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Differential diagnosis between nocturnal temporal lobe epilepsy (NTLE) and parasomnia: case report and literature review
Nocturnal epilepsy may be a difficult condition to diagnose. It can often be mistaken as sleep disturbance and has a high mortality rate related to sudden unexpected death in epilepsy (SUDEP). Nocturnal complex partial seizures of temporal lobe are sometimes responsible for phenomena resembling sleep terror or somnambulism and may be associated with violence. We report a case of a patient with a typical history of NREM parasomnia that was diagnosed as nocturnal temporal lobe epilepsy after clinical evaluation and polysomnography.
The purpose of this report is to show the importance of evaluating differential diagnoses facing complex movement during sleep.
A 39-year-old woman was evaluated at our sleep clinic reporting abnormal movements and confusional awakenings during sleep. Symptoms had started 15 years before and were characterized by muscle contractions and occasional urinary incontinence. The patient also mentioned that sometimes she woke up in other rooms of the house, with faucets turned on or home appliances plugged in and running. Since the beginning of the condition phenobarbital and clonazepam were prescribed without improvement of symptoms.
A polysomnography showed two epileptic seizures during slow wave sleep. These episodes lasts approximately four minutes and presented an electroencephalographic pattern of epileptiform activity in all channels. Subsequently, she performed a long-term video-electroencephalography, which evidenced epileptiform discharges like sharp waves over the right temporal region. We diagnosed NTLE and the patient was treated with carbamazepine 200mg twice daily, with significant improvement of her clinical condition.
Seizure during sleep is not a classical feature of NTLE, in these cases, usually there are infrequent and non clustered seizures, with rare familial history of epilepsy. NTLE usually presents during adolescence with seizures nearly exclusively at nighttime sleep. In most cases, seizures are characterized by sudden awakening from sleep with a sensory aura, which progresses to a focal seizure with impaired awareness. It is often associated with amnestic automatisms, mimicking a confusional arousal and are responsible for late diagnosis in several cases.
Distinguishing nocturnal epileptic seizures from complex movement disorders and parasomnia can be challenging. Knowing the differential diagnosis and the diagnostic criteria are essential to properly conduct this case.
Sleep; Seizures; Parasomnia
Relato de Caso
IPQ - HCFMUSP - Sao Paulo - Brasil
Viviane Vieira Passini, Cassio Batista Lacerda, Mariana Delgado Fernandes, Andrea Cecilia Toscanini, Daniel Guilherme Suzuki Borges, Alexandre Pinto de Azevedo, Rosa Hasan