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or exclusively nocturnal episodes of coarse, occasionally
violent, movements of the limbs associated with tonic
spasms, often occurring multiple times nightly. Vocaliza-
tion or laughter can occur. EEGs between events are
normal; during events, EEGs display movement artifact,
often without clear evidence of electrical seizure activ-
ity. 151 , 152 The cyclic alternating pattern of cortical excit-
ability may play a modulatory role in this condition. 19 It is
clear that NPD is a seizure disorder. 153 NPD may be uni-
lateral, 154 and there can be a family history. 155 Nocturnal
and diurnal paroxysmal dystonia may exist in the same
patient, as can reflex and hypnogenic paroxysmal dystonia.
There is considerable overlap among the different clinical
categories of paroxysmal dyskinesias. 156 NPD may be post-
traumatic 157 and can coexist with panic disorder. 158 Carba-
mazepine is often very effective in eliminating these spells.
Vigilance level-dependent tonic seizures 159 and familial
paroxysmal hypnogenic dystonia 155 likely represent vari-
ants of this condition.
Pure tonic seizures also likely represent a manifestation
of ADNFE with arousal (or paroxysmal polyspike activity
with arousal). They appear as insomnia or hypersomnia
due to seizure-induced arousals or sleep fragmentation. An
interesting subtype of hypnic tonic postural seizures has
been described in 10 children, many with a positive family
history. 160 This may be a benign epilepsy syndrome similar
to benign childhood epilepsy with centrotemporal spikes, 161
childhood epilepsy with occipital paroxysms, 162 , 163 and
primary reading epilepsy. 160
Autonomic or diencephalic seizures are thought to
be rare and could occur with such manifestations as
intermittent or paroxysmal apnea, 91 , 164 stridor, 165 vomit-
ing, 166 coughing, 167 laryngospasm, 168 , 169 chest pain and
arrhythmias, 170-173 paroxysmal flushing, and localized
hyperhidrosis. 174 , 175 Isolated autonomic symptoms are a
well-documented manifestation of seizures and are proba-
bly much more common than generally suspected. These
simple autonomic seizures are easily confused with other
primary or secondary sleep parasomnias or are misattrib-
uted to disorders of other organ systems. 176
myoclonus (such as palatal myoclonus 185 or diaphragmatic
flutter186) 186 ) and paroxysmal dystonia. 187 Respiratory dyskine-
sias may also be the manifestation of neuroleptic-induced
dyskinesias, which do not always persist during sleep. 188
These dyskinesias should be differentiated from unusual
nocturnal seizures that manifest with primarily or exclu-
sively respiratory symptoms. 89
Gastrointestinal Manifestations
The sole manifestation of nocturnal seizures may be par-
oxysmal choking. 189
Case Study
A girl who was 3 years and 9 months old and who
had tuberous sclerosis was referred for evaluation of
progressively severe nocturnal choking and gagging
episodes that began at 1 1 2 years of age. There was
a remote history of diurnal spells, felt to be seizures,
that resolved spontaneously. Aggressive treatment
for gastroesophageal reflux had been ineffective. Her
father, a nurse anesthetist, was so concerned that
she might die during one of these spells that he slept
in the same bed with her and kept an intubation tray
at her bedside.
A sleep study was requested to evaluate for sleep-
disordered breathing, because a tonsillectomy and
adenoidectomy were being considered as treatment
for these nocturnal choking spells. Because of the
possibility of nocturnal seizures, a full-seizure
montage was employed. Numerous paroxysmal gen-
eralized bursts of electrical seizure activity, occasion-
ally associated with coughing or gagging sounds,
were present ( Fig. 92-7 ). Carbamazepine adminis-
tered at bedtime resulted in immediate cessation of
the nocturnal gagging episodes.
Nocturnal Panic Attacks
Nocturnal panic attacks can occur in patients with diurnal
panic or, rarely, can precede the appearance of diurnal
panic. In some cases, panic attacks are exclusively noc-
turnal. 190 The striking similarity of the symptoms of
dream anxiety attack, sleep terrors, nocturnal seizures,
and nighttime panic urges extreme caution in diagnosis.
Obstructive sleep apnea can also cause symptoms of
nocturnal panic attacks. 191 The common association of
the affect of fear as an accompaniment of nocturnal
seizures intensifies their confusion with nocturnal panic
attack. It must be remembered that seizures and panic
can coexist. 192
ELECTRICAL STATUS EPILEPTICUS OF SLEEP
Electrical status epilepticus of sleep (ESES) may be
detected during a polysomnogram (PSG) performed for
other reasons and is characterized by continuous spike and
wave activity during NREM sleep. 177 ESES is seen in chil-
dren who may have a history of seizures or neurologic
dysfunction. The prognosis is variable, because ESES can
be asymptomatic. 178 ESES may share some features with
the Landau-Kleffner syndrome. 179
Cardiopulmonary Manifestations
CARDIAC ARRHYTHMIAS
Cardiac arrhythmias, including asystole, may be a manifes-
tation of seizures masquerading as nocturnal cardiac
abnormalities. 180 , 181 Conversely, primary cardiac events
(e.g., prolonged QT interval) can manifest as seizures. 182
Seizures can manifest as syncope, 183 or vice versa. 184
Psychogenic Dissociative States
Complex and potentially injurious behavior, occasionally
confined to the sleep period, may be the manifestation of
a psychogenic dissociative state (Video 92-8). A history of
childhood physical or sexual abuse, or both, is virtually
always present but may be difficult to elicit. In this condi-
tion, unlike other parasomnias or nocturnal seizures,
during EEG monitoring the complex behavior is seen to
arise from clear EEG-determined wakefulness. 193 Pseudo-
seizures can also arise from apparent sleep. 193
RESPIRATORY DYSKINESIAS
Peculiar respiratory irregularities can occur or persist
during the sleep period. Examples include segmental
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