Elsevier

Sleep Medicine Reviews

Volume 11, Issue 4, August 2007, Pages 255-267
Sleep Medicine Reviews

CLINICAL REVIEW
Movement disorders in sleep: Guidelines for differentiating epileptic from non-epileptic motor phenomena arising from sleep

https://doi.org/10.1016/j.smrv.2007.01.001Get rights and content

Summary

Seizures, namely in certain epileptic conditions, may be precipitated by sleep. Nocturnal frontal lobe epilepsy seizures, characterized by bizarre motor behaviour and autonomic activation, appear almost exclusively during sleep. The differential diagnosis between this condition and sleep-related non-epileptic paroxysmal motor phenomena, in particular the parasomnias, is arduous. Moreover, accepted criteria for the diagnosis of nocturnal frontal lobe seizures are lacking and even ictal scalp EEG recording could fail to disclose paroxysmal abnormalities. The clinical and polygraphic features of the different types of seizures in nocturnal frontal lobe epilepsy and of the more common non-epileptic paroxysmal events during sleep are described. The main differentiating features characterizing nocturnal frontal seizures are: onset at any age, several attacks per night at any time during the night, brief duration (s) with stereotyped motor pattern. As video-polysomnographic recordings of the attack, the gold-standard for diagnosis, are expensive and not readily available everywhere, home-made video recordings may be helpful. Further investigations on pathophysiology, genetics and epidemiology are needed to clarify the relationship between epileptic and non-epileptic sleep related paroxysmal phenomena.

Section snippets

The influence of sleep on epileptic activity

The influence of sleep stages on paroxysmal activity and seizures is well known. Epileptic interictal discharges may be influenced by the state of arousal and seizures, particularly in some epileptic conditions, may be precipitated by sleep or occur primarily according to a recognizable circadian rhythm.1 Drowsiness and NREM sleep EEG activity facilitate the propagation and synchronization of epileptiform discharges. In the presence of a diminished, but still preserved, muscular tone, these

The wide spectrum of nocturnal frontal lobe epilepsies

NFLE is a peculiar form of partial epilepsy in which seizures, characterized by bizarre motor behaviour or sustained dystonic posture, appear almost exclusively during sleep. The clinical spectrum of NFLS comprises distinct paroxysmal sleep-related attacks of variable duration and complexity.6, 7, 8, 9, 10, 11, 12, 13, 14 In a large series studied by video-polysomnographic recording,6 we described four main semeiological patterns: minor motor events, the so called paroxysmal arousals (PAs),15

The difficulties of differential diagnosis

Distinguishing nocturnal seizures originating from the frontal lobe from paroxysmal non-epileptic sleep disorders is often difficult and sometimes impossible on clinical grounds alone, even for experienced epileptologists and sleep physicians.16, 17, 28, 29, 30, 32, 34

There are three orders of problems in differentiating epileptic seizures from non-epileptic sleep-related events on the basis of clinical history:

First, the behavioural patterns encountered in NREM arousal parasomnias, REM

Clinical and polygraphic features of non-epileptic paroxysmal events during sleep

According to the International Classification of Sleep Disorders (ICSD-II) (Table 1), the non-epileptic paroxysmal motor events during sleep include different categories such as (1) parasomnias, (2) sleep-related movement disorders, and (3) isolated symptoms, apparently normal variants and unresolved issues. We will treat only the motor phenomena which in our experience tend to pose differential diagnostic difficulties with epileptic seizures.

  • (1)

    Parasomnias

    • (a)

      NREM parasomnias

      • Confusional arousals

      • Sleep

Open problems

Video-polysomnography may be indicated to assist in the diagnosis of PAs or other sleep disruption thought to be seizure related or in a presumed parasomnia,64 but accepted criteria for the diagnosis of nocturnal frontal lobe seizures are lacking and even ictal scalp EEG recordings could fail to disclose paroxysmal abnormalities. The difficulties in distinguishing nocturnal epileptic seizures from parasomnias reflect just one aspect of the intriguing issue of the physiopathological

Final considerations

In recent decades, motor phenomena during sleep have been the topic of intensive studies, mainly since the introduction of video-polysomnographic recording techniques. Many conditions have been described and others are under investigation. The differentiation between physiological and pathological events during sleep is part of neurologists’ daily work either as epileptologists or sleep experts. However, much work has yet to be done in this field. Given the absence of standardized clinical or

Acknowledgements

We thank our EEG and sleep laboratory technicians and Elena Zoni and Massimo Armaroli for help in manuscript editing.

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