Nancy Foldvary-Schaefer, DO, MS
Sleep Disorders and Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
Madeleine Grigg-Damberger, MD
University of New Mexico School of Medicine, Department of Neurology, University of New Mexico, Albuquerque, NM
A 25-year-old, right-handed man with focal epilepsy since age 15 years presented to the epilepsy clinic. His seizures consisted of a visual change that was “like seeing bubbles through a microscope” and lightheadedness that progressed to unresponsiveness with staring, lip smacking, and unintelligible speech lasting 1 to 2 minutes; this was followed by tiredness for several hours. Focal seizures occurred several times per week and secondary generalization once per month despite trials of multiple antiepileptic drugs (AEDs). Birth and development were unremarkable. The patient had had 2 concussions with brief loss of consciousness in early childhood. Neurologic examination was normal.
Video electroencephalogram (EEG) monitoring showed left parieto-occipital spikes (95%) and generalized spike-and-wave complexes (5%). One typical seizure with secondary generalization was recorded as having a generalized, maximal, left-hemisphere EEG pattern. Ictal single-photon emission computed tomography (SPECT; 25-second injection) revealed left temporoparietal hyperfusion. Two subclinical seizures from the left parieto-occipital region were also recorded. Mild bilateral hippocampal atrophy and left hippocampal dysmorphism were seen on magnetic resonance imaging (MRI). Fluorodeoxyglucose (FDG)-positron emission tomography (PET) demonstrated left posterior temporoparietal hypometabolism. The patient underwent intracranial monitoring, which recorded spikes over the left temporo-occipital region, but no seizures were captured. He was discharged with a recommendation to consider vagus nerve stimulation (VNS) therapy.
The patient reported snoring, frequent nocturnal awakenings, and dozing while in sedentary situations. He had a body mass index of 30 kg/m 2, a circumference of 42 cm, and oropharyngeal crowding. He had had a tonsillectomy in childhood, had gained 14 kg in the last 6 months following job loss, and reported feeling depressed. An overnight polysomnogram (PSG) was performed to detect suspected obstructive sleep apnea (OSA). It showed he had moderate OSA (17 obstructive events per hour of sleep) and oxygen desaturation to 67%. Continuous positive airway pressure (CPAP) therapy eliminated snoring and respiratory events and normalized oxygen saturation. The patient was started on CPAP at home, and the frequency of his seizures decreased without further adjustment of his AEDs. Months later, implantation of the VNS device was performed, and he became seizure free for 8 years despite a lead fracture and a battery failure. After 10 years of VNS and CPAP therapy, the patient had recurrence of daytime sleepiness and rare breakthrough seizures, prompting repeat CPAP titration resulting in airway pressure increase. He remains seizure free.
Diagnosis: Intractable focal epilepsy with comorbid obstructive sleep apnea responsive to CPAP and VNS therapy
Questions and Answers:
1. How common are sleep disorders in people with epilepsy?
Sleep disturbances are 2 to 3 times more common in people with epilepsy than in age-matched controls, with insomnia and OSA being the most common. The prevalence of OSA in adults with epilepsy exceeds 40%, with 16% of cases having moderate to severe OSA. Treatment of OSA in patients with epilepsy, using CPAP therapy in adults or tonsillectomy in children, has been shown to reduce seizures, alleviate daytime sleepiness, and improve sleep quality, depressive symptoms, and quality of life. Treatment of moderate to severe OSA has been shown to reduce the risk of hypertension, type 2 diabetes, obesity, cardiac arrhythmia, heart failure, myocardial infarction, stroke, and sudden death during sleep. This patient’s seizures began to improve after CPAP was initiated even before VNS device implantation and remained controlled despite 2 lapses in VNS therapy over time.