/ regression EEG Pattern-Slow spike-and-wave pattern
- 4. Hierarchy of Symptoms Resnick T. Journal of Child Neurology, 2017.
- 5. LGS awake EEG: Slow Spike and Wave 11/19/2017
- 6. EEG: Paroxysmal Fast Activity 11/19/2017
- 7. EEG in LGS Paroxysmal Fast 10Hz Activity -This is associated with tonic seizures- mainly in sleep. or can occur with minimal clinical manifestations, such as apnea or perhaps truncal rigidity. Can be seen mainly during non-REM sleep. 11/19/2017
- 8. EEG in LGS Since a diagnosis relies so heavily on finding that classic EEG feature and since tonic seizures tend to occur mostly during sleep, a sleep EEG is essential. These fast rhythms that are essential for diagnosis and are essential in differentiating Lennox-Gastaut Syndrome from other epilepsy syndromes in which slow spike in wave discharges can be seen. Misdiagnosis or over diagnosis of LGS 11/19/2017
- 9. Features of Several Epileptic Disorders Resnick T. Journal of Child Neurology, 2017.
- 10. Seizure Triggers 11/19/2017 Missed dose of medication Sleep deprivation Illness Stress, anxiety, overstimulation Hormonal changes Alcohol and drugs of abuse Hyperventilation Flashing lights Temperature extremes Dehydration
- 11. Common Sleep Comorbidities Sleep provides an opportunity to examine and potentially improve epilepsy Insomnia Excessive daytime somnolence Sleep apnea - both Central and Obstructive events Epilepsy and obstructive sleep apnea (OSA) frequently coexist, and treating OSA in epilepsy patients may reduce seizure frequency and improve daytime sleepiness 11/19/2017
- 12. Pharmacologic Treatment Antiepileptic Drugs valproic acid Lamotrigine Topiramate Rufinimide Clobazam Benzodiazepines Diazepam Clonazepam Clobazam
- 13. Medications and sleep Benzodiazepines are generally safe in low doses but in higher doses and in select patients they may be associated with respiratory depression, hypoventilation, hypoxemia, and obstructive sleep apnea (OSA). Narcotics can be associated with apneas and hypoventilation with increased risk with higher doses and use of other central nervous system depressants. Antidepressants may partially improve OSA by suppressing stage rapid eye movement and increasing upper airway tone but do not completely treat OSA. 11/19/2017 Medication Effects on Sleep and Breathing clinics in Chest Medicine 2014 GilbertSedaMD, PhDaSheilaTsaiMDbTeofiloLee-ChiongMDc
- 14. Common Sleep Comorbidities Nocturnal seizures lead to disturbed quality of sleep at night and leads to excessive daytime somnolence Medications Polysomnogram or sleep study to rule out sleep apnea. Obstructive sleep apnea treatment- CPAP/BiPAP, ENT surgery. Evaluating for Central sleep apnea 11/19/2017
- 15. LGS and Sleep Thorough Sleep history Evaluating for sleep disorders Treatment strategies- Eliminating/ minimizing the contributing factors 11/19/2017
- 16. 11/19/2017
- 17. References Resnick T, Sheth RT. Early Diagnosis and Treatment of Lennox-Gastaut Syndrome. Journal of Child Neurology 2017;32(11):947-955. Sforza E, Mahdi R, Roche F, et al. Nocturnal interictal epileptic discharges in adult Lennox-Gastaut syndrome: the effect of sleep stage and time of night. Epileptic Disord 2016;18(1):44-50. Eisensehr I, Parrino L, Noachtar S, et al. Sleep in Lennox– Gastaut syndrome: the role of the cyclic alternating pattern (CAP) in the gate control of clinical seizures and generalized polyspikes. Epilepsy Research 2001;46:241–250.
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- 21. Associated EEG patterns – generalized 1-2hz slow spike and wave (see figure), generalized slowing, paroxysmal activity (recruiting rhythm) during sleep (see figure) 11/19/2017
- 22. Psychiatric and Behavioral Characteristics Attention-deficit hyperactivity disorder (ADHD) Depression Anxiety Aggression Psychosis
- 23. Non-Pharmacologic Therapy Ketogenic Diet Surgery Focal, lobar, or multilobal resection vs hemispherectomy Vagus nerve stimulation Corpus callosotomy
Editor's Notes
- Approximately 10% of children who experience epilepsy before the age of 5 years will be diagnosed with Lennox-Gastaut syndrome Deaths often related to accidents or status epilepticus; limited data suggest that 20 years after diagnosis, approxi- mately one-quarter of Lennox-Gastaut syndrome patients are likely to have died ~ 20 years after diagnosis, approximately one-quarter of Lennox-Gastaut syndrome patients are likely to have died
- Initial EEG with both awake and sleep is important.
- Some people consider the presence of 10-hertz fast activity as an essential for diagnosis.
- Among antiepileptic drugs, valproic acid is generally con- sidered first-line therapy, and has demonstrated efficacy in the treatment of myoclonic, atypical absence, and atonic seizures. Its use is limited, however, by the rare but serious risk of liver toxicity, and by its potential to interact with other antiepileptic drugs.3 Valproic acid–induced liver toxicity is associated with the neurometabolic disorder Alpers-Huttenlocher syndrome, which is caused by rare mutations in the gene for mitochondrial DNA polymerase g (POLG). Various benzodiazepines (diazepam, clo- nazepam, and nitrazepam, in addition to clobazam) have also been used in the treatment of Lennox-Gastaut syndrome; how- ever, association with sedation, drooling, and exacerbation of the frequency of seizures in children with Lennox-Gastaut syn- drome, in particular tonic seizures, make them less desirable as first-line therapy Early treatment of Lennox-Gastaut syndrome could potentially alter the course of the disease, as a result of slowing or limiting structural changes, reducing cognitive decline, and reducing drop attack– associated injuries. When there is failure to suppress seizures, particularly in patients with intractable frequent daily seizures, the likelihood of a variety of serious risks associated with seizures, such as anoxia, status epilepticus, falls and accidents, and death, is high
- These characteristics are frequently seen in pediatric patients with Lennox-Gastaut syndrome. Drug treatment of Lennox-Gastaut syndrome can have a direct exacerbating impact on these comorbidities, and also an indirect impact via drug-drug interactions.
- It is important to note that early treatment should not be confined to antiepileptic drug use, but should also include consideration of a ketogenic diet, vagus nerve stimulation, and epilepsy surgery, as well as various combinations of these therapies to both optimize seizure control and improve quality of life in patients with Lennox-Gastaut syndrome. A ketogenic diet is a high-fat, moderate protein, and low-carbohydrate diet that has long been in use for seizure treatment, and emerged from the observed reduction in seizures among patients with epilepsy during fasting periods when ketone levels are elevated.37 A Johns Hopkins study of 71 pediatric patients with Lennox-Gastaut syndrome given a keto- genic diet found that after 1 year, 44% of patients had a >50% reduction in seizures, and 18% had a 90% to 99% seizure reduction. Notably, the rate of seizure reduction diminished over the 1-year period, with better efficacy being seen at 3 months and 6 months compared to 1 year. Vagus nerve stimulation is used in cases of refractory epilepsy and involves the implantation in the chest of a generator of intermittent electrical stimuli to an electrode wrapped around the left vagus nerve in the neck.37 In the overall Lennox-Gastaut syndrome patient pop- ulation, more than half experience a >50% reduction in sei- zures after initiation of vagus nerve stimulation.37 With regard to specific Lennox-Gastaut syndrome subtypes, vagus nerve stimulation has been found to be effective for children who experience myoclonic seizures, but has shown limited efficacy in tonic seizures, and has been less effective than corpus callosotomy for atonic seizures. Corpus callosotomy is usually employed in refractory epilepsy, when all other options have failed. Vagus nerve stimulation is typically tried first in these patients, because it is reversible and is not associated with the risks inherent with craniotomy.41 Corpus callosotomy has been shown to reduce seizure frequency among patients with Lennox-Gastaut syn- drome, particularly in those with atonic seizures, although in other types of seizures associated with Lennox-Gastaut syn- drome, the efficacy of corpus callosotomy is approximately equivalent to that of vagus nerve stimulation