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 by
her 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 by
her primary care physician.

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

No history of:
• RLS symptoms
• REM behavior disorder
• Sleep paralysis
• Cataplexy
• Narcolepsy
 PMHx
Co-morbidities:
DM
Dyslipidemia
Stroke
Epilepsy
Medications:
Lipitor
Phenytoin
Insulin Novolog
Insulin Lantus
Vitamin 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 Galen (129 – circa 200)
seizure of this sort.
• Cautioned epileptics about
Accordingly, … their
subsequent habitual seizures sleepiness knowing
occur in sleep, not in waking importance of sleep in
hours.’ 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. Voltage
4. Phase (-)/(+)
5. Reactive
6. 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 form
2. Interrupt background activity
3. More than one phase fast (-) then (+)
4. First phase usually (-)
5. Asymmetric slope
6. Seen in more than one field
7. Followed by a slow wave
 Sleep Spindles
Sleep spindles result from interactions between cells in the thalamus and the cortex
burst 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

Insufficient sleep syndrome :

•failing to spend enough time in bed.

Sleep hygiene:

•Sleep timing
•Sleep environment
•outside activity

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

Sleep
disturbance Epilepsy

Sleep
OSA 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
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

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
Reduction of REM sleep Sleep efficiency

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.
 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 brainstem

structures, including the reticular activating
system and the thalamus, are directly
involved in both the cerebral hypersynchrony
seen in sleep and the synchronous discharges
of generalized seizures.

Adapted from Saper 2005, pg 1258 [99].

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.
 Sleep & epilepsy
NREM > REM

•cats have a lower electroconvulsive seizure

threshold in slow-wave sleep compared with
wakefulness and REM sleep

Adapted from Saper 2005, pg 1258 [99].

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

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.
 Sleep stage and epilepsy

(54%)

CPS duration asleep vs. awake

(p < 0.025)

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.
 The effect of sleep stages on epileptiform
discharge

Temporal vs. Frontal lobe CPS

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.
 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 Favorability

Phenytoin      
Phenobarb      
Carbamazepine      
Valproate      
Ethosuximide      
Gabapentin      
Levetirecitam      
 OSA and the effect of PAP therapy on Epilepsy

Sleep
disturbance Epilepsy

Sleep
OSA 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.

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.
 OSA and the effect of PAP
therapy on Epilepsy

•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.

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

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

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

•The biochemical mechanisms for these findings is unclear. However

brainstem reticular formation and thalamus are critical in both the expression
of sleep and complex partial seizures, suggesting that electrochemical
changes underlying cerebral hypersynchrony during sleep also facilitate
seizure generalization.

•Sleep deprivation might be a cause of uncontrolled seizures in some epilepsy

syndromes, treatment of sleep disordered breathing might provide better
control 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 and
aroused brain. Science, 1993. 262(5134): p. 679-85.
3. Kusske, J.A., Interactions between thalamus and cortex in experimental epilepsy in the cat. Exp
Neurol, 1976. 50(3): p. 568-78.
4. Sato, M. and T. Nakashima, Kindling: secondary epileptogenesis, sleep and catecholamines. Can J
Neurol 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.