Evaluation of sleep quality in patients with refractory seizures who undergo epilepsy surgery

Sleep Spindle Generation Before and After Epilepsy Surgery: A Source Imaging Study in Children with Drug-Resistant Epilepsy

INTRODUCTION

Literature lacks studies investigating the cortical generation of sleep spindles in drug-resistant epilepsy (DRE) and how they evolve after resection of the epileptogenic zone (EZ). Here, we examined sleep EEGs of children with focal DRE who became seizure-free after focal epilepsy surgery, and aimed to investigate the changes in the spindle generation before and after the surgery using low-density scalp EEG and electrical source imaging (ESI).

METHODS

We analyzed N2-sleep EEGs from 19 children with DRE before and after surgery. We identified slow (8-12 Hz) and fast spindles (13-16 Hz), computed their spectral features and cortical generators through ESI and computed their distance from the EZ and irritative zone (IZ). We performed two-way ANOVA testing the effect of spindle type (slow vs. fast) and surgical phase (pre-surgery vs. post-surgery) on each feature.

RESULTS

Power, frequency and cortical activation of slow spindles increased after surgery (p < 0.005), while this was not seen for fast spindles. Before surgery, the cortical generators of slow spindles were closer to the EZ (57.3 vs. 66.2 mm, p = 0.007) and IZ (41.3 vs. 55.5 mm, p = 0.02) than fast spindle generators.

CONCLUSIONS

Our data indicate alterations in the EEG slow spindles after resective epilepsy surgery. Fast spindle generation on the contrary did not change after surgery. Although the study is limited by its retrospective nature, lack of healthy controls, and reduced cortical spatial sampling, our findings suggest a spatial relationship between the slow spindles and the epileptogenic generators.

Sleep macrostructure and cyclic alternating pattern in patients who underwent surgery for hippocampal sclerosis: A prospective controlled polysomnographic study

INTRODUCTION

Temporal lobe epilepsy due to hippocampal sclerosis (TLE-HS) is one of the most common drug-resistant epilepsy. Surgery is currently accepted as an effective and safe therapeutic approach compared to antiseizure medications (ASMs). The study aims to evaluate the effect of surgical treatment of TLE-HS on sleep profile and architecture by subjective and objective evaluation of sleep in basal condition after one month and one year.

METHODS

Thirteen patients with TLE-HS were recruited to undergo overnight polysomnography and a subjective evaluation of nocturnal sleep utilizing the Pittsburgh Sleep Quality Index (PSQI) and daytime somnolence through the Epworth Sleepiness Scale (ESS) in basal condition (T0), one month (T1) and one year after surgery (T2), respectively. Thirteen healthy controls (HC) matched for age, sex and BMI were recruited. Scoring and analysis of sleep macrostructure and cyclic alternating pattern (CAP) parameters were performed.

RESULTS

The comparison between patients in basal condition (T0) and HC showed a significant lower sleep efficiency (p = 0.003) and REM percentage (p < 0.001). Regarding CAP, patients at T0 showed higher total CAP rate (p < 0.001), CAP rate in N2 (p < 0.001), higher A3 (%) (p = 0.001), higher mean duration of A1 (p = 0.002), A3 index (p < 0.001), cycle in sequences (p < 0.001), lower B duration (p < 0.001), cycle mean duration (p < 0.001) than HC. Surgery did not induce significant changes in nocturnal macrostructural polysomnographic variables in T1 and T2. Lower CAP rate (T1 vs T0 and T2 vs T0 p < 0.001), CAP rate in N3 (T1 vs T0 and T2 vs T0 p < 0.001), A3 (%) (T1 vs T0 and T2 vs T0 p < 0.001); lower phase A2 index (T1 vs T0 p < 0.001) and A3 index (T1 vs T0 p < 0.001), lower phase A1 index (T2 vs T0 p < 0.001) and cycle in sequences (T2 vs T0 p = 0.002) higher B mean duration (T2 vs T0 p = 0.002). No significant differences were found between T1 and T2 in CAP parameters.

CONCLUSION

We found a significant NREM sleep instability in patients with TLE-HS compared with HC. In addition, anterior temporal lobectomy (ATL) induced a significant improvement in sleep continuity as evaluated by cyclic alternating pattern already one month later and this effect persisted after one year. ALT seems to restore a more resilient sleeping brain.

Quantitative study of the effects of early standardized ambulation on sleep quality in patients after hepatectomy

Background

Sleep quality has been always an important problem for patients after hepatectomy. The main purpose of the study is to investigate the effects of early ambulation on sleep quality in patients after liver resection via a quantitative study.

Methods

Patients undergoing liver tumor resection were randomly divided into two groups, and the Pittsburgh Sleep Quality Index (PSQI) was used to assess the postoperative activities and sleep quality.

Results

Patients who started early ambulation after liver resection had significantly better sleep quality, faster recovery of gastrointestinal function and shorter lengths of postoperative hospital stay compared with the control group. And there was no significant difference in the incidence of postoperative complications between the two groups.

Conclusion

Early standardized physical activities are feasible for patients after liver resection, which can significantly improve patient's sleep quality, reduce patient's pain and the nursing workload, and achieve rapid recovery.

Effects of anti-seizure therapies on sleep in patients with epilepsy: A literature review

Sleep disorder is common in epilepsy. With a recent rapid development in sleep medicine, it has been increasingly recognized that anti-seizure therapies, either anti-seizure medications (ASMs) or non-pharmaceutical approaches, can take direct or indirect influence on sleep in patients with epilepsy. Here, we systematically review the effect of anti-seizure treatments on sleep. ASMs targeting at different sites exerted various effects on both sleep structure and sleep quality. Non-pharmaceutical treatments including resective surgery, ketogenic diet, and transcranial magnetic stimulation appear to have a positive effect on sleep, while vagus nerve stimulation, deep brain stimulation, and brain-responsive neurostimulation are likely to interrupt sleep and exacerbate sleep-disordered breathing. The potential mechanisms underlying how non-pharmacological approaches affect sleep are also discussed. The limitation of most studies is that they were largely based on small cohorts by short-term observations. Further well-designed and large-scale investigations in this field are warranted. Understanding the effect of anti-seizure therapies on sleep can guide clinicians to optimize epilepsy treatment in the future.

Sleep and Temporal Lobe Epilepsy – Associations, Mechanisms and Treatment Implications

In this systematic review, we aim to describe the association between temporal lobe epilepsy (TLE) and sleep, with bidirectional links in mechanisms and therapeutic aspects. Sleep stages may variably impact seizure occurrence, secondary generalization and the development, frequency and distribution of interictal epileptiform discharges. Conversely, epilepsy affects sleep micro- and macroarchitecture. TLE, the most frequent form of drug resistant epilepsy (DRE), shares an enduring relationship with sleep, with some intriguing potential mechanisms specific to anatomic localization, linking the two. Sleep characteristics of TLE may also inform localizing properties in persons with DRE, since seizures arising from the temporal lobe seem to be more common during wakefulness, compared to seizures of extratemporal origin. Polysomnographic studies indicate that persons with TLE may experience excessive daytime somnolence, disrupted sleep architecture, increased wake after sleep onset, frequent shifts in sleep stages, lower sleep efficiency, decreased rapid eye movement (REM) sleep, and possibly, increased incidence of sleep apnea. Limited literature suggests that effective epilepsy surgery may remedy many of these objective and subjective sleep-related concerns, via multipronged effects, apart from reduced seizure frequency. Additionally, sleep abnormalities also seem to influence memory, language and cognitive-executive function in both medically controlled and refractory TLE. Another aspect of the relationship pertains to anti-seizure medications (ASMs), which may contribute significantly to sleep characteristics and abnormalities in persons with TLE. Literature focused on specific aspects of TLE and sleep is limited, and heterogeneous. Future investigations are essential to understand the pathogenetic mechanisms linking sleep abnormalities on epilepsy outcomes in the important sub-population of TLE.

Sleep Disruption Worsens Seizures: Neuroinflammation as a Potential Mechanistic Link

Sleep disturbances, such as insomnia, obstructive sleep apnea, and daytime sleepiness, are common in people diagnosed with epilepsy. These disturbances can be attributed to nocturnal seizures, psychosocial factors, and/or the use of anti-epileptic drugs with sleep-modifying side effects. Epilepsy patients with poor sleep quality have intensified seizure frequency and disease progression compared to their well-rested counterparts. A better understanding of the complex relationship between sleep and epilepsy is needed, since approximately 20% of seizures and more than 90% of sudden unexpected deaths in epilepsy occur during sleep. Emerging studies suggest that neuroinflammation, (e.g., the CNS immune response characterized by the change in expression of inflammatory mediators and glial activation) may be a potential link between sleep deprivation and seizures. Here, we review the mechanisms by which sleep deprivation induces neuroinflammation and propose that neuroinflammation synergizes with seizure activity to worsen neurodegeneration in the epileptic brain. Additionally, we highlight the relevance of sleep interventions, often overlooked by physicians, to manage seizures, prevent epilepsy-related mortality, and improve quality of life.

Effects of anti-seizure medications on sleep architecture and daytime sleepiness in patients with epilepsy: A literature review

Anti-seizure medications (ASMs) may improve or be detrimental to sleep. A literature review (as an update to the 2014 review by Jain and Glauser [https://doi.org/10.1111/epi.12478]) of 25 ASMs of interest (articles from 12 ASMs included) on the effect of ASMs/non-drug treatments on sleep in patients with epilepsy was conducted. The most common objective instrument was polysomnography, and the most common subjective measures were the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index. Eslicarbazepine acetate, lacosamide, and perampanel improved or had no effect on sleep. Perampanel was associated with low incidence of insomnia, and lacosamide with low incidence of daytime sleepiness adverse events. Clonazepam, felbamate, lamotrigine, oxcarbazepine, and phenobarbital worsened or had no effect on sleep. Lamotrigine may be associated with insomnia risk and phenobarbital with daytime sleepiness. Data for valproic acid were mixed. Overall, cannabidiol, carbamazepine, and levetiracetam had no effect on sleep. Epilepsy surgery may benefit sleep in patients with a good surgical outcome. Some ASMs, and, possibly, epilepsy surgery, may have positive effects on sleep, possibly linked to achieving seizure control. Nonetheless, other ASMs may worsen sleep in some settings. Clinicians should consider such observations when making treatment decisions, particularly for patients with comorbid sleep disorders.

Sleep profile and Polysomnography in patients with drug-resistant temporal lobe epilepsy (TLE) due to hippocampal sclerosis (HS) and the effect of epilepsy surgery on sleep-a prospective cohort study

OBJECTIVES

We analyzed changes in sleep profile and architecture of patients with drug-resistant TLE-HS using three validated sleep questionnaires- Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), NIMHANS Comprehensive Sleep Disorders, and polysomnography (PSG). We studied the effect of epilepsy surgery in a subset of patients.

METHODS

In this prospective observational cohort study, sleep profile of 40 patients with drug-resistant TLE-HS was compared to 40 healthy matched controls. Sleep architecture of 22 patients was studied by overnight PSG and compared to 22 matched controls. Sleep profile was reassessed in 20 patients after a minimum period of three months after epilepsy surgery.

RESULTS

The mean PSQI was higher among patients compared to controls(P=0.0004) while mean ESS showed no difference. NCSDQ showed fewer patients feeling refreshed after a night's sleep compared to controls (p=0.006). PSG revealed a higher time in bed (p=0.0001), longer total sleep time (p=0.006) and more time spent in NREM stage 1 (p=0.001) and stage 2 (p=0.005) while spending less time in stage 3 (p=0.039) among TLE patients. Sleep efficiency was worse in patients on ≥3 ASMs compared to those on 2 ASMs (p-0.044). There was no change in mean ESS (p=0.48) or PSQI (p=0.105) after surgery.

CONCLUSIONS

Patients with drug-resistant TLE-HS have an altered sleep profile and architecture. Patients on ≥3 ASMs have a lower sleep efficiency. Reassessment at short intervals after epilepsy surgery did not reveal significant changes in sleep profile.

Course and impact of sleep disturbance in newly diagnosed epilepsy: A prospective registry study

OBJECTIVE

To determine the course of sleep distrurbance (insomnia symptoms and short sleep duration) after a diagnosis of epilepsy and their associations with seizure control, mood, disability, and quality of life.

PATIENTS AND METHODS

One hundred and sixty-nine adults were drawn from the Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC), a prospective, multicenter, community-wide study in Sydney, Australia. Socio-demographic, psychosocial, clinical characteristics, and information on sleep disturbance were obtained early (median 48 [IQR15-113] days) after a diagnosis of epilepsy, and at 12 months. Logistic regression models were used to determine associations between patterns of sleep disturbance with outcomes at 12 months.

RESULTS

Insomnia symptoms and/or short sleep duration were present in 18-23% of participants at both time points, with over half (54-61%) showing a chronic pattern. There was no association of sleep disturbance pattern with recurrent seizures, medication use or disability. Chronic insomnia symptoms and short sleep duration were strongly associated with worse mental health (aOR 3.76, 95% CI 1.28-11.06; and aOR 5.41, 95% CI 1.86-15.79) and poorer quality of life at 12 months (aOR 3.02, 95% CI 1.03-8.84; and aOR 3.11, 95% CI 1.10-8.82), after adjusting for clinical features of epilepsy and comorbidity. Those whose sleep disturbance remitted had no adverse outcomes.

CONCLUSIONS

Insomnia symptoms and short sleep duration are less common in people with recently-diagnosed than chronic epilepsy. The temporal association with poor psycholosocial outcomes supports specific interventions addressing sleep disturbance.

Impaired vigilance networks in temporal lobe epilepsy: Mechanisms and clinical implications

Mesial temporal lobe epilepsy (mTLE) is a neurological disorder in which patients suffer from frequent consciousness-impairing seizures, broad neurocognitive deficits, and diminished quality of life. Although seizures in mTLE originate focally in the hippocampus or amygdala, mTLE patients demonstrate cognitive deficits that extend beyond temporal lobe function-such as decline in executive function, cognitive processing speed, and attention-as well as diffuse decreases in neocortical metabolism and functional connectivity. Given prior observations that mTLE patients exhibit impairments in vigilance, and that seizures may disrupt the activity and long-range connectivity of subcortical brain structures involved in vigilance regulation, we propose that subcortical activating networks underlying vigilance play a critical role in mediating the widespread neural and cognitive effects of focal mTLE. Here, we review evidence for impaired vigilance in mTLE, examine clinical implications and potential network underpinnings, and suggest neuroimaging strategies for determining the relationship between vigilance, brain connectivity, and neurocognition in patients and healthy controls.

Sleep quality and related clinical features in patients with epilepsy: A preliminary report

OBJECTIVE

The relationship between sleep and epilepsy is complex and involves multiple mechanisms. Patients with epilepsy (PWE) often report fatigue and daytime sleepiness, and are often diagnosed with comorbid sleep disorders that are thought to be a direct corollary of seizures, adverse effects of antiepileptic drugs (AEDs), or a combination of these two factors. The emergence of depressive symptomatology in PWE can also lead to decreases in quality of life. The aim of this study was to investigate the relationship between sleep quality, clinical characteristics, excessive daytime sleepiness (EDS), fatigue, and depression in PWE.

METHODS

Seventy-five consecutive PWE were included in the study. Demographic data, type and frequency of seizures, treatment regimens, number of seizures in the last 12 months, and relationship between seizures and sleep quality were recorded. Sleep quality, fatigue, daytime sleepiness, and depression symptoms were evaluated using the Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), and Beck Depression Inventory (BDI), respectively.

RESULTS

Patients (43 females, 32 males) had a mean age of 31.3 ± 11 years, a mean age of epilepsy onset of 18 ± 11.4 years, and a mean disease duration of 13.2 ± 9.9 years. Thirty-two (42.7%) patients had poor sleep quality, while 44 (58.7%) had fatigue, 18 (24%) had daytime sleepiness, and 56 (74.7%) had depression. The FSS, ESS, and BDI scores of the patients with PSQI ≥5 were significantly higher (p = 0.048, p = 0.018, p < 0.001, respectively). Patients with poor sleep quality had more frequent seizures (p = 0.040).

CONCLUSIONS

Our study found that poor sleep quality in PWE may be associated with frequency of seizures and symptoms of fatigue, daytime sleepiness, and depression. Determining sleep disorders in PWE is essential as it may be a determinant of the patients' quality of life.

Changes in sleep patterns after vagus nerve stimulation, deep brain stimulation or epilepsy surgery: Systematic review of the literature

PURPOSE

Perform a systematic review of the literature on the effects of vagus nerve stimulation (VNS), deep brain stimulation (DBS) and epilepsy surgery in subjective and objective sleep parameters.

METHODS

We performed a literature search in the main medical databases: Medline, Embase, Cochrane, DARE and LILACS, looking for studies that evaluated the effects of VNS, DBS or epilepsy surgery on sleep parameters. In all, 36 studies, coming from 11 countries, including reviews, cohort studies, case series and case reports were included.

RESULTS

VNS induces sleep apnoea dependent of the stimulation variables. This condition can be reverted modifying these settings. Surgical procedures for epilepsy cause an improvement in objective and subjective sleep parameters that depend on the success of the procedure evaluated through ictal frequency control. There is evidence that non-pharmacologic treatment of epilepsy has different effects on sleep patterns.

CONCLUSION

It is advisable to include objective and subjective sleep parameters in the initial evaluation and follow-up of patients considered for invasive procedures for epilepsy control, especially with VNS due to the risk of sleep apnoea. More high quality studies are needed.

The Mutual Interaction Between Sleep and Epilepsy on the Neurobiological Basis and Therapy

BACKGROUND

Sleep and epilepsy are mutually related in a complex, bidirectional manner. However, our understanding of this relationship remains unclear.

RESULTS

The literatures of the neurobiological basis of the interactions between sleep and epilepsy indicate that non rapid eye movement sleep and idiopathic generalized epilepsy share the same thalamocortical networks. Most of neurotransmitters and neuromodulators such as adenosine, melatonin, prostaglandin D2, serotonin, and histamine are found to regulate the sleep-wake behavior and also considered to have antiepilepsy effects; antiepileptic drugs, in turn, also have effects on sleep. Furthermore, many drugs that regulate the sleep-wake cycle can also serve as potential antiseizure agents. The nonpharmacological management of epilepsy including ketogenic diet, epilepsy surgery, neurostimulation can also influence sleep.

CONCLUSION

In this paper, we address the issues involved in these phenomena and also discuss the various therapies used to modify them.

Sleep disturbances among patients with epilepsy

AIM

The aim of this study was to analyze the prevalence of sleep disorders among patients with epilepsy and to compare the incidence of sleep disorders between the clinical and demographics factors.

MATERIALS AND METHODS

The study was conducted among 302 patients with epilepsy. Sleep disturbances were measured with the Polish version of the Pittsburgh Sleep Quality Questionnaire (PSQI). The questionnaire prepared and applied by the authors contained questions relating to sociodemographic characteristics, clinical status, and sleep.

RESULTS AND CONCLUSION

Mean PSQI score in the study group was 9±2 points, with the range of 4-16 points. PSQI test results were analyzed with regard to clinical and demographic characteristics of those suffering from epilepsy: gender, age, profession, body mass index, illness duration, number of medicines taken, type of seizures, frequency of seizures, time which elapsed since last seizure, provocative factor of seizure attacks, occurrence of adverse effects of antiepileptic drugs (AEDs). Furthermore, the existence of a relationship between PSQI test result and particular sleep-related factors or particular sleep conditions was examined. However, the examination of a relationship between certain independent variables and the final PSQI test result did not prove the existence of a statistically relevant influence (in all cases P>0.05).

Daytime sleepiness in de novo untreated patients with epilepsy

The aims of our study were to evaluate excessive daytime sleepiness in a group of de novo untreated people with epilepsy using a comprehensive and standardized approach, including subjective evaluation and neurophysiological and performance tests, and to compare these results with those obtained in a control group. Forty-seven patients with epilepsy (17 affected by primary generalized epilepsy and 30 by partial epilepsy), with a new epilepsy diagnosis and never treated, and 44 controls underwent Multiple Sleep Latency Test (preceded by nocturnal polysomnography), simple/complex visual reaction times, and Epworth Sleepiness Scale evaluation. Newly diagnosed and drug-free patients with epilepsy did not differ from controls in any of the tests performed to evaluate daytime sleepiness. In clinical practice, daytime sleepiness is a well-known and frequent complaint of patients with epilepsy, but different mechanisms and causes, such as associated psychiatric or sleep disorders, nocturnal seizures, sleep fragmentation, and antiepileptic drugs, must be taken into account. Excessive daytime sleepiness should not be considered an unavoidable consequence of epilepsy. Thus, a complete diagnostic work-up in patients with epilepsy and sleepiness should be undertaken whenever possible.

Excessive daytime sleepiness and epilepsy: a systematic review

Background. Sleep complaints are common in patients with epilepsy (PWE). Excessive daytime sleepiness (EDS) is one of the most reported complaints and its impact is still a matter of debate. Objective. Evaluate the relationship between EDS and epilepsy, with emphasis on prevalence, assessment, and causes. Methods. A systematic review on PubMed database in the last 10 years (2002 to 2012). The search returned 53 articles and 34 were considered relevant. After citation analysis, 3 more articles were included. Results. Most studies were cross-sectional and questionnaire based. 14 papers addressed EDS as the primary endpoint. 14 adult and 3 children studies used subjective and objective analysis as methodology. The number of studies increased throughout the decade, with 21 in the last 5 years. Adult studies represent almost three times the number of children studies. EDS prevalence in PWE varies from 10 to 47.5%. Prevalence was higher in developing countries. Conclusion. EDS seems to be related more frequently to undiagnosed sleep disorders than to epilepsy-related factors, and although it affects the quality of life of PWE, it can be improved by treating comorbid primary sleep disorders.

Excessive sleepiness and sleep patterns in patients with epilepsy: a case-control study

The aim of this study was to assess excessive daytime sleepiness (EDS), sleep quality, and sleep disorders in a cohort of patients with epilepsy in the city of Florianopolis in southern Brazil. One hundred and forty patients diagnosed with epilepsy were assessed by questionnaires that included demographic and clinical variables, the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Stanford Sleepiness Scale (SSS), and the Fletcher & Luckett Adapted Questionnaire (FLAQ). These data were then compared to data from a control group (n=85). Compared to controls, patients with epilepsy (PWE) had significantly higher scores on the ESS (p=0.003), higher scores on the "daytime dysfunction" domain of the PSQI (p=0.002), and more symptoms that suggested obstructive sleep apnea in the FLAQ (p<0.001). By performing multiple linear regression models, we demonstrated that age, male gender, the presence of secondarily generalized seizures, and phenobarbital use were slightly to moderately correlated with PSQI (r=0.38) and FLAQ (r=0.51) but not with SSS scores. We concluded that PWE had more EDS, daytime dysfunction, and sleep disorders compared to a control group.

Sleep and epilepsy

The intimate relationship between sleep and epilepsy has long been recognized, yet our understanding of the relationship is incomplete. In this article we address four key issues in this area. First, we consider the reciprocal interaction between sleep and epilepsy. Sleep state clearly influences seizure onset, particularly in certain epilepsy syndromes. The converse is also true; epilepsy may disrupt sleep, either directly through seizures and epileptiform activity, or indirectly through medication-related effects. Unraveling the influences of sleep stage, epilepsy syndrome, and drug effects is challenging, and the current state of knowledge is reviewed. Secondly, accurate diagnosis of sleep-related epilepsy can be difficult, particularly the distinction of nocturnal frontal lobe epilepsy (NFLE) from arousal parasomnias. The challenges in this area, along with work from the authors, are discussed. Thirdly, we will explore the putative relationship between obstructive sleep apnea (OSA) and epilepsy, including the effect of OSA on quality of life; this will lead us to a brief exploration of the effects of OSA on neuroendocrine function. Finally, we will review the evidence surrounding the role of sleep in sudden unexpected death in epilepsy (SUDEP).

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.

Sleep disturbances in juvenile myoclonic epilepsy: a sleep questionnaire-based study

Sleep and epilepsy share a complex pathophysiological association. Juvenile myoclonic epilepsy (JME) is a common sleep-sensitive epilepsy in which the effect of seizures could have therapeutic implications in terms of sleep disturbances and seizure control. This study aimed to analyze the effect of epilepsy on sleep in patients with JME. Fifty patients on valproic acid (VPA) monotherapy, and age- and gender-matched controls were recruited into this prospective, hospital-based, case-control study after informed consent and screening for inclusion criteria. They underwent a detailed clinical assessment, electroencephalogram (EEG) and neuroimaging, and were administered validated sleep questionnaires, which included the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and NIMHANS Sleep Disorders Questionnaire. The patient and control groups had identical numbers of males and females (M: F=22: 28), without any significant difference in the age and body mass index (BMI). The clinical profile of JME was similar to published literature while the prevalence of EEG abnormalities was less compared to similar studies. The mean ESS and PSQI scores and the number of subjects with abnormal scores on one or both questionnaires were significantly more in patients. Patients had a higher prevalence of sleep disturbances, insomnia and excessive daytime somnolence. No significant seizure- or treatment-related factors influencing sleep could be identified. This study, the first of its kind, revealed that patients with JME have significant sleep disturbances characterized by excessive daytime sleepiness and disturbed night sleep, despite adequate medications and good seizure control. The role of VPA in the genesis of these symptoms needs clarification.

Excessive daytime sleepiness in patients with epilepsy: a subjective evaluation

OBJECTIVE

The main objective of the study was to evaluate excessive daytime sleepiness (EDS) in patients with epilepsy from a tertiary outpatient clinic in Rio de Janeiro, Brazil.

METHODS

Ninety-nine unselected patients from the epilepsy outpatient clinic were invited and their sleep-wake habits were assessed by means of a clinical interview and four validated instruments: Epworth Sleepiness Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Basic Nordic Sleep Questionnaire. Sociodemographic information and characteristics of the epilepsy syndrome were collected.

RESULTS

Complaints about EDS (Epworth Sleepiness Scale score >10) were reported by 47.5% (95% CI: 37.3-57.7) of the patients. In the sample, 52.6% (95% CI: 0.41-0.60) were overweight or obese, and 53.1% (95% CI: 0.43-0.62) had less than 8 years of formal education. Mainly anxiety, but also neck circumference, was correlated with EDS. Our patients did not exhibit quantitative sleep deprivation. No other epilepsy-related variable showed relationship with EDS. The prevalence of EDS in our population was higher than in similar studies performed in other countries. This finding does not seem to be related to epilepsy itself, but rather to other clinical factors, such as neck circumference, and mainly psychiatric factors, such as anxiety.

CONCLUSIONS

Psychiatric comorbidities such as anxiety are linked to EDS and should be recognized and treated. More studies based on objective sleep quality analysis are needed to help elucidate these relationships in the Brazilian population.

Epilepsy and sleep

PURPOSE OF REVIEW

There is a complex relationship between epilepsy, sleep and sleep disorders. Recent studies have provided new insights into the links between the disorders that may facilitate differential diagnosis and treatment but may also improve our understanding of underlying pathophysiological mechanisms.

RECENT FINDINGS

Sleep and sleep deprivation have long been recognized to influence interictal epileptiform discharges and seizures. More recent studies have shown that primary sleep disorders such as obstructive sleep apnoea may worsen epilepsy and treatment of these sleep disorders can lead to improved seizure control. Seizures may interfere with night-time sleep structure and cause excessive day-time somnolence (EDS). Antiepileptic drugs may also cause EDS or influence sleep. Despite more frequent use of video-electroencephalographic telemetry and polysomnography, the differential diagnostic challenges between nonrapid eye movement parasomnia and nocturnal frontal lobe epilepsy remain. There is also ongoing debate regarding the possibility of a common pathogenic background for parasomnias and nocturnal seizures that is summarized in the review.

SUMMARY

Accurate identification and diagnosis of sleep disorders as well as epilepsy is clinically important to ensure optimal treatment of both epilepsy and sleep disorders. Further studies of these nocturnal events may advance our understanding of underlying pathological mechanisms and the complex relationship between sleep and epilepsy.

Sleep characteristics of patients with epilepsy with pure sleep-related seizures

OBJECTIVE

Our aim was to investigate the clinical features and sleep characteristics of patients with pure sleep-related seizures.

METHODS

Patients with pure sleep epilepsy were prospectively enrolled and their clinical, EEG, and MRI findings investigated. The Medical Outcomes Study Sleep Scale (MOS-SS) was administered after receiving consent.

RESULTS

Thirty-nine of 1401 consecutive patients (2.7%) with pure sleep-related seizures were included. Of these, 30 (76.9%) had epilepsy of unknown cause and 7 had epilepsy with known structural etiologies. Twenty-seven patients reported less than one seizure per month and 19 had been seizure free for at least 1 year. Thirty-four patients participated in our MOS-SS study. Comparison of sleep problems between those with epilepsy and healthy controls and between the subgroups with frequent and rare seizures did not reveal significant differences.

CONCLUSION

Patients with pure sleep seizures had mostly undetermined etiology usually with a good prognosis, and this rare condition did not seem to affect their sleep quality.

Sleep disturbances in people with epilepsy; prevalence, impact and treatment

The interaction between epilepsy and sleep is thoroughly studied and is very complex. This review focuses on prevalence, impact on quality of life and effects of treatment of sleep disorders on the course of epilepsy. Self-reported sleep disturbances in people with epilepsy are about twice as prevalent as in healthy controls. People with epilepsy with sleep disturbances have a significant impairment of quality of life compared to those with no sleep disturbances. In children with epilepsy, sleep problems may lead to detrimental effects on daytime behavior and cognition. Most is known about obstructive sleep apnea syndrome (OSAS). Co-morbidity of epilepsy and OSAS is shown to be far higher than expected by chance. Treatment of OSAS significantly improves seizure control in people with epilepsy. More studies on the prevalence of other sleep disorders in people with epilepsy and the effect of treatment are required. Reports on the effect of treatment for other sleep disorders are scarce and not unequivocal.