Nocturnal epilepsy or sleep epilepsy

In this article, we will find out what nocturnal epilepsy or epilepsy in a dream is, we will find out what seizures can be in a dream, what are the differences between epilepsy in a dream and sleep disturbance.
Epileptic seizures in relation to the time of day can be: only night seizures, mainly night seizures, seizures at any time of the day, only daytime. The characteristic time for epileptic seizures during sleep is when falling asleep or on awakening, especially during early violent awakening or sleep deprivation (sleep deprivation).

It is known that a third of all patients with epilepsy (according to various sources, 10-45%) have only nocturnal epilepsy or occur mainly during sleep, that is, about 30% have epilepsy during sleep.

The patients dubbed this sleep-related epilepsy nocturnal epilepsy. Although officially such a term has not been introduced in epileptology .

There are a number of terms that refer to sleep events:

• sleep-related epileptic seizures;
• night attacks;
• nocturnal paroxysms;
• attacks when falling asleep (on awakening, against the background of sleep deprivation);
• paroxysms in a dream of non-epileptic genesis;
• parasomnias (somnambulism = sleepwalking, sleepwalking = sleepwalking );
• insomnia ;
• sleep disorders;
• hyperkinesis;
• benign myoclonus when falling asleep and other options.

So many terms related to nocturnal attacks speak of the variability of manifestations in sleep, the high frequency of paroxysms, and the complexity of diagnosis. Combinations of several of these and other disorders with and without epilepsy are possible.

Nocturnal cause epilepsy

The likelihood of epileptic seizures during sleep is determined by the physiology of sleep. Let’s find out what happens in the cerebral cortex during sleep epilepsy.

During sleep, the excitability of nerve cells changes, their work becomes asynchronous.

Sleep can be disturbed with epilepsy, more often with focal forms.

On the EEG during epileptic seizures, there is an increase or increase in the index of epic activity in the phase of slow wave sleep.
In the rapid eye movement sleep phase, there is a violation of the synchronicity of bioelectric activity Due to the asynchronous nature of the discharges in the rapid eye movement sleep phase, the propagation of discharges to other parts of the brain is suppressed.

In violation of sleep phases, with a shortening of the sleep phase of rapid eye movement, excitability is noted, and on the EEG there is an increase in the spread of discharges, which is sometimes called a decrease in the threshold of convulsive readiness.

Sleep deprivation results in increased drowsiness, which contributes to falling asleep during the EEG recording. When recording an electroencephalogram during sleep, it is more likely to identify pathological activity.

In addition to deprivation (deprivation) of sleep , violent awakening, nourishing food, and some medications (mild sedatives) can provoke epic activity .

Generalized epilepsy and sleep

Sleep seizures are characteristic of idiopathic generalized epilepsies. This connection is explained by damage to the thalamocortical structures.

In idiopathic generalized epilepsies, sleep deprivation stimulates epiativity and increases the likelihood of an epileptic seizure .

Attacks are more likely to occur when falling asleep or waking up, especially with early violent awakening .

So, in the first 15 minutes – 1 hour after waking up, patients with juvenile myoclonic epilepsy have epileptic seizures : myoclonus (more often like twitching in the hands) or, especially with ineffective therapy, generalized tonic-clonic seizures.

In ESES, even the name suggests that the manifestations of the disease are associated with sleep. A feature of these forms of epilepsy is the presence of continued epileptiform activity with a high index of epiactivity (more than 80%) during slow wave sleep. And in the phase of rapid eye movement sleep, the index of epiativity decreases.

Nocturnal seizures in epileptic encephalopathies with electrical status of slow wave sleep can be in the form of: focal motor seizures during sleep, generalized tonic-clonic seizures. Daytime seizures, both focal and generalized, are also possible .

Symptomatic secondary generalized epilepsy is less dependent on sleep-wake cycles. With this form of epilepsy, epileptiform activity and epileptic seizures can occur at any time of the day with equal probability.

Focal epilepsy and sleep

In focal epilepsy, seizures occur more often during sleep, in any phase of sleep, but more often during slow wave sleep.

In symptomatic temporal lobe epilepsy, epiativity is more often detected during slow wave sleep, and seizures are more often daytime.

Nocturnal epilepsy symptoms

With autosomal dominant nocturnal frontal epilepsy, the following nocturnal seizures are noted:

• attacks with sudden nocturnal awakening, can be short, sometimes missed by patients, can be with a cry, affect (fright);
• hypermotor attacks (high-amplitude, pretentious movements), tonic (stretching, arching), clonic (sharp contractions of the muscles of the limbs, trunk), consisting of cyclic movements ( boxing , pedaling ) or jerks;
• nocturnal attacks, similar to sleepwalking , accompanied by fear (for example, jumping out of bed, running, looking around, screaming, speaking articulate phrases);
• there can be various combinations of these attacks in a dream.

Features of the symptoms of autosomal dominant nocturnal frontal epilepsy:

• family history of epilepsy is burdened (relatives have cases of epilepsy or parasomnias );
• the onset of epilepsy at puberty (10-14 years);
• there can be only nocturnal attacks or mainly during sleep with rare daytime;
• attacks are frequent, there may be 1-5 attacks per night every night;
• an attack provocateur is emotional and physical stress, weather changes, menstruation, sleep disturbances;
• in treatment, oxcarbazepine , combinations of antiepileptic drugs are used; but a third of patients are pharmacoresistant .

“Nocturnal epilepsy of adults”, “Nocturnal epilepsy in children”, “epilepsy in sleep” – this is how patients often call it Autosomal dominant nocturnal frontal epilepsy. This type of epilepsy can begin at any age: in childhood and as an adult. In 30% of patients, it is resistant to antiepileptic drugs, so it can continue throughout the life of patients. From the use of polytherapy of this form, it is possible to achieve only a slight decrease in the strength, frequency and duration of nocturnal epileptic seizures.

Sleep epilepsy or sleep disturbance

How to distinguish nocturnal seizures, are seizures a manifestation of epilepsy during sleep, or is it a sleep disorder?

Differential diagnosis of paroxysmal sleep events

To clarify the nature of nocturnal seizures, an objective research method is to conduct a video EEG- polysomnography . An option for diagnosing epilepsy in sleep is EEG video – monitoring, studies are more informative after sleep deprivation.

If, during a paroxysm, epiactivity is simultaneously recorded on the EEG of sleep, then these paroxysms of epileptic genesis, that is, these are epileptic seizures in a dream.

Nocturnal seizures can be short, and not accompanied by epileptiform EEG discharges, then these disorders are not epileptic genesis, are more often referred to as parasomnias .

Sleep disorders are often associated with specific sleep stages and have a characteristic clinical picture.

At the reception of an epileptologist, there are also such options when the patient has nocturnal seizures and epiativity , but this is not epilepsy.

Here is a clinical example of seizures during sleep, accompanied by epileptiform activity on the EEG, but not related to epilepsy.

A boy, 3 years old, came to the reception with paroxysms of the night in the form of sleepwalking , sleeping-talk . In the words of my mother: “2 hours after falling asleep, he gets out of bed, says, walks around the apartment. As if he is looking for something. More often something is indistinct. Some of the words can be understood, connected with sleep, with the events of the day. Sometimes the son laughs, cries, groans, is afraid, in a hurry. The eyes are open, but the look is unconscious or “wild.” After 10 minutes I manage to calm him down, put him down. He falls asleep calmly. After treatment with sedatives, there was a break in his sleepwalking for 4 months, and then gradually increased up to 2-4 times a month. ” On the EEG, the patient has epiativity of the type of benign epileptiform discharges of childhood in a small amount in the background and during sleep. When conducting an EEG with sleep deprivation: during the recording of sleep, neurophysiologists described paroxysm (sat on the bed, did not react, said a few words), but at that moment there was no EEG epiactivity .
Diagnosed with Parasomnias ( sleepwalking , sleep- speaking ). Concomitant diagnosis: Benign childhood epileptiform disorders. There are currently no data for active epilepsy.
Antiepileptic drugs have never been prescribed to this patient. Emphasis was placed on the need to observe a rational daily routine. In therapy, he received sedatives or nootropics in age-specific doses as monotherapy (pantothenic acid, adaptol , atarax , phenibut , herbal decoction, novopassit ) for 1-2 months, 1-3 courses per year. The response to such therapy is always good: the parasomnias described above completely stopped for 4-8 months or significantly decreased; could be worn out (sits on the bed in a dream, sits for 3-5 seconds, lies down and sleeps on; no more than 1-2 times a month).
The child has been observed by an epileptologist for several years. Over time, the complaints of sleep disturbance gradually become less and less. According to the EEG, the epiactivity of the DEDD type persists : in different records it can be in a small index or is absent.

What is the difference between nocturnal seizures of epilepsy and parasomnias :

• parasomnias more often occur in early childhood (from 1-3 years to 12 years), and nocturnal epileptic seizures develop later and can begin at any age;
• parasomnias are longer (on average, duration 5-30 minutes) compared to nocturnal seizures (on average, duration 20 seconds – 5 minutes);
• parasomnias are more variable, epileptic seizures in sleep are more stereotyped (similar to each other);
• parasomnias gradually stop on their own or against the background of sedation by the age of 12; epileptic seizures during sleep only respond to antiepileptic therapy;
• after parasomnias , daytime sleepiness is rarely observed, and after a nighttime epileptic seizure, lethargy, drowsiness, “weakness”.

What can be confused with nocturnal epilepsy?

Sleep disorders similar to sleep epilepsy:

• Parasomnias (somnambulism, night fears, awakenings with “confusion”).
• Rhythmic movement during sleep (benign sleep myoclonus , involuntary limb movements, bruxism = grinding teeth).
• Enuresis (bedwetting).
• Violation of the rhythm of breathing during sleep (sleep apnea, including physiological apnea in children, obstructive apnea in adults).
• Movements during the REM sleep phase.
• Sleep automatisms (swinging, yakting ).
• Nocturnal “paralysis” (or nocturnal “intoxication”).

Sleep epilepsy similar to sleep disturbances

What forms of epilepsy are often overlooked and treated as non-epileptic sleep disorders:

• Symptomatic focal temporal lobe epilepsy, complex focal seizures with complex symptoms.
• Symptomatic focal frontal epilepsy, complex focal seizures.
• Autosomal dominant nocturnal frontal epilepsy.

The clinical manifestations in these focal epilepsies are similar to non-epileptic sleep disorders . But there is also a difficulty in diagnostics: when conducting an EEG, including an EEG of sleep with sleep deprivation, it is far from always possible to identify the presence of epiactivity . MRI data of the brain also cannot always reveal a morphological defect.

For an accurate diagnosis of epilepsy during sleep, you should:

• take a thorough history,
• examine complaints with a detailed description of the seizures,
• strongly recommend that patients make a video recording of seizures during sleep and demonstrate at a doctor’s appointment,
• neurological examination;
• EEG with sleep deprivation with sleep recording, if possible and necessary, recording EEG monitoring video;
• MRI of the brain;
• individually, according to indications, carry out other diagnostic methods (biochemical analysis, consultation with an otolaryntologist , genetics, and others).

In difficult cases, we prescribe a trial treatment with antiepileptic drugs and evaluate the effect of the therapy.

And sometimes, when there are clear doubts about the correctness of the diagnosis of epilepsy, in a hospital setting, the previously prescribed anticonvulsants should be canceled; and make a conclusion on the effect of the cancellation.

So, from all the variety and complexity of the topic of nocturnal epilepsy, we note that about a third of patients with epilepsy have seizures during sleep; nocturnal seizures can be manifestations of various forms of epilepsy, more often generalized idiopathic in children or focal (temporal and frontal) epilepsies; nocturnal seizures can be both a manifestation of epilepsy and sleep disturbance of non-epileptic genesis.

From the article, we learned: what is nocturnal epilepsy or epilepsy in a dream, what are epilepsy attacks in a dream, the causes of epilepsy in a dream, about epilepsy in a dream in children, which sleep seizures are not epilepsy, about the differences between epilepsy in a dream and sleep disorders, about sleep disorders in epilepsy, about parasomnia .

It is important to remember that for any seizures in a dream, you need to consult a neurologist to clarify the diagnosis and timely help.