Sleep & Epilepsy

Sleep & epilepsy

Abdul Alraiyes MD

Objectives

•EEG:•10 -20 EEG electrode placement•EEG montage•Spike and wave

•Sleep and epilepsy:•AASM criteria•Epilepsy sleep disturbance•Epilepsy and sleep stages•Types of seizures during sleep•Epilepsy and OSA

HPI

79 year-old male referred for evaluation of obstructive sleep apnea byher primary care physician due to:

• nocturnal symptoms include:• Snoring• witnessed apneas

• And daytime symptoms include:• Fatigue• Unpleasant dry mouth• Epworth sleepiness scale 12/24

HPI

79 year-old male referred for evaluation of obstructive sleep apnea byher primary care physician.

The patient’s usual bedtime is 11:00 and wake time is 7:00 and obtains7 hours of sleep on average no naps.

No history of:• RLS symptoms• REM behavior disorder• Sleep paralysis• Cataplexy• Narcolepsy

PMHxCo-morbidities:

DM

DyslipidemiaStrokeEpilepsy

Medications:LipitorPhenytoinInsulin NovologInsulin LantusVitamin D

PSG

The patient went for over night PSG study

EEG

EEG History

Aristotle (384 – 322 BC)

• ‘For sleep is like epilepsy, and, in a sense, actually is a seizure of this sort. Accordingly, … their subsequent habitual seizures occur in sleep, not in waking hours.’

Galen (129 – circa 200)

• Cautioned epileptics about sleepiness knowing importance of sleep in seizure control

EEG

Bipolar Montage

Referential Montage

Spike and Wave

diffuse increase in cortical excitability (either through enhanced excitation or diminished inhibition) can lead to spike-and-wave patterns through thalamocortical loops

Spike and Wave

Spike and wave description:

1. Location (montage)2. Frequency (single/run/rhythmic) 3. Voltage4. Phase (-)/(+)5. Reactive6. Revolution/devolution

Spike and Wave

diffuse increase in cortical excitability (either through enhanced excitation or diminished inhibition) can lead to spike-and-wave patterns through thalamocortical loops

Spike and wave criteria:1. Distinct form2. Interrupt background activity 3. More than one phase fast (-) then (+)4. First phase usually (-)5. Asymmetric slope6. Seen in more than one field7. Followed by a slow wave

Sleep Spindles

Sleep spindles result from interactions between cells in the thalamus and the cortexburst of brain activity visible on an EEG that occurs during stage 2 sleep.

Patient PSG

Obstructive Sleep Apnea Syndrome: The patient has an overall Respiratory (AHI) 27.2 on this study as well as oxygen desaturation which is consistent with this diagnosis

Patient’s EEG

Patient’s EEG

Patient’s EEG

Patient’s EEG

Patient’s EEG

Patient’s EEG

Patient’s EEG

Patient’s EEG

Following the PSG

•EEG reviewed by neuroscience department•The patient called for phenytoin level check

Phenytoin: 2mcg/m

Sleep & epilepsy

Sleep Related Epilepsy (AASM)ICD-9 = 345.0

Diagnostic Criteria: • two of the following:

•Abrupt awakening from sleep•Generalized tonic –clonic movement•Focal limb movement•Automatism•Urinary incontinence•Tongue biting•Postictal confusion and lethargy

•> 70% of episodes occur during sleep•PSG criteria:

•An epileptiform EEG discharge with symptoms•Interictal epileptiform EEG activity in any stage of sleep

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.

Epilepsy and Sleep disturbance

Malow, B.A., G.A. Fromes, and M.S. Aldrich, Usefulness of polysomnography in epilepsy patients. Neurology, 1997. 48(5): p. 1389-94.

Insufficient sleep syndrome :

•failing to spend enough time in bed.

Sleep hygiene:

•Sleep timing •Sleep environment •outside activity

Epilepsy and Sleep disturbance

Sleep Disorders and Epilepsy:

•63 epilepsy patients who underwent polysomnography•(78%) obstructive sleep apnea•(46%) excessive sleepiness•(19%) characterization of nocturnal spells.

Epilepsy

Sleep disturbance OSA

Sleep disturbance

Malow, B.A., G.A. Fromes, and M.S. Aldrich, Usefulness of polysomnography in epilepsy patients. Neurology, 1997. 48(5): p. 1389-94.Bazil, C.W., Epilepsy and sleep disturbance. Epilepsy Behav, 2003. 4 Suppl 2: p. S39-45.

Epilepsy and Sleep disturbance

Malow, B.A., G.A. Fromes, and M.S. Aldrich, Usefulness of polysomnography in epilepsy patients. Neurology, 1997. 48(5): p. 1389-94.Bazil, C.W., Epilepsy and sleep disturbance. Epilepsy Behav, 2003. 4 Suppl 2: p. S39-45.

Effects of seizures on sleep:

•Sleep fragmentation due to:•Frequent awakening•Postictal phase•Reduced sleep efficiency•Reduced REM sleep

•Treatment of nocturnal seizures shown improvement in:•sleep efficiency•decreased arousals•increases in rapid eye movement (REM) sleep

Epilepsy and Sleep disturbance

Bazil, C.W., L.H. Castro, and T.S. Walczak, Reduction of rapid eye movement sleep by diurnal and nocturnal seizures in temporal lobe epilepsy. Arch Neurol, 2000. 57(3): p. 363-8.

Reduction of REM sleep Sleep efficiency

Epilepsy and Sleep disturbance

Bazil, C.W., L.H. Castro, and T.S. Walczak, Reduction of rapid eye movement sleep by diurnal and nocturnal seizures in temporal lobe epilepsy. Arch Neurol, 2000. 57(3): p. 363-8.

Sleep Spindles Spike and Wave

Sleep & epilepsy

There is abundant evidence that brainstemstructures, including the reticular activatingsystem and the thalamus, are directlyinvolved in both the cerebral hypersynchronyseen in sleep and the synchronous dischargesof generalized seizures.

Steriade, M., D.A. McCormick, and T.J. Sejnowski, Thalamocortical oscillations in the sleeping and aroused brain. Science, 1993. 262(5134): p. 679-85.Kusske, J.A., Interactions between thalamus and cortex in experimental epilepsy in the cat. Exp Neurol, 1976. 50(3): p. 568-78.

Adapted from Saper 2005, pg 1258 [99].

Sleep & epilepsy

Sato, M. and T. Nakashima, Kindling: secondary epileptogenesis, sleep and catecholamines. Can J Neurol Sci, 1975. 2(4): p. 439-46.

Adapted from Saper 2005, pg 1258 [99].

NREM > REM

•cats have a lower electroconvulsive seizurethreshold in slow-wave sleep compared withwakefulness and REM sleep

Sleep stage and epilepsy

Bazil, C.W. and T.S. Walczak, Effects of sleep and sleep stage on epileptic and nonepileptic seizures. Epilepsia, 1997. 38(1): p. 56-62.

retrospectively examined video-EEG monitoring of 188 patients with 1,116 seizures (average of 5.9 seizures/patient; standard deviation, 4.8; range, 1-34).Two hundred twenty-eight (20%) of 1,116 occurred during sleep

Sleep stage and epilepsy

Bazil, C.W. and T.S. Walczak, Effects of sleep and sleep stage on epileptic and nonepileptic seizures. Epilepsia, 1997. 38(1): p. 56-62.

(54%)

CPS duration asleep vs. awake

(p < 0.025)

The effect of sleep stages on epileptiform discharge

Bazil, C.W. and T.S. Walczak, Effects of sleep and sleep stage on epileptic and nonepileptic seizures. Epilepsia, 1997. 38(1): p. 56-62.

Temporal vs. Frontal lobe CPS

Antiepileptic medication and sleep

• Have short and long term effects on sleep

• Can cause sedation or insomnia

• Adverse effect of AED on sleep may be minimal in comparison to sleep improvement after seizure control from AED

Slp latency Arousal WASO SWS REM

Phenytoin

Phenobarb

Carbamazepine

Valproate

Ethosuximide

Gabapentin

Levetirecitam

Favorability

OSA and the effect of PAP therapy on Epilepsy

Malow, B.A., et al., Identification and treatment of obstructive sleep apnea in adults and children with epilepsy: a prospective pilot study. Sleep Med, 2003. 4(6): p. 509-15.

Epilepsy

Sleep disturbance OSA

Sleep disturbance

Sleep deprivation has known to increase the risk of seizures in syndromes like juvenile myoclonic epilepsy.However, a controlled study of patients with refractory partial epilepsy failed to show an effect.

OSA and the effect of PAP therapy on Epilepsy

Malow, B.A., et al., Identification and treatment of obstructive sleep apnea in adults and children with epilepsy: a prospective pilot study.Sleep Med, 2003. 4(6): p. 509-15.

•Six of 13 adults and 3 of 5 children met PSG criteria for OSA (AHI > 5)

•Three adults and 1 child were treated with continuous positive airway pressure (CPAP):

•Treatment were tolerant of the device•no change in AED doses• All four had at least a 45% reduction in seizure frequency during CPAP treatment.

Summary

• CPSs (particularly TLCPSs) generalize more frequently during sleep thanduring wakefulness.

•Partial seizures are relatively less common during slow-wave and particularlyREM sleep.

•Partial seizures arising during sleep do not last longer than those beginningduring wakefulness.

•The biochemical mechanisms for these findings is unclear. Howeverbrainstem reticular formation and thalamus are critical in both the expressionof sleep and complex partial seizures, suggesting that electrochemicalchanges underlying cerebral hypersynchrony during sleep also facilitateseizure generalization.

•Sleep deprivation might be a cause of uncontrolled seizures in some epilepsysyndromes, treatment of sleep disordered breathing might provide bettercontrol of the seizure disorder.

Questions?

Thank You

References

1. Bazil, C.W. and T.S. Walczak, Effects of sleep and sleep stage on epileptic and nonepileptic seizures.Epilepsia, 1997. 38(1): p. 56-62.

2. Steriade, M., D.A. McCormick, and T.J. Sejnowski, Thalamocortical oscillations in the sleeping andaroused brain. Science, 1993. 262(5134): p. 679-85.

3. Kusske, J.A., Interactions between thalamus and cortex in experimental epilepsy in the cat. ExpNeurol, 1976. 50(3): p. 568-78.

4. Sato, M. and T. Nakashima, Kindling: secondary epileptogenesis, sleep and catecholamines. Can JNeurol Sci, 1975. 2(4): p. 439-46.

5. Malow, B.A., G.A. Fromes, and M.S. Aldrich, Usefulness of polysomnography in epilepsy patients.Neurology, 1997. 48(5): p. 1389-94.

6. Bazil, C.W., Epilepsy and sleep disturbance. Epilepsy Behav, 2003. 4 Suppl 2: p. S39-45.7. Bazil, C.W., L.H. Castro, and T.S. Walczak, Reduction of rapid eye movement sleep by diurnal and

nocturnal seizures in temporal lobe epilepsy. Arch Neurol, 2000. 57(3): p. 363-8.8. Malow, B.A., et al., Identification and treatment of obstructive sleep apnea in adults and children

with epilepsy: a prospective pilot study. Sleep Med, 2003. 4(6): p. 509-15.9. Dinner, D.S., Effect of sleep on epilepsy. J Clin Neurophysiol, 2002. 19(6): p. 504-13.10.Malow, B.A., Sleep and epilepsy. Neurol Clin, 2005. 23(4): p. 1127-47.11.Malow, B.A., Paroxysmal events in sleep. J Clin Neurophysiol, 2002. 19(6): p. 522-34.12.Bazil, C.W., Sleep and epilepsy. Semin Neurol, 2002. 22(3): p. 321-7.13.Shouse, M.N., A.M. da Silva, and M. Sammaritano, Circadian rhythm, sleep, and epilepsy. J Clin

Neurophysiol, 1996. 13(1): p. 32-50.14.Malow, B.A., Sleep and epilepsy. Neurol Clin, 1996. 14(4): p. 765-89.