Psychogenic pseudoepileptic seizures: clinical and electroencephalogram (EEG) video-tape recordings

This paper presents a clinical and electrophysiological analysis of type and duration of seizures recorded by means of long-term video electroencephalogram (EEG) monitoring, a method which enables accurate diagnosis of psychogenic pseudoepileptic seizures occurring with or without epileptic seizures. Analysis is based on 1083 patients, hospitalized at our department between 1990 and 1997, with a preliminary diagnosis of epilepsy. Psychogenic pseudoepileptic seizures were diagnosed in 85 patients (7.8%). In 48 patients, pseudoepileptic seizures alone were diagnosed (group 1), whereas 37 patients had a mixed condition in which pseudoepileptic seizures were accompanied by epileptic seizures (group 2). For comparison of duration of pseudo- and epileptic seizures a control group (group 3), consisting of 55 patients randomly selected from the population of patients suffering from epileptic seizures alone, was parceled out. Long-term video EEG monitoring was performed in 70 patients. In 55 (79%) of these patients 230 seizures (221 pseudoepileptic and nine epileptic) were recorded. In 30 patients (32%), the diagnosis was based on clinical observation of the seizures and on the number of EEG recordings, including activating procedures such as sleep deprivation, photostimulation, hyperventilation and anti-epileptic drug withdrawal. We found that the duration of epileptic seizures was significantly shorter than the duration of psychogenic pseudoepileptic seizures. Our study has exposed the difficulties involved in the diagnosis of psychogenic pseudoepileptic seizures and the negligible value of neuroimaging techniques and interictal EEG recordings in the differential diagnosis of epileptic versus nonepileptic seizures. In this study, psychogenic seizures were significantly more frequent in women than in men; patient history analysis did not confirm the hypothesis that sexual abuse may cause psychogenic seizures.     

Postoperative EEG and Electrocorticography: Relation to Clinical Outcome in Patients with Temporal Lobe Surgery

Summary: To evaluate the role of different EEG methods with respect to postoperative clinical follow-up, 32 non-lesionary epilepsy patients who had undergone temporal lobectomy were studied preoperatively and at 2-week, 3-month, and 1-year postoperative follow-up. Routine, sleep, and sphenoidal EEG recordings as well as intraoperative electrocorticography (ECoG) were made for all patients. At 1-year follow-up, the EEGs with sphenoidal electrodes and with sleep deprivation procedure provided important prognostic information; the appearance of seizures was associated with the presence of interictal epileptiform abnormalities in EEG. In the postresection ECoG, however, epileptiform abnormalities were not associated with clinical outcome or with postoperative epileptiform EEG at 1 year. Routine EEG reliably reflects clinical outcome after temporal lobectomy; with sphenoidal electrodes as well as with sleep deprivation procedure, the diagnostic yield can be further improved.     

Sleep organization in children with partial refractory epilepsy

Although it is currently known that sleep can influence epilepsy and epilepsy can influence sleep organization, few data have been published on this mutual interaction concerning the pediatric population. The objective of this study was to verify the eventual presence of sleep alterations in children with partial refractory epilepsy. Seventeen patients with partial refractory epilepsy were submitted to whole-night polysomnography as part of their epilepsy investigation. Polysomnographic recordings were performed on a digital video-electroencephalography (EEG) system and consisted of the registration of EEG (24 channels), electro-oculogram, electromyogram, electrocardiogram, and nasal airflow and abdominal respiratory movements. Sleep stages were visually scored following standard criteria, and ictal events were classified according to the international classification of seizures. The patients were also subdivided into two subgroups based on the presence or absence of ictal episodes during the recording night. The results concerning sleep organization were compared with those obtained from a normal control group. The analysis of the sleep parameters showed a reduction of total time in bed and total sleep time in both subgroups of epileptic children; there was a higher number of stage shifts per hour in the control group than in both epileptic subgroups. The percentage of stage 2 shifts is significantly reduced in patients with epilepsy and seizures during the night and the percentage of stage 3 to 4 shifts is increased. Nonsignificant differences are evident for the number of awakenings per hour and the percentage of stage 1 shifts. The percentage of rapid eye movement (REM) sleep is reduced, and first REM latency is increased in both epileptic subgroups, compared with normal controls, without statistical significance. Nine of 17 patients had seizures during the polysomnographic recording; nocturnal ictal events occurred mostly during non-REM sleep stage 2. Our results show that patients with partial refractory epilepsies have only mild sleep structure abnormalities, and this can be considered as an effect of the epileptic syndrome per se or as a result of the chronic antiepilepsy drug treatment.     

Postictal SPECT in Epileptic Versus Nonepileptic Seizures

Despite advances in video-electroencephalogram (EEG) technology, in many patients distinguishing epileptic seizures from nonepileptic seizures (NES) remains a challenge. Reliable methods to make this distinction are needed. In a pilot study, we performed postictal and interictal single photon emission computed tomography (SPECT) in 22 patients undergoing video-EEG monitoring who had altered responsiveness during an episode. Eleven had seizures, defined as episodes associated with EEG seizure patterns or postictal prolactin (PRL) elevations greater than 1.5 times the highest interictal baseline PRL; 11 had NES. Among the 11 seizures, postictal SPECT was abnormal in seven (regions of hypoperfusion in six and hyperperfusion in one) and normal in four. In six cases (55%), the interictal and postictal SPECT changed. Among the 11 NES cases, postictal SPECT was abnormal in three cases (all hypoperfusion abnormalities) and normal in eight cases. In no case did the interictal and postictal SPECT change. This small sample revealed a trend toward greater hypometabolism (postictal versus interictal) on SPECT for epileptic seizures compared to NES (p < 0.12). There were postictal SPECT changes in two of five seizures unassociated with postictal PRL elevation. Prolactin was elevated in two cases unassociated with change on SPECT. Comparision of postictal to interictal SPECT may help distinguish epileptic seizures from NES. Results from SPECT may also help identify epileptic seizures unassociated with PRL elevation.     

Discriminatory Effect of Cyclic Alternating Pattern in Focal Lesional and Benign Rolandic Interictal Spikes During Sleep

Twenty epileptic patients (10 male and 10 female) were polygraphically recorded during nocturnal sleep. Ten subjects, with a wide age range, were affected by focal lesional epilepsy, and 10 were children affected by benign epilepsy with rolandic spikes (BERS). In five cases a bihemispheric expression of the focal lesional bursts emerged occasionally during the night recordings. The behavior of interictal electroencephalographic (EEG) paroxysms were analyzed with respect to the two arousal states of non-rapid-eye-movement (REM) sleep: (a) the cyclic alternating pattern (CAP), expressed by biphasic EEG periodic activities and related to long-lasting fluctuations between greater (phase A) and lesser (phase B) arousal levels; and (b) the non-CAP (NCAP), manifested by EEG stationarities that reflect a sustained relative stability of arousal. The CAP/NCAP modality affected the spiking activity and distribution of the focal lesional EEG paroxysms, which appeared enhanced during CAP and which were mostly collected in phase A. The even more powerful influence of CAP and especially phase A on the secondary bisynchronous bursts suggests a crucial integration among thalamocortical circuits, arousal modulation, and epileptic generalization mechanisms. Conversely, in the BERS recordings no significant differences emerged throughout CAP and NCAP. The intense activity of the rolandic foci induced by sleep as such could be explained on the basis of the greater dependence of these functional cortical EEG abnormalities on the degree of synchronization during sleep.     

Sleep Grand Mal—All-Night Polygraphic EEG Recordings in 20:Cases

Abstract: All-night polygraphic EEG recordings were carried out in 20 :epileptic patients who are characterized as follows; 1) clinical attacks took the form of generalized tonic-clonic seizure (GTCS), which occurred only or at least 90% during sleep without other seizure types in awakening, 2) no epileptic discharges were revealed in routine EEG examinations, also including sphenoidal electrode deriving during daytime, 3) recognizable organic brain damage in these patients had been excluded by neurological examinations and CT-scan. Interictal records showed epileptiform abnormalities in 5 :of the 20 :patients, which were all related with NREM sleep. Four patients exhibited bilateral synchronous paroxysms of 3–3.5 Hz spike-wave short burst and only one patient had temporal-localized discharges. The results of this study demonstrated that although there was a difference compared with other reports, the most characteristic features seen in our patients diagnosed as idiopathic generalized epilepsy (ICE) were as follows: 1) less frequent SGM seizures within a year, 2) SZ onset around teen age, 3) seizures were easily evoked by some precipitating factors and 4) no recognizable organic lesions. As a conclusion, patients with an uncertain or unknown type of epilepsy should always be examined with sleep recordings and all-night sleep recordings if necessary.     

Understanding Lennox–Gastaut syndrome: insights from focal epilepsy patients with Lennox–Gastaut features

To delineate the clinical and EEG features of adults with focal epilepsy associated with a generalized paroxysmal fast activity (GPFA) pattern on EEG who developed refractory seizures, notably drop attacks, but do not fulfill the classical triad for the diagnosis of Lennox–Gastaut syndrome (LGS) and provide further insight into LGS mechanisms. Among 957 patients admitted to video-EEG monitoring between 2002 and 2015, we retrospectively research adult patients with refractory focal epilepsy, drop attacks and GPFA on EEG. We collected demographic, anamnestic, and clinical data from medical records. We reviewed for all patients the interictal and ictal video-EEG recordings. We identified ten patients with focal epilepsy and electro-clinical features of LGS. As compared to classical LGS patients, our patients: (1) began epilepsy later (15.4 ± 8 years); (2) exhibited exclusively focal onset seizures, including drop attacks seizures linked to focal asymmetrical tonic posturing seizures; (3) had a stable cognition over time and (4) evolved favourably with a good secondary response to treatments in 80% of cases. Interestingly, all patients exhibited apparent diffuse interictal and ictal EEG abnormalities but a detailed analysis revealed that 50% had asymmetrical GPFA and 70% secondary bilateral synchrony processes. We may hypothesize here that a process of “secondary LGS” occurred which produced a worsening of seizures with the apparition of drop attacks and GPFA on EEG. This study brings arguments to consider that some cases of LGS could be linked to the development of a “secondary epileptic network” driven by a primary focal epileptic zone.     

Adult epileptic spasms: a clinical and video-polygraphic study.

PURPOSE: To analyse the video-polygraphic features of two patients with adult epileptic spasms (ES). METHODS: Two patients with epileptic encephalopathy related to different cortical malformation; epileptic spasms had been present since the age of 18 and 25 years respectively. The patients underwent a clinical and neurophysiological examination (awake and sleep video-polygraphic monitoring). RESULTS: In patient 1, epileptic spasms were characterized by loss of contact and a drooping forward of the head and upper extremities. ES were in clusters, of brief duration, lasting for 20'-1'; all events occurred during eating. Awake and sleep interictal EEG disclosed asynchronous paroxysmal abnormalities in the temporo-parieto-occipital regions. The ictal EEG showed a diffuse slow wave complex with intermingled fast activity, prevalent on both anterior regions; on polygraphic recordings, the prevalence of the muscle activation, in crescendo-decrescendo, was in the neck and the right side. In patient 2, ES were characterized by loss of awareness, head deviation to the left, jerks of the head and left limbs. ES occurred in cluster, and were of brief duration (< 1"), usually on awakening. Interictal EEG showed epileptiform abnormalities in the right fronto-centro-temporal regions; abnormalities present in the awake EEG were enhanced during NREM sleep. The ictal EEG showed a diffuse, slow wave complex with intermingled fast activity, prevalent in the right regions, with concomitant muscle activation, in crescendo-decrescendo, on the left deltoid and tibialis anterior. CONCLUSIONS: Our two cases of adult ES were characterized by distinct clinical and polygraphic features, which were of brief duration, mild intensity, rare frequency per minute, and with preservation of cluster organization. In one patient, ES were induced by eating (reflex periodic spasms triggered by eating). A firm diagnosis of adult ES can be reached using video-polygraphic monitoring.     

Movement disorders in sleep: guidelines for differentiating epileptic from non-epileptic motor phenomena arising from sleep

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.     

Benign partial epilepsy in infancy and early childhood with vertex spikes and waves during sleep: a new epileptic form

International epilepsy classification includes different epileptic syndromes with favourable outcomes in paediatric age, both partial and generalised. This is true in childhood while no partial benign forms are accepted in infancy. In 1987, Watanabe first described a new entity and he defined it as 'benign complex partial epilepsies in infancy'. In 1992, Vigevano referred similar but familial cases whose seizures had secondary generalisation. Both these forms had no interictal EEG abnormalities neither awake nor during sleep. This article presents a survey of 12 cases of partial epilepsy with favourable outcome differing from Watanabe and Vigevano's cases, both for the presence of interictal EEG abnormalities only during sleep and for seizure picture. All our patients are neurologically and neuroradiologically normal. Psychomotor development is unremarkable. Age onset range is 13-30 months. All cases present characteristic spikes and waves during slow-sleep in vertex cerebral areas. Awake EEG is always normal, at follow-up too. Our cases have such homogeneous electroclinical features as to hypothesise a new partial idiopathic epileptic syndrome with favourable outcome in infancy and early childhood. We propose to define it as 'benign partial epilepsy in infancy and early childhood with vertex spikes and waves' (BVSE).     

Epileptic spasms without hypsarrhythmia showing astatic seizures in clusters

It is difficult to differentiate astatic seizures among atonic, myoclonic and tonic seizures without the help of ictal polygraphic recordings. We described a girl with epilepsy presenting periodic astasia caused by epileptic spasms. Her seizures had occurred in clusters since 1-year and 7-month of age. Her interictal electroencephalogram (EEG) showed intermittent diffuse (poly) spike (s) and wave discharges, without a trace of hypsarrhythmia. She had a diagnosis of epilepsy with myoclonic-astatic seizures at a previous hospital, and her seizures had been resistant to multiple antiepileptic agents. After she was referred to our hospital, the ictal video-EEG recordings were made before and after ACTH administration, which revealed that her astatic seizures were epileptic spasms with presumed cortical origin. We should carefully evaluate the astatic seizures during early childhood which may be an atypical presentation of epileptic spasms.     

额叶癫痫发作录像脑电图特点分析

目的通过录像脑电图观察额叶癫痫的临床特征、发作期及发作间歇期的脑电图特点。方法使用录像脑电图（ｖｉｄｅｏＥＥＧ,ＶＥＥＧ）对５０例确诊为额叶癫痫的患者进行常规及长时间记录,对其中１７例（２０次）癫痫发作的临床表现及脑电图所见进行分析。结果额叶癫痫常见的发作形式有：姿势性发作,具有额叶癫痫特点的自动症;复杂部分性发作时伴发声、偏转或表情的变化,有时出现发作性情绪改变或强迫思维等少见症状。其发作特点为：持续时间短,发作相对较频繁,无明显发作后意识障碍。发作间歇期脑电图有时可无阳性所见,典型的临床发作及发作时ＶＥＥＧ记录到的额部爆发性节律有助于诊断。本组９例儿童期起病的额叶癫痫患者,以夜间频繁的躯体自动症发作为主,检查均未发现相应的脑器质性病变。脑电图睡眠描记可见频繁的额部导联癫痫样放电。临床治疗观察预后良好,提示可能为一组儿童原发性部分发作型癫痫综合征。结论额叶癫痫是一组较为特征性的癫痫综合征,临床并不少见,及时而正确的诊断有助于治疗。     

Long-term outcome of epilepsy in Kabuki syndrome

Purposes and methods

Kabuki syndrome (KS) is a rare dysmorphic disorder characterized by multiple congenital anomalies and mental retardation. Although epilepsy is one of the most common clinical complications associated with KS, few studies have evaluated its electroclinical aspects and long-term outcome. Therefore, we describe here a clinical series of 10 Caucasian KS patients who developed epilepsy in childhood. We followed all children for at least 5 years.

Results

All patients presented partial seizures and interictal EEGs revealed focal epileptic paroxysms with prevalent involvement of temporo-occipital areas. Seven children had no central nervous system abnormalities, but enlargement of lateral ventricles, corpus callosum hypoplasia, and adenohypophysis hypoplasia were revealed in three. Although antiepileptic drug (AED) treatment was effective in controlling seizures and normalizing EEG abnormalities in 8 patients, the other 2 cases were resistant to multiple AEDs. In one of these two patients, withdrawal of AED resulted in status epilepticus and death.

Conclusions

Partial seizures and temporo-occipital abnormalities on interictal EEG are common features of KS patients who suffer from epilepsy. Prognosis of this epilepsy is favourable in the majority of cases with complete disappearance of seizures and EEG abnormalities.     

Ictal and interictal EEG abnormalities in ADHD children recorded over night by video-polysomnography

In this paper we explore the prevalence of ictal and interictal epileptiform discharges (IEDs) and sleep disorders in ADHD children referred to a sleep clinic for all night video-PSG. Forty-two ADHD outpatients (35 males and 7 females) underwent video-PSG and a behavioural/neuropsychological assessment. Spearman correlation coefficients (p<0.05 criterion level) were used to assess the association between cognitive, behavioural, clinical (co-morbidity), sleep (sleep efficiency) and EEG (seizures, IEDs, localization of IEDs foci) variables. Sleep disorders were found in 86% of ADHD children; among these, 26% had RLS. 53.1% of ADHD children had IEDs (28.2% centro-temporal spikes, 12.5% frontal spikes, 9.3% temporal-occipital spikes and 2.3% generalized S-W). Nocturnal seizures were recorded in three patients: two with atypical interictal rolandic spikes and one with left frontal slow abnormalities. A significant relationship (p<0.05) emerges between nocturnal seizures and WISC-R IQ score and visual-spatial memory test and between some cognitive variables and interictal rolandic spikes. High levels of inattention, impulsivity/hyperactivity and oppositional behaviours were related (p<0.01 or 0.05) with Restless Leg Syndrome diagnosis. In conclusion, ADHD is a condition often associated with EEG epileptiform abnormalities. Seizures/IEDs presence seems to play a role on cognitive abilities, conversely sleep disorders have a stronger impact on behavioural rather than cognitive indicators.     

Occipitotemporal Epilepsies: Evaluation of Selected Patients Requiring Depth Electrodes Studies and Rationale for Surgical Approaches

Summary: In 8 patients in whom it was uncertain whether they had occipital or temporal lobe (TL) epilepsy, clinical, scalp EEG, and radiologic features were correlated with the sites of seizure onset as determined by depth EEG. The 8 patients were selected from >40 with occipital epilepsy because they had (a) an aura considered to be of occipital lobe (OL) origin, (b) an occipital interictal epileptic focus, (c) an OL lesion, or (d) a combination of all of these. Scalp EEG and clinical patterns suggested temporal involvement in all, however. Extracranial EEG recordings were often misleading, showing multilobar interictal epileptic abnormalities, and seizure onset was of poor localizing value and did not clarify the problem sufficiently. Intracranial EEG recordings showed that seizure onset could be ordered along an Occipitotemporal gradient. Consistent OL seizure onset was observed in patients who had only elementary visual auras. Those who had inconsistent aura or no aura, suggesting OL origin, had onset of most attacks in the TL. All patients had a seizure spread pattern suggesting early TL involvement. To prevent visual field defect, surgical approaches included temporal resection when temporal seizure origin or spread was demonstrated; although occasionally this produced excellent results, it was of limited benefit in most patients, even when some seizures were proven to originate in TL structures. In patients with malignant epilepsy and in those with an occipital lesion, occipital resection should be considered.     

Periventricular nodular heterotopia: classification, epileptic history, and genesis of epileptic discharges

PURPOSE: Periventricular nodular heterotopia (PNH) is among the most common malformations of cortical development, and affected patients are frequently characterized by focal drug-resistant epilepsy. Here we analyzed clinical, MRI, and electrophysiologic findings in 54 PNH patients to reevaluate the classification of PNH, relate the anatomic features to epileptic outcome, and ascertain the contribution of PNH nodules to the onset of epileptic discharges. METHODS: The patients were followed up for a prolonged period at the Epilepsy Center of our Institute. In all cases, we related MRI findings to clinical and epileptic outcome and analyzed interictal and ictal EEG abnormalities. In one patient, EEG and stereo-EEG (SEEG) recordings of seizures were compared. RESULTS: We included cases with periventricular nodules, also extending to white matter and cortex, provided that anatomic continuity was present between nodules and malformed cortex. Based on imaging and clinical data, patients were subdivided into five PNH groups: (a) bilateral and symmetrical; (b) bilateral single-noduled; (c) bilateral and asymmetrical; (d) unilateral; and (e) unilateral with extension to neocortex. The latter three groups were characterized by worse epileptic outcome. No differences in outcome were found between unilateral PNH patients regardless the presence of cortical involvement. Interictal as well as ictal EEG abnormalities were always related to PNH location. CONCLUSIONS: The distinctive clinical features and epileptic outcomes in each group of patients confirm the reliability of the proposed classification. Ictal EEG and SEEG recordings suggest that seizures are generated by abnormal anatomic circuitries including the heterotopic nodules and adjacent cortical areas.     

Dreams and Epilepsy

The relationship between dreams and epilepsy is illustrated by two patients whose awake epileptic seizures and recurrent dreams during night sleep had similar content. In both of our cases the EEG showed right anterior temporal spike discharge, suggesting a role for the temporal lobe in the association between dreams and seizures.     

Nap polygraphic recordings after partial sleep deprivation in patients with suspected epileptic seizures.

A review of the literature shows that nap recordings make a significant contribution to epilepsy studies, providing evidence of specific EEG findings in patients suspected of having epilepsy. In addition, sleep deprivation can cause paroxysmal EEG activity and clinical seizures. We studied retrospectively 686 patients, 51.8% males and 48.2% females, who had experienced at least one episode classified from the clinical point of view as epileptic in origin. They were divided into six age groups. Patients underwent a two-hour (1 P.M.-3 P.M.) nap-video-polygraphic recording (EEG 13 channels using the standard 10-20 system, EOG, ECG, EMG and respiration), following a partial sleep deprivation (1 to 3 h) the night before. A second recording was made in 40 patients. In 35.3% of patients, a complete sleep cycle was obtained; in 64.6% sufficient light and deep NREM sleep was obtained, but not REM stage; in 9.3%, we only observed drowsiness and stage 1 of sleep, and this group was excluded from the analysis. Interictal and/or ictal epileptic discharges were observed during the first nap recording in 245 patients (40.4% of the sample). In addition, in 40 patients (11%) with normal or inconclusive first nap EEG, a second recording was able to demonstrate epileptic abnormalities in 35% of cases. Because of its good cost/benefit ratio and availability in most western laboratories, we consider the 'nap plus partial sleep deprivation' method as advantageous over other activation procedures.     

Localizing value of rapid eye movement sleep in temporal lobe epilepsy

Sleep state is a physiological modulator of epilepsy. Non rapid-eye-movement (NREM) sleep generally increases interictal epileptiform discharges (IEDs) and expands their field of distribution. In contrast, rapid eye movement (REM) sleep tends to suppress IEDs and may limit their spread outside of the region of primary seizure origin. The ability of REM sleep to restrict IEDs may have localizing value in temporal lobe epilepsy patients undergoing evaluations for epilepsy surgery. We present the case of a woman with medically-refractory seizures secondary to a mesial temporal glioma. Although scalp and intracranial electroencephalographic (EEG) seizure recordings supported bilateral epileptic foci, the IEDs recorded during REM sleep were restricted to the region of the glioma, and the patient had a successful surgical outcome. Our findings support the usefulness of combining sleep recordings with EEG monitoring in the evaluation of candidates for epilepsy surgery.     

Hypnogenic paroxysmal dystonia: a new type of parasomnia?

Four cases of hypnogenic paroxysmal dystonia are described. The patients (three males and one female), aged between 12 and 39 were subjected to neurological, physical and psychological examination, and routine lab tests and brain CT scan were carried out within normal limits. One of the patients suffered from diurnal epileptic seizures. Repeated EEG recordings during wakefulness were normal. During polysomnographic and TV recordings the patients showed different types of dystonic fits occurring several times a night, always brief, and starting during NREM sleep. Carbamazepine therapy proved to be relatively effective in three subjects.