Nocturnal epilepsy

2. Nocturnal Epilepsy
• It has long been known that seizures, both convulsive and nonconvulsive, often occur
during sleep, especially in children.
• This is such a frequent occurrence that the practice of inducing sleep has been adopted
as an activating EEG procedure to obtain confirmation of epilepsy.
• Seizures may occur soon after the onset of sleep or at any time during the night, but
mainly in stages 1 and 2 of NREM sleep or, rarely, in REM sleep . They are also common
during the first hour after awakening.
• On the other hand, deprivation of sleep may be conducive to a seizure.

3. Nocturnal Epilepsy
• Sleeping epileptic patients may attract attention to their seizures by a cry, violent
motor activity, unusual but stereotyped actions, such as sitting up and crossing
the arms over the chest, the adoption of a "fencing" posture, or labored
breathing.
• After the tonic-clonic phase, patients become quiet and fall into a state
resembling deep sleep, but they cannot be aroused from it for some minutes or
longer.

4. Nocturnal Epilepsy
• If the nocturnal seizure is unobserved, the only indication of it may be disheveled
bedclothes, a few drops of blood on the pillow from a bitten tongue, wet bed linen from
urinary incontinence, or sore muscles.
• Or the occurrence of a seizure may be disclosed only by confusion, muscle soreness, or
headache, the common aftermaths of a major generalized seizure.
• Rarely, a patient may die in an epileptic seizure during sleep, sometimes from
smothering in the bed clothes or aspirating vomitus or for some obscure reason (possibly
respiratory or cardiac dysrhythmia).

5. Nocturnal Epilepsy
• Epilepsy occasionally occurs in conjunction with night terrors and somnambulism
• EEG studies during a nocturnal period of sleep are most helpful in such cases.
• Measurement of serum creatine kinase concentration in the hours following an
event may distinguish seizure from night terrors, and the other described sleep-
related motor behaviors.

6. Nocturnal frontal lobe epilepsy
• characterized by paroxysmal bursts of generalized choreoathetotic, ballistic, and dystonic movements
occurring during NREM sleep
• Sometimes the patient appears awake and has a fearful or astonished expression, or there are repetitive
utterances and an appearance of distress, similar to what is seen in night terrors.
• the main differential diagnosis discussed further on. The attacks may begin at any age, affect both sexes, and
are usually nonfamilial.
• Two forms of this disorder have been recognized: in one, the attacks last 60 s or less; they may be diurnal as
well as nocturnal
• all respond to treatment with carbamazepine.

7. • In a second and more rare type, the attacks are longer lasting (2 to 40
min). Ictal and interictal EEGs during wakefulness and sleep are
normal, and these attacks do not respond to anticonvulsants of any
type.
• Except for the lack of familial incidence and occurrence only during
sleep, the disorder is very much the same as the "familial paroxysmal
dystonic choreoathetosis"
Nocturnal frontal lobe epilepsy

8. Semiology of Nocturnal frontal lobe epilepsy
• The most common type, originating in the supplementary motor area, takes the
form of a turning movement of the head and eyes to the side opposite the
irritative focus, often associated with a tonic extension of limbs, also on the side
contralateral to the affected hemisphere.
• This may constitute the entire seizure, or it may be followed by generalized clonic
movements.
• The extension of the limbs may occur just before or simultaneously with loss of
consciousness but a lesion in one frontal lobe may give rise to a major
generalized convulsion without an initial turning of the head and eyes.

9. Episodic phenomena in sleep
I. Normal physiological movements :
 Whole body jerks commonly occur in normal subjects on falling asleep.
 Fragmentary physiological myoclonus usually involves the peripheries or the face, and occurs
during stages 1 and 2 and REM sleep.
 Periodic movements of sleep may be an age related phenomenon, being seen in
less than 1% of young adults, but occurring with increasing frequency during
middle and old age such that they are present in perhaps half the elderly
population.
 Typically these movements occur at regular intervals of 10-60 seconds and may occur in clusters
over many minutes.

10. • The night terror (pavor nocturnus) is mainly a problem of childhood.
• It usually occurs soon after falling asleep, during stage 3 or 4 sleep.
• The child awakens abruptly in a state of intense fright, screaming or
moaning, with marked tachycardia (150 to 1 70 beats/min) and deep, rapid
respirations.
• Children with night terrors are often sleepwalkers as well, and both kinds
of attack may occur simultaneously.
• The entire episode lasts only a minute or two, and in the morning the child
recalls nothing of it or only a vague unpleasant dream.

11. REM parasomnias
• nightmares are far more frequent than night terrors and affect
children and adults alike. They occur during periods of normal REM
sleep.
• Autonomic changes are slight or absent, and the content of the
dreams can usually be recalled in considerable detail.
• Some of these dreams (e.g., the ones occurring in the alcohol-
withdrawal period) are so vivid that the patient may later have
difficulty in separating them from reality; indeed, they may merge
with the hallucinations of delirium tremens.

12. Sleep Apnea
• Patients with sleep apnoea usually present with day-time
hypersomnolence.
• However, the apnoeic episodes may cause episodic grunting, flailing
about or other restless activity that appears to mimic nocturnal
epilepsy.
• Occasionally the resultant hypoxia leads itself to secondary seizures.

13. Restless leg syndrome
• The restless leg syndrome is characterised by an urge to move the
legs especially in the evening when lying or sitting.
• It may be associated with various unpleasant paraesthesiae.
• All p
atients with restless legs have periodic movements of sleep. These
may be severe and can also occur during wakefulness.
• In addition there may be a variety of brief daytime dyskinesias.