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      Nocturnal Frontal Lobe Epilepsy Presenting as Obstructive Type Sleep Apnea

      case-report

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          Abstract

          A 20-year-old man presented with sleep apnea. Polysomnography was performed and it revealed nine apneas and two hypopneas. Contrary to typical apnea, however, rhythmic epileptiform discharges appeared at bifrontal area on EEG just before the start of apnoea. Video-EEG monitoring was performed to classify these events, and to evaluate the relationship of apnoea and ictal discharge. Ictal EEG revealed paroxysmal fast activity over the bifrontal area. Ictal SPECT showed hyperperfusion in right frontal area. Given these findings, we concluded that these events were epileptic seizures presenting as obstructive sleep apnea. Antiepileptic medication was initiated, and the events were decreased. This case demonstrates that nocturnal frontal love epilepsy may be the potential cause of obstructive sleep apnea (OSA).

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          Nocturnal frontal lobe epilepsy. A clinical and polygraphic overview of 100 consecutive cases.

          E Lugaresi, G Plazzi, F Provini … (1999)
          Nocturnal frontal lobe epilepsy (NFLE) has been delineated as a distinct syndrome in the heterogeneous group of paroxysmal sleep-related disturbances. The variable duration and intensity of the seizures distinguish three non-rapid eye movement-related subtypes: paroxysmal arousals, characterized by brief and sudden recurrent motor paroxysmal behaviour; nocturnal paroxysmal dystonia, motor attacks with complex dystonic-dyskinetic features; and episodic nocturnal wanderings, stereotyped, agitated somnambulism. We review the clinical and polysomnographic data related to 100 consecutive cases of NFLE in order to define the clinical and neurophysiological characteristics of the different seizure types that constitute NFLE. NFLE seizures predominate in males (7:3). Age at onset of the nocturnal seizures varies, but centres during infancy and adolescence. A familial recurrence of the epileptic attacks is found in 25% of the cases, while 39% of the patients present a family history of nocturnal paroxysmal episodes that fit the diagnostic criteria for parasomnias. A minority of cases (13%) have personal antecedents (such as birth anoxia, febrile convulsions) or brain CT or MRI abnormalities (14%). In many patients, ictal (44%) and interictal (51%) EEGs are uninformative. Marked autonomic activation is a common finding during the seizures. NFLE does not show a tendency to spontaneous remission. Carbamazepine completely abolishes the seizures in approximately 20% of the cases and gives remarkable relief (reduction of the seizures by at least 50%) in another 48%. VideoEEG recordings confirm that NFLE comprises a spectrum of distinct phenomena, different in intensity but representing a continuum of the same epileptic condition. We believe that the detailed clinical and videoEEG characterization of patients with NFLE represents the first step towards a better understanding of the pathogenic mechanisms and different clinical outcomes of the various seizure types that constitute the syndrome.
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            From nocturnal paroxysmal dystonia to nocturnal frontal lobe epilepsy.

            F Provini, G Plazzi, E Lugaresi (2000)
            Nocturnal paroxysmal dystonia (NPD) is the term used to describe motor attacks characterized by complex behavior, with dystonic-dyskinetic or ballic movements arising from NREM sleep. NPD together with paroxysmal arousals (PA), the briefest attacks, and episodic nocturnal wanderings (ENW), the most prolonged ones, constitute nocturnal frontal lobe epilepsy (NFLE). PA are sudden awakenings associated with stereotyped dystonic-dyskinetic movements, sometimes accompanied by screaming and a frightened expression. ENW are episodes of agitated ambulation, with complex, sometimes violent, motor behavior and dystonic postures involving head, trunk and limbs. NPD, PA and ENW coexist in most patients. NFLE is predominant in males and usually begins during adolescence. A familial recurrence of parasomnias in NFLE patients is much more common than in the general population. Autosomal dominant inheritance has been documented in 6% of our cases. Few patients present personal antecedents or positive neuroradiological findings. Seizures are frequent, occurring every or almost every night, many times per night. Interictal wake and sleep EEG tracings are often normal and ictal epileptic activity is recorded in a relatively small number of cases. Carbamazepine controls or significantly reduces seizures in about 70% of cases; the remainder are drug-resistant. Videopolysomnographic recordings, showing stereotyped abnormal movements during attacks, are mandatory to confirm the diagnosis of NFLE.
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              Nocturnal frontal lobe epilepsy misdiagnosed as sleep apnea syndrome.

              A Oldani, M Zucconi, C Castronovo … (1998)
              Some clinical features as the awakenings with feeling of choking, the abnormal motor activity during sleep and the excessive daytime sleepiness are relatively common both in obstructive sleep apnea syndrome and in nocturnal frontal lobe epilepsy. In these cases, a full-night video-polysomnographic monitoring is of the utmost importance to provide a differential diagnosis between the two conditions, and to verify, in the case of the co-existence of the two disorders, which is the one responsible for sleep disruption. In the present case reports, we described 2 patients referred to our Sleep Disorders Center with the above mentioned clinical features and with a previous clinical diagnosis of obstructive sleep apnea syndrome. After the recording of them, by means of full-night video-polysomnography, they were both diagnosed as having nocturnal frontal lobe epilepsy as the main sleep disorder and then successfully treated with carbamazepine.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Epilepsy Res
                Journal ID (iso-abbrev): J Epilepsy Res
                Journal ID (publisher-id): ER
                Title: Journal of Epilepsy Research
                Publisher: Korean Epilepsy Society
                ISSN (Print): 2233-6249
                ISSN (Electronic): 2233-6257
                Publication date Collection: December 2011
                Publication date (Electronic): 30 December 2011
                Volume: 1
                Issue: 2
                Pages: 74-76
                Affiliations
                [1 ]Department of Neurology, Pusan National University Yangsan Hospital;
                [2 ]Department of Neurology, Dankook University College of Medicine, Cheonan, Korea
                Author notes
                Corresponding author: Jae Wook Cho, Department of Neurology, Pusan National University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 626-770, Korea, Tel. +82-55-360-2122, Fax. +82-55-360-2152, E-mail; sleep.cho@ 123456gmail.com
                Article
                Publisher ID: er-1-2-74-7
                DOI: 10.14581/jer.11014
                PMC ID: 3952334
                SO-VID: c4b72de2-0b5e-43eb-8757-e11c7571c7c1
                Copyright © Copyright © 2011 Korean Epilepsy Society
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 15 November 2011
                Date accepted : 30 November 2011
                Categories
                Subject: Case Report

                Keywords: obstructive sleep apnea,epilepsy,epileptic apnea,apneic seizure,nocturnal frontal lobe epilepsy
                Data availability:
                Keywords: obstructive sleep apnea, epilepsy, epileptic apnea, apneic seizure, nocturnal frontal lobe epilepsy

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