Non-epileptic paroxysmal manifestations during sleep in infancy and childhood

Repetitive sleep starts: An important differential diagnosis of infantile spasms

OBJECTIVE

Repetitive sleep starts (RSS) are clusters of nonepileptic, spasm-like movements occurring during sleep onset. However, their characteristics have yet to be defined. We conducted a clinicoelectroencephalographic study of children with RSS to clarify their detailed characteristics.

METHODS

To differentiate starts from epileptic spasms, we recruited children with brief "crescendo-decrescendo" muscle contractions that simultaneously involved the limbs and trunk without electroencephalogram changes, and that fulfilled the following criteria: (1) repeated occurrence (five or more) and (2) manifestation during sleep stage N1-N2. A total of nine children met these criteria. Their clinical information and video-electroencephalogram data were analyzed retrospectively.

RESULTS

The background conditions observed at onset of RSS were perinatal hypoxic-ischemic encephalopathy (n = 4), West syndrome of unknown etiology (n = 1), and traumatic brain injury (n = 1). The age at onset of RSS, the number of starts in a given RSS cluster, the interval between starts, and the duration of surface electromyogram activity were between 3 and 46 months, 5 and 547, <1 and 60 s, and 0.3 and 5.4 s, respectively. None of the median value of these parameters differed between children with and without corticospinal tract injury. During the median follow-up period of 33 months, RSS disappeared spontaneously in five.

CONCLUSION

This is the largest case series of RSS clarifying their clinicoelectroencephalographic characteristics reported to date. To avoid unnecessary antiepileptic therapies, clinicians should be aware of RSS and distinguish it from other disorders involving involuntary movements or seizures, especially epileptic spasms.

Development of a Risk Predictive Scoring System for Epilepsy in Infants with Paroxysmal Motor Events: A Retrospective Single-Center Study

Purpose: Paroxysmal motor events are common clinical symptoms in infants visiting pediatric neurology clinics. Due to the heterogeneous clinical symptoms and the difficulty of interpreting electroencephalography (EEG) in infants, differentiating paroxysmal motor events from epileptic events is challenging. This study aimed to investigate the risk factors for the diagnosis of epilepsy in infants and to develop a scoring system that predicts the risk of epilepsy.Methods: We retrospectively analyzed data from patients who presented with paroxysmal motor events in infancy between January 2008 and December 2009 at Asan Medical Center. Electronic medical records were reviewed for patients’ demographics, medical history, clinical characteristics associated with specific situations, and motor symptoms. Laboratory findings, EEG, and brain magnetic resonance imaging were also reviewed. Results: In total, 111 infants with paroxysmal motor events were enrolled. Non-epileptic paroxysmal motor events (NEPMs) were associated with specific situations (P<0.001). Patients with epilepsy were likely to have focal motor symptoms (P=0.08), a medical history of a neurologic disorder, and/or a family history of epilepsy (P<0.05). A risk scoring system was developed based on these risk factors; using this system, infants with 2 or more points could be diagnosed with epilepsy with 61.76% sensitivity and 88.31% specificity.Conclusion: Infants with paroxysmal motor events were more likely to be diagnosed with NEPMs than with epilepsy. An absence of specific situations for paroxysmal events, focal motor seizures, and a medical history of another illness were associated with the final diagnosis of epilepsy.

Sleep and epilepsy in children and adolescents

Epilepsy and sleep disorders are considered by many to be common bedfellows. Several sleep phenomena may occur during nighttime taking a wide variety of forms and which can mimic seizures. Although most seizure sub-types have the potential to occur during sleep or wakefulness, sleep has a well-documented and strong association with specific epilepsy syndromes. Seizures in sleep also tend to occur during lighter stages of non-REM (NREM) sleep. The neurophysiologic process involved in the deepening of NREM sleep may also facilitate both seizures and IEDs. Epilepsy per se and/or seizures themselves promote sleep disruption and significantly affect the quality, quantity, and architecture of sleep. There are many causes of sleep disruption in patients with epilepsy, including inadequate sleep hygiene, coexisting sleep disorders, and circadian rhythm disturbances. Seizures themselves can disrupt sleep, even when they occur during wakefulness. Anti-epileptic drugs (AEDs) can also alter sleep in positive and negative ways, and these effects are independent of anticonvulsant actions. The end result of sleep disruption is excessive daytime sleepiness, worsening seizures, and poor quality of life. Screening for sleep disorders in the epilepsy population and appropriate intervention strategies will lead to overall improved quality of life and seizure control.

Benign neonatal sleep myoclonus: a review of the literature

OBJECTIVE

Neurologically normal term infants sometimes present with repetitive, rhythmic myoclonic jerks that occur during sleep. The condition, which is traditionally resolved by 3 months of age with no sequelae, is termed benign neonatal sleep myoclonus. The goal of this review was to synthesize the published literature on benign neonatal sleep myoclonus.

METHODS

The US National Library of Medicine database and the Web-based search engine Google, through June 2009, were used as data sources. All articles published after the seminal description in 1982 as full-length articles or letters were collected. Reports that were published in languages other than English, French, German, Italian, Portuguese, or Spanish were not considered.

RESULTS

We included 24 reports in which 164 term-born (96%) or near-term-born (4%) infants were described. Neonatal sleep myoclonus occurred in all sleep stages, disappeared after arousal, and was induced by rocking the infant or repetitive sound stimuli. Furthermore, in affected infants, jerks stopped or even worsened by holding the limbs or on medication with antiepileptic drugs. Finally, benign neonatal sleep myoclonus did not resolve by 3 months of age in one-third of the infants.

CONCLUSIONS

This review provides new insights into the clinical features and natural course of benign neonatal sleep myoclonus. The most significant limitation of the review comes from the small number of reported cases.