Isolated paroxysmal arousals as focal epilepsy.

Paroxysmal motor phenomena and arousals during sleep are frequent. The differential diagnoses between benign hypnic transient events, epileptic and non-epileptic seizures represent a common clinical problem. Video-EEG monitoring during sleep, recording several episodes in the same patient, is essential in order to characterize these phenomena. It offers the possibility to compare electro-clinical data, to demonstrate the eventual stereotyped pattern of motor phenomena and their progression in time, and to study EEG-polygraphic correlates. The recently described double split-screen synchronized display (DSSSD) technique represents a useful tool for comparing particular clinical patterns of epileptic seizures when dealing with complex, hypermotor phenomena observed in frontal lobe epilepsy. We reviewed the data of 24 patients admitted during a two-year period (2002-2003) to our epilepsy sleep unit for isolated paroxysmal sleep motor events. Four patients presented with very brief paroxysmal arousals without daytime fits. Three of our patients presented isolated paroxysmal arousals, whereas in one, the events were associated with hypermotor seizures. We present a simplified variant of the DSSSD method (modified DSSSD) that can be used to study episodes of paroxysmal arousals in order to confirm their stereotyped motor pattern. The clinical aspects and the EEG-polygraphy patterns were informative, with the absence of asymmetrical tonic or dystonic posturing of the limbs. Scalp EEG alone does not usually provide much information in patients with isolated paroxysmal arousals. Coupled to the modified DSSSD technique, it may allow confirmation of the diagnosis of frontal epilepsy, as was the case in our four patients. [Published with video sequences].     

Sleep-related hypermotor seizures in aspartylglucosaminuria: A case report

From the age of 24 years a young man with a definitive diagnosis of aspartylglucosaminuria (AGU) presented short-lasting sleep-related paroxysmal events characterized by sudden awakening with a frightened look, hyperventilation, and complex bilateral motor activity. Nocturnal video-polysomnography recorded several events consistent with a diagnosis of hypermotor epileptic seizures. This pattern of sleep-related epileptic seizures has been reported in rare familial cases, more often in cryptogenic and symptomatic patients in the spectrum of nocturnal frontal lobe epilepsy. Epilepsy and sleep-related nonepileptic problems are common in patients with AGU, but no case of hyperkinetic nocturnal frontal lobe seizures has been reported to date. Differential diagnosis of abnormal paroxysmal motor events in sleep is frequently a challenge for the clinician: Video-polysomnographic recordings might serve to identify the possible epileptic origin of some of the excessive motor activities during sleep referred in patients with AGU.     

Prise en charge d’une première crise épileptique de l’adulte : peut-on prévoir l’avenir ?

The new definition of epilepsy recently proposed by an international panel of experts relies on the association of a first clinically certain seizure and of an enduring predisposition of the brain increasing the likelihood of future seizures. In the first part of this review, we will expose and organize into a hierarchical order the risk factors of subsequent recurrence. The major factors are: seizure(s) prior to presentation, paroxysmal abnormalities on early EEG, a remote symptomatic etiology. In the second part of this review, we will address the issue of clinical uncertainty when assessing the epileptic origin of a first clinical paroxysmal event, the reasons of uncertainty and the means to minimize it. We will analyze successively: the accuracy of eyewitness observations of transient loss of consciousness, the reliability and predictive validity of clinical criteria used for seizure assessment, the issue of overlapping clinical features between seizure and other non epileptic paroxysmal events (such as psychogenic non epileptic seizures), and finally the reliability and diagnostic value of early EEG for seizure assessment. To conclude, seizure assessment and diagnosis of epilepsy cannot be dissociated from syndrome and etiology diagnosis, which should be periodically reassessed towards a greater accuracy during the course of the disease.     

Epilepsy and narcolepsy-cataplexy in a child

We report a 5-year-old boy with epilepsy and narcolepsy-cataplexy. He developed myoclonic seizures at the age of 4 years, which manifested as head shaking to the left. Approximately 6 months later, narcolepsy-cataplexy with excessive daytime sleepiness occurred. Although a short-time electroencephalography (EEG) and 24-hour ambulatory EEG monitoring found epileptiform discharges, no seizures were determined. Oxcarbazepine was used and led to increased attacks. Video EEG testing finally confirmed the diagnosis of epilepsy; therefore, valproate was given and seizures were controlled completely. Typical cataplexy triggered by laughing, together with the positive multiple sleep latency tests confirmed a diagnosis of narcolepsy-cataplexy. Human leukocyte antigens DQB1*0602 was positive, and the hypocretin level in cerebrospinal fluid was found to be decreased. Combination of valproate, methylphenidate, and clomipramine treatment improved the symptoms of both narcolepsy-cataplexy and seizure. The coexistence of both disorders in this single patient indicated that there might be a common mechanism between epilepsy and narcolepsy-cataplexy.     

Seizures and epilepsy in elderly patients of an urban area of Iran: clinical manifestation, differential diagnosis, etiology, and epilepsy subtypes

The incidences of seizures and epilepsy in the population show a peak after 60 years of age. Due to the lack of reported clinical aspects of seizure and epilepsy in the older patients in our region in Iran, this study was conducted to describe the clinical manifestation, etiology, differential diagnosis, and epilepsy subtypes of epilepsy and seizure. A cross-sectional retrospective study was performed on all consecutively elderly seizure and epilepsy patients, referred to the Epilepsy Association in the city of Qom, Iran over a 10-year period. A total of 466 patients aged >60 years were admitted. 31 % of the patients had epilepsy or seizure and 69 % of them had non-epileptic events. The most prevalent differential diagnoses in the beginning were syncope and cardiovascular disorders. The most frequent clinical symptom of epilepsy was generalized tonic–clonic seizures (75 %). The most common cause of seizure was systemic metabolic disorder (27 %). In epileptic elderly patients, no cause was ascertained for 38 % and the most frequently observed pathological factors were cerebrovascular diseases, which accounted for 24 %. The most common type of epileptic seizure was generalized epileptic seizures (75 %). 10 % of elderly epileptic patients suffered from status epilepticus, which was primarily caused by anoxia. Despite the rising rate and potentially profound physical and psychosocial effects of seizures and epilepsy, these disorders have received surprisingly little research focus and attention in Iran. Referring older patients to a specialist or a specialist epilepsy center allows speedy assessment, appropriate investigation and treatment, and less likely to miss the diagnosis.     

Two cases of childhood narcolepsy mimicking epileptic seizures in video-EEG/EMG

Narcolepsy is characterized by excessive sleepiness, hypnagogic hallucinations, and sleep paralysis, and can occur with or without cataplexy. Here, we report two children with narcolepsy presenting with cataplexy mimicking epileptic seizures as determined by long-term video-electroencephalography (EEG) and electromyography (EMG) monitoring.Case 1 was a 15-year-old girl presenting with recurrent episodes of “convulsions” and loss of consciousness, who was referred to our hospital with a diagnosis of epilepsy showing “convulsions” and “complex partial seizures”. The long-term video-polygraph showed a clonic attack lasting for 15?s, which corresponded to 1–2?Hz with interruption of mentalis EMG discharges lasting for 70–300?ms without any EEG changes. Narcolepsy was suspected due to the attack induced by hearty laughs and the presence of sleep attacks, and confirmed by low orexin levels in cerebrospinal fluid (CSF). Case 2 was an 11-year-old girl presenting with recurrent episodes of myoclonic attacks simultaneously with dropping objects immediately after hearty laughs, in addition to sleep attacks, hypnagogic hallucinations, and sleep paralysis. The long-term video-polygraph showed a subtle attack, characterized by dropping chopsticks from her hand, which corresponded to an interruption of ongoing deltoid EMG discharges lasting 140?ms without any EEG changes. A diagnosis of narcolepsy was confirmed by the low orexin levels in CSF.These cases demonstrate that children with narcolepsy may have attacks of cataplexy that resemble clonic or myoclonic seizures.     

Narcolepsy: clinical approach to etiology, diagnosis, and treatment

Narcolepsy is a neurologic disorder characterized by excessive daytime sleepiness and manifestations of disrupted rapid eye movement sleep stage. The pathologic hallmark is loss of hypocretin neurons in the hypothalamus likely triggered by environmental factors in a susceptible individual. Patients with narcolepsy, in addition to excessive daytime sleepiness, can present with cataplexy, sleep paralysis, sleep fragmentation, and hypnagogic/hypnopompic hallucinations. Approximately 60% to 90% of patients with narcolepsy have cataplexy, characterized by sudden loss of muscle tone. Only 15% of patients manifest all of these symptoms together. Narcolepsy can be misdiagnosed as a psychiatric disorder or even epilepsy. An appropriate clinical history, polysomnogram, Multiple Sleep Latency Test, and, at times, cerebrospinal fluid hypocretin levels are necessary for diagnosis. The treatment of narcolepsy is aimed toward the different symptoms that the patient manifests. Excessive daytime sleepiness is treated with amphetamine-like or non-amphetamine-like stimulants. Cataplexy is treated with sodium oxybate, tricyclic antidepressants, or selective serotonin and norepinephrine reuptake inhibitors. Sleep paralysis, hallucinations, and fragmented sleep may be treated with benzodiazepine hypnotics or sodium oxybate. Patients with narcolepsy should avoid sleep deprivation, sleep at regular hours, and, if possible, schedule routine napping.     

Use of modafinil in patients with epilepsy

Fatigue and excessive daytime sleepiness are common symptoms in patients with neurological injury. Modafinil has been shown to ameliorate these symptoms, but its use in patients with seizures has been limited because of safety concerns. Using a large centralized clinical registry, we performed a retrospective chart review of patients with a diagnosis of epilepsy who were given modafinil over a 10-year period. A total of 205 patients were analyzed. There were 91 patients who had seizures while taking modafinil; there was no relationship between modafinil dosage and whether the patient had seizures. There were 6 patients in whom modafinil was discontinued because of concern for seizure exacerbation, and 4 patients had de novo seizures after starting modafinil. In 29 patients with epilepsy only, no major seizure exacerbation was seen. Modafinil is potentially safe in patients with epilepsy, but further prospective studies are needed to fully determine its safety and efficacy.     

Diagnostic inaccuracy in children referred with "first seizure": role for a first seizure clinic

PURPOSE: To determine (a) the range of diagnoses, and (b) the prevalence of previous seizures in children presenting to a first seizure clinic. METHODS: One hundred twenty-seven children were seen in a tertiary care First Seizure Clinic. Inclusion criteria were age 1 month-17 years with an unprovoked event suggestive of seizure. Data collected included referring physician specialty, child's age, gender, developmental status, and clinical diagnosis of epileptologist (nonepileptic vs. epileptic). For those with epileptic events, seizure type, syndrome (if identifiable), presumed etiology (idiopathic, cryptogenic, and symptomatic), presence of prior afebrile and febrile seizures, provoking factors, family history, pre/perinatal complications and EEG results were recorded. RESULTS: The diagnosis was epileptic in 94 (74%), nonepileptic in 31 (24%) and unclassifiable in two (2%). Pediatricians were more likely to refer true epileptic events (92%) than ED physicians (76%) or family physicians (65%). Mean age at presentation was 8 years. Fifteen percent of children were developmentally delayed and neurological examination was abnormal in 11%. For those diagnosed with epileptic events, 32 presented with generalized while 62 presented with partial onset seizures. An epilepsy syndrome was identifiable in 15 cases. Thirty-eight percent experienced a prior probable seizure which was recognized by the referring physician in only one case. An EEG was done in all children with seizures and was abnormal in 41%. Early EEG was performed in 20% of children and did not show statistical significance. CONCLUSIONS: Diagnostic inaccuracy is common in first seizure. One quarter of children were incorrectly diagnosed as having a seizure while the diagnosis of epilepsy was missed in over one-third of children.     

Epilepsy and obstructive sleep apnea

A few publications documented the coexistence of epilepsy and obstructive sleep apnea (OSA). The extent, nature, and clinical relevance of this association remain poorly understood. We retrospectively reviewed the database of our sleep center to identify patients with both sleep apnea and epilepsy. Characteristics of epilepsy, sleep history, presence of excessive daytime sleepiness [Epworth Sleepiness Scale (ESS)] and polysomnographic data were assessed. The effect of continuous positive airway pressure (CPAP) on seizure reduction was prospectively analyzed after a median interval of 26 months (range: 2-116 months) from the diagnosis of OSA. OSA was found in 29 epilepsy patients (25 men and 4 women) with a median age of 56 years (range: 37-79). The median apnea hypopnea index was 33 (range: 10-85), the oxygen desaturation index was 12 (range 0-92), and 52% of the patients had an ESS score >10. In 27 patients, epilepsy appeared 1 month to 44 years prior to the diagnosis of OSA. In 21 patients, the appearance of OSA symptoms coincided with a clear increase in seizure frequency or the first appearance of a status epilepticus. Treatment with CPAP was continued with good compliance in 12 patients and led to a significant reduction of both ESS scores and seizure frequency in 4 patients. Our data suggest the importance of considering diagnosis and treatment of OSA in epilepsy patients with poor seizure control and/or reappearance of seizures after a seizure-free interval.     

长程视频脑电监测对癫痫间的诊断价值

目的 评价长程视频脑电图对癫痫间等发作性疾病的诊断价值,提高癫痫间及癫痫间综合征的诊断。方法 对在本院神经内科癫痫间中心门诊及住院患者中首次以发作性疾病就诊的患者进行不同时程的视频脑电图监测,对其临床资料进行回顾性分析。结果 24 h组视频脑电监测对癫痫间异常脑波放电的阳性检出率较高(76.9%),8 h组最低(30.1%),15 h组介于两者之间(55.4%),在24 h组1920例患者中有1476例有异常放电,287例记录到临床同步发作,其中153例明确癫痫间发作类型,153例中96例进一步明确为癫痫间综合征,使对癫痫间的分型及癫痫间综合征的分类更加明了细化。结论 24 h视频脑电监测能够显著提高癫痫间患者的诊断率及异常脑波的检出率,有效地降低了假阴性率并且在癫痫间的鉴别诊断、分型及癫痫间综合症的诊断方面有重要的临床意义,同时对其他发作性疾病的鉴别提供了可靠的的临床依据。     

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.     

Concepts of Epilepsy

Summary: The word “epilepsy” refers to a group of disorders characterized by recurrent epileptic seizures. Differential diagnosis first requires distinction between epileptic seizures and the many systemic, neurologic, and psychiatric disorders associated with paroxysmal behaviors that might be mistaken for epilepsy. By definition, isolated epileptic seizures that occur as a natural reaction to a noxious insult are not sufficient evidence for a diagnosis of epilepsy. Many factors contribute to the appearance of an epileptic condition, including nonspecific predisposing factors that alter the threshold for epilepsy and specific epileptogenic disturbances that cause chronic epilepsy to become manifest in susceptible individuals, both of which can be either genetic or acquired. Endogenous or exogenous precipitating factors determine when specific ictal events occur. The many clinical expressions of epileptic seizures reflect the location and extent of the cerebral disturbance, as well as diverse fundamental mechanisms that involve alterations of excitatory and inhibitory influences, resulting in hyperexcitability, hypersynchronization, or both. The various forms of epilepsy and epileptic syndromes are defined by a constellation of signs and symptoms that include characteristic seizure types, other clinical features, and family history. Whereas treatment is largely based on seizure type, identification of a specific epileptic syndrome often provides additional insights into management and prognosis. An example of the usefulness of syndromic classification is the existence of surgically remediable syndromes that have a known poor prognosis with pharmacotherapy, but an excellent prognosis with surgical intervention. Research on underlying basic mechanisms of the epilepsies, particularly molecular genetics designed to identify specific biological defects in idiopathic epilepsies and invasive investigations carried out in the epilepsy surgery setting to elucidate the pathophysiology of symptomatic epilepsies, may reveal definitive substrates that will ultimately permit epileptic syndromes to be reclassified as diseases.     

1例发作性睡病的6岁孩子最初误诊为不典型癫痫的病例报告(英文)

本文报告1例6岁女童首次发生发作性睡病被误诊为不典型癫痫。之后10个月在8家不同医院被误诊为其他疾病,最后才得以确诊。发作性睡病的诊断在小儿中比较困难,因为睡眠发作、猝倒、入睡前幻觉和睡眠麻痹四个主要症状都存在的病例在儿童中极少见到。患儿往往发作期更长、症状多样化。为了缩短从首次发病到确诊的时间,我们建议对所有不明原因过度睡眠的患儿监测睡眠并进行睡眠潜伏期试验,以排除发作性睡病的可能,而不论其相关症状如何。该病例凸显出罕见精神障碍的表现可以是多种多样的,特别是儿童。这就需要临床医生在采集病史时要充分考虑这些病例的非典型表现。     

Sleep complaints and epilepsy: the role of seizures, antiepileptic drugs and sleep disorders.

Patients with epilepsy commonly complain of daytime sleepiness and poor sleep quality. These problems are frequently attributed to antiepileptic drugs and seizures. Antiepileptic drugs and seizures have effects on sleep architecture often leading to daytime sleepiness. However, sleep symptoms may also be caused by poor sleep hygiene and primary sleep disorders. Primary sleep disorders should be suspected in patients with persistent daytime sleepiness, particularly those on AED monotherapy or with low serum drug concentrations and well-controlled seizures. Treatment of sleep disorders and improved sleep hygiene may improve seizure control and quality of life.     

Generalized paroxysmal fast activity in EEG: An unrecognized finding in genetic generalized epilepsy

ObjectiveTo study generalized paroxysmal fast activity (GPFA) in patients with genetic generalized epilepsy (GGE).IntroductionGPFA is an electroencephalographic (EEG) finding in patients with symptomatic generalized epilepsy consisting of 15-25 Hz bifrontally predominant generalized fast activity seen predominantly in sleep. Historically GPFA is linked to epileptic encephalopathy with drug resistant epilepsy and intellectual disability. However, GPFA has been rarely described as an atypical finding in patients with GGE without negative prognostic implication. We report cognitive profile and seizure characteristics in seven patients with GGE and GPFA.MethodsThe Vanderbilt EMU and EEG reports were searched for the keywords “idiopathic generalized epilepsy”, “GPFA”and “generalized spike and wave discharges (GSWD)”. We reviewed the EEG tracings and the electronic medical records of patients thus identified. The seizure type, frequency, neurological work-up, clinical profile and imaging data were recorded.ResultsAwake and sleep states were captured on EEGs of all patients. On EEG tracing review six patients were confirmed to have GSWD and GPFA; one patient had GPFA but no GSWD. All patients had normal cognitive function. Four had a normal brain MRI and one a normal head CT (two were never imaged). None of the patients had tonic seizures. The main seizure type was generalized tonic-clonic seizures (GTCS) in five patients, absence in two. Age at onset of epilepsy ranged from 4 to 24 years. The mean GTC seizure frequency at the time of EEG was 3; two patients were seizure free on two antiepileptic drugs (AEDs).ConclusionsGPFA can be an unrecognized electrographic finding in patients with genetic generalized epilepsy. While GPFA remains an important diagnostic EEG feature for epileptic encephalopathy (Lennox-Gastaut syndrome) it is not specific for this diagnosis. Thus, GPFA may have a spectrum of variable phenotypic expression. The finding of GPFA is not necessarily indicative of unfavorable outcome.     

Distinctive polysomnographic traits in nocturnal frontal lobe epilepsy

Purpose: To describe the polysomnographic features and distribution of epileptic motor events, in relation to conventional sleep measures and cyclic alternating pattern (CAP) parameters, in 40 untreated patients with nocturnal frontal lobe epilepsy (NFLE). Methods: We analyzed the basal polysomnographic recordings of 40 patients (20 male and 20 female; mean age: 31 ± 10 years) with a diagnosis of nocturnal frontal lobe epilepsy. Conventional sleep measures and CAP parameters were assessed. Polysomnographic recordings were subdivided in sleep cycles. The distribution of the epileptic motor events (including minor motor events, paroxysmal arousals, tonic‐dystonic, or hyperkinetic seizures and epileptic nocturnal wandering) was analyzed throughout: total sleep time, non–rapid eye movement (NREM) and REM sleep, light sleep (S1 + S2), slow wave sleep (SWS), each sleep cycle, CAP or non‐CAP sleep, phase A and phase B of CAP. Only clear epileptic motor events supported by video–polysomnographic evidence were taken into consideration. Polysomnographic findings of patients with NFLE were compared with those of 24 age‐ and gender‐balanced healthy subjects without sleep complaints. Key Findings: Compared to controls, patients with NFLE showed a significant increase in wake after sleep onset, SWS duration, and REM latency, whereas REM sleep duration was significantly lower in NFLE patients. The patients with NFLE showed a significant increase of CAP time, CAP rate (72% vs. 32% in control group), CAP cycles, and mean duration of a CAP sequence. These findings were associated with a significant enhancement of all subtypes of the A phases of CAP (mainly subtype A1). A total of 139 epileptic motor events supported by video‐polysomnographic evidence were counted: 98% of all seizures occurred in NREM sleep and 72% of NREM seizures emerged from SWS, the latter being particularly collected in the first sleep cycles and decreasing in frequency together with the progressive decline of deep sleep. Ninety percent of total NREM seizures occurred during a CAP sequence, and CAP‐related seizures occurred in association with a phase A. Significance: Significant polysomnographic alterations seem to emerge in patients with NFLE (increased REM latency, epileptic fragmentation of SWS, and increase of CAP rate). The analysis of seizure distribution showed that most epileptic events occurred in SWS, with predominance in the first sleep cycle and decreasing in frequency together with the homeostatic decline of SWS across the night. Within the NREM sleep, CAP is a manifestation of unstable sleep and represents a powerful predisposing condition for the occurrence of nocturnal motor seizures, which arise in concomitance with a phase A.     

Spécificités des crises d’épilepsie chez le sujet âgé : proposition d’un score électro-radioclinique d’orientation

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis… and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia…). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.     

Fibromyalgia and seizures

The purpose of this case‐matched study was to determine how frequently fibromyalgia is associated with different paroxysmal neurological disorders and explore the utility of fibromyalgia as a predictor for the diagnosis of psychogenic non‐epileptic seizures. The billing diagnosis codes of 1,730 new, non‐selected patient encounters were reviewed over a three‐year period for an epileptologist in a neurology clinic to identify all patients with historical diagnoses of fibromyalgia. The frequency with which epileptic seizures, psychogenic non‐epileptic seizures, and physiological non‐epileptic events were comorbid with fibromyalgia was assessed. Age and gender case‐matched controls were used for a between‐group comparison. Wilcoxon tests were used to analyse interval data, and Chi‐square was used to analyse categorical data (p<0.05). Fibromyalgia was retrospectively identified in 95/1,730 (5.5%) patients in this cohort. Females represented 95% of the fibromyalgia sample (age: 53 years; 95% CI: 57, 51). Forty‐three percent of those with fibromyalgia had a non‐paroxysmal, neurological primary clinical diagnosis, most commonly chronic pain. Paroxysmal events were present in 57% of fibromyalgia patients and 54% of case‐matched controls. Among patients with fibromyalgia and paroxysmal disorders, 11% had epileptic seizures, 74% had psychogenic non‐epileptic seizures, and 15% had physiological non‐epileptic events, compared to case‐matched controls with 37% epileptic seizures, 51% psychogenic non‐epileptic events, and 12% physiological non‐epileptic events (p = 0.009). Fibromyalgia was shown to be a predictor for the diagnosis of psychogenic non‐epileptic seizures in patients with undifferentiated paroxysmal spells. However, our results suggest that the specificity and sensitivity of fibromyalgia as a marker for psychogenic non‐epileptic seizures in a mixed general neurological population of patients is less than previously described.     

Distinguishing sleep disorders from seizures: diagnosing bumps in the night

BACKGROUND: Abnormal paroxysmal events in sleep may be parasomnias or epileptic seizures. In nocturnal frontal lobe epilepsy (NFLE), the unusual seizure features often lead to diagnostic confusion with nonepileptic parasomnias; video-electroencephalography monitoring is usually required to make the diagnosis. OBJECTIVE: To examine the reliability of the clinical history in diagnosing NFLE, using the Frontal Lobe Epilepsy and Parasomnias (FLEP) scale. DESIGN: The FLEP scale, comprising specific questions reflecting the diagnostic features of NFLE and parasomnias, was developed by an expert panel following review of the literature. It was then validated in a sample of individuals with firmly diagnosed nocturnal events. SETTING: Patients were recruited after appropriate diagnostic workup in tertiary sleep and epilepsy referral centers in Melbourne, Australia. PARTICIPANTS: Sixty-two patients (45 males) [corrected] with paroxysmal nocturnal events. Intervention Two independent interviews were conducted in each case, with the patient and a witness, by researchers blinded to the diagnosis. MAIN OUTCOME MEASURE: The diagnosis obtained from scores on the FLEP scale was compared with the confirmed diagnosis in each patient. RESULTS: Nocturnal frontal lobe epilepsy was correctly diagnosed from the FLEP score in 31 of 31 patients, with a sensitivity of 1.0 (95% confidence interval [CI], 0.85-1.00), specificity of 0.90 (95% CI, 0.73-0.97), positive predictive value of 0.91 (95% CI, 0.75-0.97), and negative predictive value of 1.00 (95% CI, 0.85-1.00). CONCLUSIONS: A diagnosis of NFLE can be made reliably using the clinical features identified in the FLEP scale. This may reduce the requirement for tertiary referral and extensive inpatient monitoring.