Elsevier

Sleep Medicine

Volume 12, Supplement 2, December 2011, Pages S27-S32
Sleep Medicine

Parasomnias and nocturnal frontal lobe epilepsy (NFLE): Lights and shadows – Controversial points in the differential diagnosis

https://doi.org/10.1016/j.sleep.2011.10.008Get rights and content

Abstract

Nocturnal frontal lobe epilepsy (NFLE) is characterized by seizures with complex, often bizarre, violent behaviour arising only or mainly during sleep. These unusual seizures and their occurrence during sleep are often accompanied by normal EEG tracings and neuroradiological findings, making it difficult to distinguish NFLE seizures from other non-epileptic nocturnal paroxysmal events, namely parasomnias. NFLE was described for the first time in 1981, but, as its epileptic origin was controversial, the condition was called nocturnal paroxysmal dystonia. Even though many aspects of parasomnias and NFLE have been clarified in the last two decades, the problem of differential diagnosis remains a challenge for clinicians. This paper discusses some controversial points still under debate. The difficulties in distinguishing nocturnal epileptic seizures from parasomnias reflect just one aspect of the intriguing issue of the pathophysiological relationships between all types of paroxysmal motor behaviours during sleep.

Section snippets

NFLE and parasomnias: The definition

Parasomnias are defined as “clinical disorders that are not abnormalities of the processes responsible for sleep and awake states, but are undesirable physical phenomena that occur predominantly during sleep” [1]. Parasomnias usually manifest as central nervous system activation, with autonomic nervous system changes and skeletal muscle activity. These events tend to occur during childhood, more often with episodic recurrence, but onset or persistence during adulthood is not rare. The

NFLE and parasomnias: The history

The difficulties in the differential diagnosis of motor events occurring during different phases of sleep arose in the early 1970s when prolonged video EEG monitoring, formerly used in the pre-surgical study of epileptic seizures, was applied to sleep studies [8], [9], [10]. In 1977 Pedley and Guilleminault described some cases of episodic nocturnal wandering (ENW) with inconclusive electroencephalography (EEG) recordings, which they considered epileptic in nature because of the bizarre complex

Controversial issues

Even if many aspects regarding parasomnias and NFLE have now been clarified, the problem of differential diagnosis remains the clinical challenge it was in the early 80s, and several controversial issues are the matter of ongoing debate.

Conclusions

So far no single, valid, and reliable diagnostic procedure (including V-PSG) or diagnostic algorithm has been defined for parasomnias and NFLE. First, we need to improve the sensitivity of the diagnostic tools, studying the use of home-made videos before or instead of hospitalization and VPSG. Second it is important to devise common criteria to develop a single classification of motor events occurring during sleep and thereby make VPSG more reliable. In addition, a reliable motor disorders

Disclosure of financial support and conflicts of interest

Professor Lugaresi and Doctors Bisulli, Vignatelli, and Leta have reported no financial support or conflict of interest. Professor Tinuper has consulted for Cyberonics, Eisai, GSK, Janssen-Cilag, Novartis, Sanofi-Aventis, UCB. Doctor Provini has consulted for Sanofi-Aventis.

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