At that examination Patient X showed no focal deficit however, due to the relatively short duration of the headaches and age of onset an E. E. G was ordered to investigate the paroxysmal activity as well as an MRI to check for structural problems. EEG results at that time indicated abnormality due to the presence of epileptiform potentials arising in the right parietal area. Additionally, MRI impressions indicated small bilateral focal areas of high signal in the occipital white matter which suggested post-infectious, inflammatory or ischemic changes.
The patient’s mother was determined to have inadequate pelvis. Therefore the patient was delivered by C-section five weeks before his expected delivery date. The patient also has a positive family history for sinus problems and cited recurrence of headaches with congestion. He suffers from multiple allergies and takes several medicnes for it. The patient displayed no inattention or hyperactivity during his examination. His mother noted no disruption in his academic or social life preceding the seizure and he has no past history of any major illness and no history of head injury in the past.
During the examination the patient was alert and oriented. Displayed higher functions appropriate to his age including the ability to follow third order commands and complete simple calculations and name objects. He was able to read, write and repeat phrases There was no pupil dilation. Examination also indicated that cranial nerves II-XII were intact and there was no indication of a tongue bite or swelling, facial asymmetry, jaw deviation, tongue swelling Discussion Seizures which occur during sleep are known as nocturnal seizures.
These can occur in REM or NREM sleep. Nocturnal seizures are a distinct subset of epilepsy. They are rarely witnessed and hence it is difficult to theoretically characterize the clinical presentation of the disorder. They are often confused with other paroxysmal events like parasomnias1. These seizures profoundly disrupt sleep structure, thus affecting daytime functioning of the patients. 6 year old Patient X presented with generalized seizure without motor activity but with unresponsiveness and a staring look which lasted for atleast 5 minutes during sleep.
Whether he had few other such episodes in the past is not clearly known. But the fact that he had 2 bed wettings in the preceding week and a few episodes of excessive sleepiness during the day time hint at probable seizure history. As mentioned before, exact characterization of nocturnal seizures is difficult. Some of the common clinical presentation of nocturnal seizures include incontinence, tongue biting, confusion, tonic- clonic movements, drooling of saliva and amnesia1. Seizures can occur when the patient is awake too.
Any nocturnal seizure disrupts normal sleep structure. Infact, most of these seizures cause at least a brief awakening. Even brief seizures can result in prolonged alterations in sleep structure1. However, there are many conditions which resemble nocturnal seizures as far as clinical presentation is concerned. Many a times parasomnias are misdiagnosed as nocturnal seizures or a nocturnal seizure is tagged as parasomnia. The most frequent differential diagnosis for nocturnal seizures is a parasomnia1.
A careful history is the most crucial step in arriving at a diagnosis of nocturnal seizures. Both seizures and parasomnias can be paroxysmal and have similar semiology1. ‘Sleep drunkenness’ is a prolonged confusion when awakening usually from the deeper non- REM stages of sleep1. The patient may exhibit many behaviours in this state like arising from bed, stumbling while walking, having slurring or incomprehensible speech and having no memory of the event1.
Confusion with nocturnal seizures occurs because the transient confusion is consistent with post- ictal state or complex partial seizures. Insomnia and idiopathic daytime somnolence are confused with seizures in case of unusual presentation. In case of obstructive sleep apnea, severe hypersomnolence can result in sleep attacks with apparent sudden loss of consciousness leading to confusion with seizures1. In case of sleep terrors, the child suddenly sits up, cries and appears confused, giving the onlooker a picture of seizures.
Sleep terrors can be distinguished from seizures by their exclusive occurrence in sleep combined with characteristic dream imagery, predominant fear and rapid recovery. Somnambulism typically occurs in slow wave period and thus can be differentiated from seizures1. The speech in somniloquy is random whereas in seizures, the speech is stereotype. Sleep enuresis along with other symptoms like drooling, tongue biting and morning muscle soreness prompts to investigate for nocturnal enuresis.
Periodic leg movements may resemble seizures but these movements are not clonic and are typically limited to a single limb, and occur many times during the night at regular intervals1. The symptoms in restless legs syndrome is usually characterized by an itching or burning sensation in the legs and can be suppressed voluntarily1. Narcolepsy can also resemble seizures. However it is a rare condition and excessive daytime sleepiness is very prominent in narcolepsy than in seizures1. Cataplectic attacks can be differentiated form seizures due to their association with strong emotions1.