Nonepileptic Behaviors During Sleep

Nonepileptic disorders during sleep can be mistaken for epilepsy (Herrmann et al., 1993; Scher and Vigevano, 1997; Fusco et al., 1999). Three groups of patients with which potential diagnostic errors can be made have been discussed. First,

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FIGURE 7.8A Example of infantile spasms at 5 months of age, showing an interictal recording with atypical hypsarrhythmia, with continuous and asynchronous spike and wave activity during the waking state. (From Dulac, O., et al., Infantile Spasm and West Syndrome, In The Treatment of Epilepsy Principles and Practice, E. Wyllie, ed., Philadelphia: Lea & Febiger, 1993, Chapter 33, p. 469, reprinted with permission.)

Hypsarrhythmic Ecg Pattern

FIGURE 7.8B Same patient as Fig. 7.8A, showing fragmentation of the hypsarrhythmic pattern during sleep. Note the more synchronized irregular, generalized spike and wave discharges. (From Dulac, O., et al., Infantile Spasm and West Syndrome, In The Treatment of Epilepsy Principles and Practice, E. Wyllie, ed., Philadelphia: Lea & Febiger, 1993, Chapter 33, p. 469, reprinted with permission.)

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FIGURE 7.8B Same patient as Fig. 7.8A, showing fragmentation of the hypsarrhythmic pattern during sleep. Note the more synchronized irregular, generalized spike and wave discharges. (From Dulac, O., et al., Infantile Spasm and West Syndrome, In The Treatment of Epilepsy Principles and Practice, E. Wyllie, ed., Philadelphia: Lea & Febiger, 1993, Chapter 33, p. 469, reprinted with permission.)

adults or children with sleep disorders that are confused as seizures include nightmares, night terrors, and other arousal disorders during NREM sleep. A second diagnostic group includes sleep disorders that could be misdiagnosed as epilepsy during either NREM sleep or REM sleep, such as head-banging, obstructive sleep apnea, automatic behavior disorders, and nocturnal enuresis. A third group represents epileptic disorders that can be mistaken for sleep disorders; nocturnal complex partial seizures of temporal or frontal lobe origin or nonconvulsive status epilepticus may be mistaken for nonepileptic nocturnal hypnogogic paroxysmal dystonia or episodic nonictal nocturnal wanderings.

For the child less than 1 year of age, a number of unique clinical phenomena occur during drowsiness or sleep that can easily be confused with epileptic events as listed in Table 7.1.

The most common sleep phenomenon during infancy that can be confused with seizures is hypnogogic myoclonus or sleep myoclonus (Fig. 7.9). Such movements may be misrepresented as possible seizures, particularly by anxious parents. Parents describe a jerk or start usually during drowsiness or light sleep. It may be problematic, even with home videotaping to document such events. Video EEG/poly-graphic monitoring can better document events that are independent to electro-graphic changes, to distinguish benign neonatal sleep myoclonus from myoclonic epilepsy or infantile spasms. Repetitive nonepileptic sleep starts may also occur in neurologically impaired children, who also may have day or nighttime seizures.

Other phenomena that may be confused with epileptic seizures include shuddering attacks during drowsiness or arousal. Infants with these movements appear tremulous, and involve not only the head but also the upper torso or extremities.

Stimulatory behavior such as head-banging, head-rocking, or masturbation can also occur during drowsiness or arousal, and may mimic clinical seizure table 7.1 Examples of Nonepileptic Paroxysmal Disorders during Sleep

Unusual movements

Shuddering (during drowsiness or arousal) Masturbation during drowsiness or arousal Benign sleep myoclonus Startle responses Episodic features of specific disorders

Gastroesophageal reflux during sleep Respiratory derangements

Apnea Behavior disorders Head-banging Nightmares Night terrors t,-0

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FIGURE 7.9 An example of benign myoclonus of the neonate. Note the prominent myogenic potentials in the absence of electrographic seizures.

EMC (Right Leg) EMG (Submental) EMC (Right Hand)

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FIGURE 7.9 An example of benign myoclonus of the neonate. Note the prominent myogenic potentials in the absence of electrographic seizures.

activity. Nightmares may occur during REM sleep, and night terrors may occur during NREM sleep in the infant less than a year old. Both of these events superficially resemble seizures. Night terrors tend to occur earlier during the night, shortly after the first NREM period, while nightmares can occur during any REM sleep segment, usually in the early morning hours.

Additional phenomena may also be a source of confusion. Dystonic events during sleep in young infants may represent gastroesophageal reflux (GER). While GER can also occur during the wakeful state, clinical events may occur predominantly or exclusively during sleep; video EEG monitoring with pH probe monitoring can help document this abnormality. While nocturnal paroxysmal dystonia generally does not occur under 2 years of age, dystonic posturing followed by sudden arousal may superficially resemble mesial frontal lobe seizures. Video monitoring may more readily document ictal and interictal electrographic abnormalities in association with such behaviors.

summary

Many epileptic syndromes affecting the older child are activated during drowsiness, sleep, or arousal from sleep. While there are specific childhood epileptic syndromes that characteristically involve sleep, few epileptic syndromes are described for the child under 1 year of age. Interestingly, this time period from birth through 1 year is rapidly evolving with respect to sleep architecture, continuity, arousal, and cycle length. While the ontogeny of circadian and ultradian organization of sleep and wakefulness is undergoing rapid and tremendous changes, few associations between sleep transitions and seizures have been described. The absence of strong circadian influence until 3 months of age, and little expression of "lighter" stages of NREM (i.e., stage 1 and 2) until after 9 months of age are two examples of maturational characteristics that may limit the expression of seizures during sleep in the neonate or infant.

Aggressive use of EEG/PSG recordings, including simultaneous video documentation, can assist in establishing whether a clinical phenomenon is epileptic or nonepileptic. Further investigations for epileptic syndromes during the neonatal and infancy periods must include both EEG and PSG evaluations. Understanding the effects of antiepileptic medications on sleep also may contribute to more accurate classification of nonepileptic behaviors during sleep.

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