Rapid eye movement sleep disturbance in patients with refractory epilepsy: A polysomnographic study

Objective/BackgroundPatients with epilepsy have disrupted sleep architecture and a higher prevalence of sleep disturbance. Moreover, obstructive sleep apnea (OSA) is more common among patients with refractory epilepsy. Few studies have compared subjective sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and those with medically controlled epilepsy. Therefore, this study aimed to evaluate the differences in sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and patients with medically controlled epilepsy.PatientsThis retrospective case–control study included 38 patients with refractory epilepsy and 96 patients with medically controlled epilepsy. Sleep parameters and indices of sleep-related breathing disorders were recorded by standard in-laboratory polysomnography. The scores from sleep questionnaires on sleep quality and daytime sleepiness were compared between the two groups.ResultsPatients with refractory epilepsy versus medically controlled epilepsy had statistically significantly decreased rapid eye movement (REM) sleep (13.5 ± 6.1% vs. 16.2 ± 6.1%) and longer REM latency (152.2 ± 84.1 min vs. 117.2 ± 61.9 min). Further, no differences were found in the prevalence of sleep-related breathing disorders, subjective sleep quality, prevalence of daytime sleepiness, and quality of life. Although not statistically significant, patients with refractory epilepsy have a lower rate of OSA compared with those with medically controlled epilepsy (21.1% vs. 30.2%).ConclusionsPatients with refractory epilepsy had more disrupted REM sleep regulation than those with medically controlled epilepsy. Although patients with epilepsy have a higher risk of OSA, in this study patients with refractory epilepsy were not susceptible to OSA.     

Polysomnographic phenotype of isolated REM sleep without atonia

ObjectiveIsolated REM sleep without atonia (iRSWA) is regarded as a prodromal phase of REM sleep behavior disorder and synucleinopathies. In iRSWA patients, we investigated the polysomnographic characteristics that are known to be altered in (prodromal) Parkinson’s disease (PD): periodic limb movements of sleep [PLMS] (increased), REM density (reduced), and heart rate variability ([HRV] (reduced).MethodsWe compared video-polysomnographic studies of 49 iRSWA subjects with 41 controls. RSWA and PLMS were scored visually. REM density (REM/hour) and HRV were calculated automatically.ResultsWe found a higher median total (15.90 vs 7.20; p = 0.001), REM (21.80 vs 11.0; p < 0.001) and non-REM (11.75 vs 5.72; p = 0.027) PLMS index, and a higher mean REM density (342.45 vs 275.96; p = 0.010) in the iRSWA group, with a significant positive correlation between RSWA severity and these variables (r = 0.39; p < 0.00, r = 0.48; p < 0.001, r = 0.24; p = 0.021, r = 0.28; p = 0.012). We found no significant difference in HRV between groups.ConclusionsOur results suggest an association between RWSA and REM density and PLMS, but not HRV. The positive correlation between these variabilities may imply overlapping pathophysiological processes.SignificanceThe evidence of higher REM density and normal HRV weakens the hypothesis that iRWSA is a prodromal PD stage. An alternative interpretation is, however, that REM density and HRV change during caudal-rostral neurodegeneration.     

Effect of successful epilepsy surgery on subjective and objective sleep parameters – a prospective study

ObjectiveTo evaluate the effect of surgery on subjective and objective measures of sleep quality among patients with medically refractory focal epilepsy.MethodsIn a prospective cohort study, patients with medically refractory epilepsy undergoing epilepsy surgery were recruited. All patients were assessed seven days pre- and three months post-surgery in terms of history pertaining to epilepsy and sleep, Epworth sleepiness score (ESS), one week sleep log and over night polysomnography (PSG).ResultsAmong 17 patients (mean age 18, 11 males), seizure frequency had reduced (p = 0.04) and self reported sleep parameters had significantly improved (reduced total duration of night time sleep, regularity on one week sleep log and ESS (p < 0.05)) three months following epilepsy surgery. Patients with good surgical outcome (n = 12) showed reduced seizure frequency (p = 0.01) and reduced ESS with corresponding reduction in arousal index (AI) (p = 0.02) and increase in total sleep time (p = 0.03), postoperatively. Three patients in the good surgical outcome group showed reduction in apnea–hypopnea index (AHI) from more than five to less than five. There was no significant change either in seizure frequency, self reported clinical parameters or PSG parameters among patients with poor surgical outcome.ConclusionEpilepsy surgery improves subjective sleep parameters in patients with medically refractory epilepsy during the early post operative period. Successful epilepsy surgery may improve objective (PSG documented) sleep quality, sleep architecture and obstructive sleep apnea with resultant reduction in excessive daytime sleepiness.     

Sleep stage distribution in persons with mild traumatic brain injury: a polysomnographic study according to American Academy of Sleep Medicine standards

Objective and backgroundSleep stage disruption in persons with mild traumatic brain injury (mTBI) has received little research attention. We examined deviations in sleep stage distribution in persons with mTBI relative to population age- and sex-specific normative data and the relationships between such deviations and brain injury-related, medical/psychiatric, and extrinsic factors.Patients and methodsWe conducted a cross-sectional polysomnographic investigation in 40 participants diagnosed with mTBI (mean age 47.54 ± 11.30 years; 56% males).MeasurementsAt the time of investigation, participants underwent comprehensive clinical and neuroimaging examinations and one full-night polysomnographic study. We used the 2012 American Academy of Sleep Medicine recommendations for recording, scoring, and summarizing sleep stages. We compared participants' sleep stage data with normative data stratified by age and sex to yield z-scores for deviations from available population norms and then employed stepwise multiple regression analyses to determine the factors associated with the identified significant deviations.ResultsIn patients with mTBI, the mean duration of nocturnal wakefulness was higher and consolidated sleep stage N2 and REM were lower than normal (p < 0.0001, p = 0.018, and p = 0.010, respectively). In multivariate regression analysis, several covariates accounted for the variance in the relative changes in sleep stage duration. No sex differences were observed in the mean proportion of non-REM or REM sleep.ConclusionsWe observed longer relative nocturnal wakefulness and shorter relative N2 and REM sleep in patients with mTBI, and these outcomes were associated with potentially modifiable variables. Addressing disruptions in sleep architecture in patients with mTBI could improve their health status.     

Revisiting the impact of REM sleep behavior disorder on motor progression in Parkinson's disease

BackgroundEstimation of progression in Parkinson's disease (PD) is useful to guide clinical decisions and to enable patients to plan and manage their life with PD. Rapid eye movement (REM) sleep behavior disorder (RBD) and REM sleep without atonia (RWA) are recognized as early harbingers of neurodegeneration and may precede motor symptoms by years. However, their impact on motor progression remains elusive.MethodsWe retrospectively analyzed polysomnographic and clinical data of 59 PD patients, grouping them into patients with RBD (n = 15), RWA (n = 22) and those with normal muscle atonia (n = 22). We compared the three groups with regard to motor progression, defined as changes in Unified Parkinson's Disease Rating Scale (UPDRS) III values per year, and selected PD specific characteristics.ResultsMotor disability at first visit and time interval between first and last visits were similar between groups. We observed a significantly faster motor progression in PD patients with RBD and RWA than in those with preserved REM sleep atonia.ConclusionOur findings suggest that impaired muscle atonia during REM sleep might represent a marker of faster motor progression in PD.     

Sleep architecture in patients with Juvenile Myoclonic Epilepsy

AimThe aim is to analyze the sleep architecture using polysomnography (PSG) in patients with Juvenile Myoclonic Epilepsy (JME): (newly diagnosed and those on valproate drug) attending epilepsy clinic at Alexandria University Hospitals.MethodsThis study involved 20 patients with JME on valproate (age: 22.40 ± 5.80 years; M:F = 6:14), 20 newly diagnosed patients (age: 18.55 ± 6.0 years; M:F = 6:14), and 20 matched healthy controls (age: 22.10 ± 5.0 years; M:F = 6:14). Clinical assessment, electroencephalogram (EEG), evaluation with comprehensive sleep questionnaire, and PSG were done for all patients.ResultsPSG showed significant alterations in sleep architecture in the total JME group in the form of reduced mean sleep efficiency (p = 0.001¹), increased mean Rapid eye movement (REM) onset latency (p = 0.046¹), decrease mean REM percentage (p = 0.011¹), increased mean wakefulness after sleep onset (p = 0.018¹), increase the index of total arousal (p = 0.005¹), increased mean periodic limb movement index (P = 0.001¹), and reduced apnea hypopnea index (P = <0.001) in comparison to control group. Valproate treated group showed increased sleep efficiency (p = 0.040¹), decreased REM arousal index (P = 0.012), longer stage 3 (P = 0.038), and prolonged stage 2 (P = 0.049¹) than the newly diagnosed group.ConclusionsSleep architecture was significantly disturbed in JME, with improvement in sleep efficiency in valproate treated patients.     

Surface EMG activity during REM sleep in Parkinson's disease correlates with disease severity

ObjectivesOver 40% of individuals with Parkinson's disease (PD) have rapid eye movement sleep behavior disorder (RBD). This is associated with excessive sustained (tonic) or intermittent (phasic) muscle activity instead of the muscle atonia normally seen during REM sleep. We examined characteristics of manually-quantitated surface EMG activity in PD to ascertain whether the extent of muscle activity during REM sleep is associated with specific clinical features and measures of disease severity.MethodsIn a convenience sample of outpatients with idiopathic PD, REM sleep behavior disorder was diagnosed based on clinical history and polysomnogram, and severity was measured using the RBD sleep questionnaire. Surface EMG activity in the mentalis, extensor muscle group of the forearms, and anterior tibialis was manually quantitated. Percentage of REM time with excessive tonic or phasic muscle activity was calculated and compared across PD and RBD characteristics.ResultsAmong 65 patients, 31 had confirmed RBD. In univariate analyses, higher amounts of surface EMG activity were associated with longer PD disease duration (srho = 0.34; p = 0.006) and greater disease severity (p < 0.001). In a multivariate regression model, surface EMG activity was significantly associated with RBD severity (p < 0.001) after adjustment for age, PD disease duration, PD severity and co-morbid sleep abnormalities.ConclusionSurface EMG activity during REM sleep was associated with severity of both PD and RBD. This measure may be useful as a PD biomarker and, if confirmed, may aid in determining which PD patients warrant treatment for their dream enactment to reduce risk of injury.     

Total durations of respiratory events are modulated within REM and NREM sleep by sleeping position and obesity in OSA patients

BackgroundSupine sleeping position and obesity are well-known risk factors for obstructive sleep apnea (OSA) and modulate the risk for OSA-related daytime symptoms. Although respiratory event durations are associated with OSA-related severe health consequences, it is unclear how sleeping position, obesity, and daytime sleepiness are associated with respiratory event durations during REM and NREM sleep. We hypothesize that irrespective of the apnea-hypopnea index (AHI), respiratory event durations differ significantly between various OSA subgroups during REM and NREM sleep.MethodsOne night in-lab polysomnographic recordings were retrospectively analyzed from 1910 untreated suspected OSA patients. 599 patients (AHI ≥ 5) were included in study and divided into subgroups based on positional dependency, BMI, and daytime sleepiness (Epworth Sleepiness Scale and Multiple Sleep Latency Test). Differences in total hypopnea time (THT), total apnea time (TAT), and total apnea-hypopnea time (TAHT) within REM and NREM sleep between the subgroups were evaluated.ResultsDuring REM sleep, positional OSA patients had lower THT (OR = 0.952, p < 0.001) and TAHT (OR = 0.943, p < 0.001) than their non-positional counterparts. Compared to normal-weight patients (BMI < 25 kg/m²), obese patients (BMI ≥ 30 kg/m²) had lower THT, TAT, and TAHT (ORs = 0.942–0.971, p ≤ 0.009) during NREM sleep but higher THT (OR = 1.057, p = 0.001) and TAHT (OR = 1.052, p = 0.001) during REM sleep. No significant differences were observed in THT, TAT, and TAHT between patients with and without daytime sleepiness.ConclusionRegardless of the AHI, respiratory event durations vary significantly between OSA sub-groups during REM and NREM sleep. Therefore, to personalize OSA severity estimation the diagnosis should be tailored based on patient's demographics, clinical phenotype, and PSG characteristics.     

Difference in severity of sleep apnea in patients with rapid eye movement sleep behavior disorder with or without parkinsonism

ObjectiveRapid eye movement sleep behavior disorder (RBD) is a common sleep disturbance in patients with neurodegenerative disorders. We aimed to compare sleep parameters among the different types of RBD patients.MethodsA total of 122 patients with dream enactment behavior were screened. Of these, 92 patients who were diagnosed with RBD by polysomnography were included in this study. Enrolled patients with RBD were classified into four groups based on the following diagnoses: idiopathic RBD (iRBD); RBD with Parkinson disease (PD-RBD); multiple system atrophy (MSA) with RBD (MSA-RBD); and dementia with Lewy bodies (DLB) with RBD (DLB-RBD). Various clinical and polysomnographic parameters were compared.ResultsAmong the 92 patients with RBD, 35 had iRBD, 25 had PD-RBD, 17 had MSA-RBD, and 15 had DLB-RBD. The mean apnea−hypopnea index of atypical parkinsonism with RBD (AP-RBD) group was 16.2 ± 17.7 events/h (MSA-RBD, 14.0 ± 16.6; DLB-RBD, 18.8 ± 19.1), which was significantly higher than the other groups (p < 0.05). The proportion of patients with 100% supine sleep in the AP-RBD group (44%) was higher than that in the iRBD group (14%; p = 0.030). The proportion of OSA with 100% supine sleep position was significantly higher in the MSA-RBD and DLB-RBD groups than in the iRBD group (p = 0.042 and p = 0.029, respectively).ConclusionOur study demonstrated that patients in the MSA-RBD and DLB-RBD groups had a tendency to sleeping in the supine position and a higher vulnerability to OSA compared to other RBD groups. Further cohort studies are needed to evaluate the influence of these factors on the development of parkinsonism.     

Effect of carbamazepine on the sleep microstructure of temporal lobe epilepsy patients: a cyclic alternating pattern-based study

BackgroundStudies looking at the effect of anti-epileptic drugs on the sleep microstructure of patients with epilepsy are scarce. The aim of this study was to compare the sleep microstructural characteristics of drug-naive temporal lobe epilepsy (TLE) patients and those on carbamazepine (CBZ) monotherapy.MethodsThree age-matched (p = 0.286) and sex-matched (p = 0.398) groups were studied: drug-naive TLE (n = 20); TLE on CBZ (n = 20); and healthy controls (n = 40). All groups underwent overnight polysomnography. Scoring and analysis of arousals and cyclic alternating pattern (CAP) parameters were performed. Comparison of arousal parameters and CAP parameters was performed using either one-way analysis of variance or the Kruskal−Wallis test, followed by pairwise comparisons (p ≤ 0.05).ResultsRapid eye movement (REM) arousal indices and overall CAP rates were higher in patients with TLE (group 1, p < 0.001; group 2, p < 0.001) compared to controls. Furthermore, the overall CAP rate was higher in patients on CBZ. The CAP cycle/sequences indices (group 1, p < 0.001; group 2, p < 0.001) were higher, and conversely, the average duration of CAP cycles/sequences (group 1, p = 0.018; group 2, p = 0.003) was lower in patients with TLE. Finally, an increase in A2 percentage was noted in patients with TLE (group 1, p = 0.011; group 2, p = 0.011).ConclusionWe found significant alterations in REM arousal indices and CAP parameters in patients with TLE as compared to controls. Moreover, many of these CAP alterations were greater in patients on CBZ. These findings suggest that anti-epileptic drugs such as CBZ may augment arousal instability in patients with TLE, and hence worsen sleep quality and continuity.     

Characteristics of refractory vs. medically controlled epilepsy patients with obstructive sleep apnea and their response to CPAP treatment

Obstructive sleep apnea (OSA) commonly coexists with epilepsy, and treatment of OSA may decrease seizure frequency. However, it is unclear whether patients with medically refractory epilepsy have a higher incidence of OSA compared with well-controlled epilepsy patients and whether the two groups carry different risk factors.PurposeThis study aimed to investigate the presence of OSA in patients with refractory vs. well-controlled epilepsy and their associated risk factors. We also assessed the benefits of treatment of OSA with continuous positive airway pressure (CPAP) in refractory epilepsy patients.MethodsWe retrospectively reviewed data from patients who presented to the Jacobs Neurological Institute Comprehensive Epilepsy Center of University at Buffalo from 2007 to 2010.ResultsThere is a tendency for much higher incidence of OSA in our epilepsy population compared with the general population (15.2% vs. 4.41%). For patients with well-controlled epilepsy, older age, male gender, and higher seizure frequency were predictors of a diagnosis of OSA. However, in medically refractory epilepsy patients, diabetes and snoring predicted a diagnosis of OSA. Treatment of OSA with CPAP in refractory epilepsy patients improved their seizure control (p < 0.02).ConclusionThis study confirms that OSA is common in epilepsy patients and treatment of OSA can improve seizure control in medically refractory cases. Patients with refractory epilepsy who have diabetes are more likely to have OSA.     

Markedly disturbed sleep in medically refractory compared to controlled epilepsy - a clinical and polysomnography study

PurposeTo evaluate sleep disturbances or sleep related events and their characteristics among patients with medically refractory epilepsy, compared to those with controlled epilepsy.MethodsIn a prospective case-controlled study, patients of medically refractory and controlled epilepsy were recruited and history pertaining to epilepsy and sleep related events and Epworth sleepiness scores were recorded and all patients underwent over night polysomnography.ResultsAmong 40 patients, 20 with medically refractory (Group 1) and 20 with controlled epilepsy (Group 2) (median age 18, range 10–35 years), the self reported sleep parameters in Group 1 patients were found to be significantly different as compared to Group 2, in terms of the duration of night time sleep, day time sleep, day time nap frequency, total sleep hours per day, excessive daytime sleepiness (EDS)(45% vs. 15%) and average sleep hours over the week prior to polysomnography. On PSG, Group 1 patients showed significantly less total sleep time [340.4 min (147–673) vs. 450.3 min (330–570)] with delayed sleep latency and REM latency, poor sleep efficiency [80.45 (40.5–98.0) vs. 95.45 (88.4–99.7)] and frequent arousals and wake after sleep onset (WASO) compared to Group 2 patients. Four patients (20%) in Group 1 compared to none in Group 2 were found to have mild obstructive sleep apnea.ConclusionsOur results indicate that medically refractory epilepsy patients believe that they spend more time sleeping, in contrast to the documented shorter sleep duration on polysomnography. This difference between perceived and actual sleep seems, by their data, to arise mainly from sleep fragmentation, disturbed architecture and the interesting finding of associated sleep apnea among the medically refractory epilepsy patients.     

Clinical Considerations of Obstructive Sleep Apnea with Little REM Sleep

MethodsPatients with a chief complaint of sleep-disordered breathing were enrolled. All subjects underwent overnight polysomnography (PSG) and completed questionnaires on sleep quality. Patients were divided into the following three groups according to the proportion of REM sleep detected in overnight PSG: little REM sleep [REM sleep <20% of total sleep time (TST)], normal REM sleep (20–25% of TST), and excessive REM sleep (>25% of TST). Multiple logistic regression analyses were applied to the data. The success rate of continuous positive airway pressure (CPAP) titration was estimated in these groups.ResultsThe age and body mass index of the patients were 47.9±15.9 years (mean±SD) and 25.2±4.1 kg/m², respectively. The 902 patients comprised 684 (76%) men and 218 (24%) women. The apnea-hypopnea index (AHI) in the little-REM-sleep group was 22.1±24.4 events/hour, which was significantly higher than those in the other two groups (p<0.05). Multiple logistic regression showed that a higher AHI (p<0.001; odds ratio, 1.512; 95% confidence interval, 1.020–1.812) was independently predictive of little REM sleep. The titration success rate was lower in the little-REM-sleep group than in the normal-REM-sleep group (p=0.038).ConclusionsThe AHI is higher and the success rate of CPAP titration is lower in OSA patients with little REM sleep than those with normal REM sleep.     

Impact of sleep on the localizing value of video EEG in patients with refractory focal seizures – A prospective video-EEG with EOG and submental EMG study

ObjectivesTo examine the role of sleep and its stages on the localizing value of video EEG in the evaluation of refractory focal seizures.MethodsVideo-electroencephalographic (VEEG) evaluation with additional polygraphic recording was carried out for 70 consecutive patients with refractory focal epilepsy, undergoing pre-surgical evaluation, over a two-year period. Localization of video EEG for each seizure was made based on clinical, ictal and interictal data. Seizure localization in each patient was assessed for concordance with MRI and other imaging data (SPECT, PET) for both wake and sleep seizures. Interictal discharges in sleep and wake were similarly compared for concordance with imaging data.ResultsA total of 608 seizures were recorded in 70 patients, 289 in sleep. Overall, concordance with imaging data was found in 218 out of 322 wake seizures (67.8%) and in 157 out of 286 sleep seizures (54.8%) (p = 0.0314). On analyzing the subset of patients with seizures recorded in both wake and sleep states (total 279 seizures recorded, 113 out of sleep), concordance was observed in 93 out of 166 (56%) wake seizures and in 80 out of 113 (70.7%) sleep seizures (OR 2.03, 95% CI 1.17 to 3.56; p 0.007). Interictal discharges were more common and more precisely localizing in sleep, mostly in stage N2.ConclusionsThis prospective VEEG-PSG study demonstrates the role of sleep versus wake state in the localizing value of different components of long-term VEEG recording for patients with medically refractory epilepsy. Our findings show that while wake state ictal EEG has more localizing value in a mixed group of patients, sleep ictal and interictal EEG is significantly more useful in patients who have seizures recorded both during wake and sleep states. In addition, interictal discharges recorded during NREM sleep have high localizing value.SignificanceThis is only the second study elucidating the effect of sleep on the localizing value of video-electroencephalographic evaluation of patients with medically refractory focal epilepsy; mainly revealing high value of sleep interictal discharges and that sleep ictal recording has two times higher localizing value than wake ictal recording, among patients in whom seizures are recorded in both states.     

Impulse control disorder and rapid eye movement sleep behavior disorder in Parkinson's disease

IntroductionThe relationship between ICD and RBD is still not yet understood and the results from the current literature are contradictory in PD. We aimed to explore the association between rapid eye movement (REM) sleep behavior disorder (RBD) and impulse control disorder in Parkinson's disease.MethodsNinety-eight non-demented patients with Parkinson's disease underwent one night of video-polysomnography recording. The diagnosis of RBD was established according to clinical and polysomnographic criteria. Impulse control disorders were determined by a gold standard, semi-structured diagnostic interview.ResultsHalf of the patients (n = 49) reported clinical history of RBD while polysomnographic diagnosis of RBD was confirmed in 31.6% of the patients (n = 31). At least one impulse control disorder was identified in 21.4% of patients, 22.6% with RBD and 20.9% without. Logistic regression controlling for potential confounders indicated that both clinical RBD (OR = 0.34, 95% CI = 0.07–1.48, P = 0.15) and polysomnographic confirmed RBD diagnoses (OR = 0.1.28, 95% CI = 0.31–5.33, P = 0.34) were not associated with impulse control disorder.ConclusionIn Parkinson's disease, REM Sleep Behavior Disorder is not associated with impulse control disorder. The results of our study do not support the notion that PSG-confirmed RBD and ICD share a common pathophysiology.     

First rapid eye movement sleep periods and sleep-onset rapid eye movement periods in sleep-stage sequencing of hypersomnias

ObjectivesDiscrimination between narcolepsy, idiopathic hypersomnia, and behavior-induced inadequate sleep syndrome (BIISS) is based on clinical features and on specific nocturnal polysomnography (NPSG) and multiple sleep latency test (MSLT) results. However, previous studies have cast doubt on the specificity and sensitivity of these diagnostic tools.MethodsEleven variables of the NPSG were analyzed in 101 patients who were retrospectively diagnosed with narcolepsy with cataplexy (N + C) (n = 24), narcolepsy without cataplexy (N−C) (n = 38), idiopathic hypersomnia with long sleep period (IHL) (n = 21), and BIISS (n = 18).ResultsFifteen out of 24 N + C and 8 out of 38 N−C entered the first rapid eye movement (REM) sleep period (FREMP) from sleep stage 1 (N1) or wake (W), though this sleep-stage sequence did not arise in the other patient groups. FREMP stage sequence was a function of REM sleep latency (REML) for both N + C and N−C groups. FREMP stage sequence was not associated with mean sleep latency (MSL) in N + C but was associated in N−C, which implies heterogeneity within the N−C group. REML also was a useful discriminator. Depending on the cutoff period, REML had a sensitivity and specificity of up to 85.5% and 97.4%, respectively.ConclusionsThe FREMP stage sequence may be a useful tool in the diagnosis of narcolepsy, particularly in conjunction with sleep-stage sequence analysis of sleep-onset REM periods (SOREMPs) in the MSLT; it also may provide a helpful intermediate phenotype in the clarification of heterogeneity in the N−C diagnostic group. However, larger prospective studies are necessary to confirm these findings.     

The influence of placebo administration on the first- night effect in patients with insomnia disorder

ObjectiveWe aimed to investigate the effects of placebo on the first-night effect (FNE) in insomniacs.MethodsIn sum, 36 patients with insomnia disorder who met the DSM-5 criteria were enrolled in this study. Sixteen patients with insomnia disorder were given two days of placebo intervention (placebo-administration group, PL). Twenty patients with insomnia disorder (drug-free group, DF) were not given any interventions. All participants underwent two consecutive nights of polysomnographic (PSG) testing in the sleep laboratory. Sleep diaries were recorded during one week at home before the PSG nights and on two subsequent nights.ResultsThe results demonstrated that compared with the DF group, sleep onset latency (SOL), time in bed (TIB) and wake after sleep onset (WASO) significantly increased and sleep efficiency (SE) significantly decreased in the first sleep lab night in the PL group (all p < 0.05). Moreover, compared with the second night, significant differences were observed in lower self-reported total sleep time (TST) and more subjective WASO during the first night in the PL group (all p < 0.05). However, no significant difference was found in the duration and percentage of N1, N2, N3 and REM between the two groups.ConclusionIn patients with insomnia disorder, placebo administration may increase the occurrence of worse sleep without causing a change in the duration and percentage of N1, N2, N3 and REM on the first sleep lab night. In some cases, a placebo may not serve as treatment but may result in a nocebo effect.     

Effects of an individualized exercise training program on severity markers of obstructive sleep apnea syndrome: a randomised controlled trial

ObjectiveObstructive sleep apnea (OSA) is a high prevalent disorder with severe consequences including sleepiness, metabolic, and cardiovascular disorders. The aim of this study was to assess the effect of an individualized exercise-training (IET) program with educational sessions vs educational sessions alone on severity markers of OSA over an eight-week duration.MethodsThis was a randomised, controlled, parallel-design study. In sum, 64 patients with moderate-to-severe OSA (apnea-hypopnea index AHI 15–45/hour), low physical activity level (Voorrips<9), body-mass index (BMI) <40 kg/m² were included in intervention group (IG) or control group (CG), and 54 patients finished the study. All underwent polysomnography (PSG), multiple sleep latency test (MSLT), constant workload exercise test, blood samples and fulfilled questionnaires twice. The primary endpoint was the change in apnea-hypopnea (AHI) at eight weeks from baseline. Main secondary endpoints were daytime sleepiness assessed by questionnaire and objective tests.ResultsNo significant between-group differences were found for changes in AHI. A reduction in AHI was found in IG only (p = 0.005). Compared to CG, exercise training leads to a greater decrease in AHI during REM sleep (p = 0.0004), with a significant increase in mean daytime sleep latency (p = 0.02). Between-group differences were significant for weight reduction, severity of fatigue, insomnia and depressive symptoms with trend for sleepiness symptoms.ConclusionsIn adult patients with moderate-to-severe OSA, IET did not decrease AHI compared to the control group but improved markers of severity of OSA, in particular AHI in rapid eye movement (REM) sleep and objective daytime sleepiness. Adding personalized exercise training to the management of patients with OSA should be considered.ClinicalTrials.gov identifierNCT01256307.     

Sleep before and after temporal lobe epilepsy surgery

PurposePatients with epilepsy often complain of non-restorative sleep. This is the consequence of the acute effect of seizures and the chronic effect of epilepsy responsible for disrupting sleep architecture. Other factors such as antiepileptic drugs (AEDs), also play a role in the alteration of sleep organization. The aim of this study was to evaluate the specific effect of seizures and interictal epileptiform abnormalities (IEAs) on sleep, in particular to see whether reducing seizure frequency by epilepsy surgery might improve sleep organization in these patients.MethodsEleven patients with refractory mesial temporal lobe epilepsy, who underwent surgical treatment and who were seizure free at the follow-up, were included in the study. Treatment with AEDs was not significantly modified before the second year of follow-up. Patients were evaluated before surgery, at 1-year and 2-year follow-up visits with a videoEEG monitoring (24 h/24). At each follow-up visit, interictal epileptiform abnormalities and sleep macrostructure parameters were assessed.ResultsAll patients showed a reduction of their IEAs. At 1-year follow-up, total sleep time and REM sleep increased significantly (p = 0.032 and p = 0.006, respectively). At 2-year follow-up, an important increase of REM sleep was observed (p = 0.028). Most significant variations were noted 1 year after surgery. No significant variations were observed between the first and the second year after surgery.ConclusionsSurgical treatment of temporal lobe epilepsy may improve sleep macrostructure by reducing the number of seizures and of IEAs. These results indirectly confirm the role of epilepsy in disrupting sleep organization chronically.     

Surgical versus conservative treatment in patients with cerebral cavernomas and non refractory epilepsy

PurposeThe optimal therapy of patients with cerebral cavernoma (CCs) and new onset epilepsy, sporadic seizures, or non well established refractory epilepsy is still not clear. The aim of this study was to compare the incidence of seizures in patients with CCs both operated and non operated, in order to obtain more information on the correct management of these patients.Materials and methodsWe studied retrospectively 43 patients with non refractory epilepsy secondary to CCs. Twenty-six of them (60.5%) underwent surgery and made up the surgical group, and 17 patients were treated medically and constituted the medical group. Seizure frequency and other clinical variables were compared between both groups.ResultsAt two years, out of the 26 operated patients, 19 (73%) remained seizure free, 4 (15%) had less than a seizure per month, and one patient (4%) had more than one seizure per month. At five years, 15 patients of the surgical group remained for analysis. Of them, 11 (73.3%) were seizure free, and 4 (26.7%) had less than one seizure a month. In the medical group, 12 out of 17 patients were seizure free (70.6%). There were no significant differences between the two groups (p = 0.2 and p = 0.3, respectively). Seven patients had postoperative neurological sequelae.ConclusionSurgical treatment of patients with non refractory epilepsy due to CCs did not significantly reduce the likelihood of seizures when compared to medical treatment. It must also be considered that surgery carries serious risks. A prospective and randomized study must be carried out to further clarify our findings.