Bi-level VNS therapy with different therapy modes at night and daytime improves seizures and quality of life in a patient with drug-resistant epilepsy.

Induction or aggravation of sleep apnea is a known side effect of vagus nerve stimulation (VNS). We report the case of a 44 year old male with drug-resistant epilepsy and depression who did not experience any seizure reduction after 1 year of VNS but a worsening of depression and daytime sleepiness. After confirming VNS-associated sleep apnea we started the first bi-level VNS therapy with standard VNS settings during daytime and reduced settings during nighttime. Anti-seizure medication remained unchanged. Within 12 months his seizure frequency was reduced by 90 % and his depression improved, permitting a cessation of his antidepressant medication. The observations made in this case have contributed to the manufacturer of VNS developing new generator models that can automatically provide bi-level VNS.

Complex sexual behaviors during sleep as a manifestation of epilepsy: a case series.

STUDY OBJECTIVES: Complex sexual behavior during sleep (CSBS) is a well described clinical entity in nonrapid eye movement (NREM) sleep parasomnias (i.e. sexsomnia). We report a retrospective case series of CSBS as clinical manifestation of epileptic seizures and compare them with the semiology of sexsomnia. METHODS: Video-electroencephalopraphy (EEG)-monitoring data of patients with epileptic and nonepileptic paroxysmal events from one tertiary epilepsy center between 2013 and 2016 were retrospectively reviewed. Clinical features and presurgical, electroclinical, and follow-up data are presented and then discussed in the context of other published cases. RESULTS: From 4,629 patients, 6 patients had CSBS. EEG, single photon emission computed tomography (SPECT), magnetic resonance imaging (MRI), and histopathology confirmed an epileptic origin in four female patients, with temporal or frontal seizures. Two male patients had sexsomnia. None of the epilepsy patients had parasomnias. Clinical criteria to differentiate epileptic from parasomnic CSBS were: events also occurred out of wakefulness; current presence of additional nonsexual manifestations of epilepsy; sexual behavior only as part of a broad spectrum of emotional and motor automatisms; stereotyped behavior pattern without modulability by bystanders; unarousability during the event; no completion of sexual intercourse. The accuracy of the clinical diagnosis was improved by the development of an algorithm comparing patients' fulfillment of the criteria of epilepsy versus parasomnia. CONCLUSIONS: In our cohort, CSBS was a rare ictal phenomenon in temporal or frontal seizures. Symptomatological similiarities with sexsomnia might be explained by the same phylogenetically primitive "central pattern generator" manifesting in ictal CSBS by activation and in sexsomnia by disinhibition. Ictal CSBS should be considered in the differential diagnosis of sexsomnia.

Deep brain stimulation of anterior nucleus thalami disrupts sleep in epilepsy patients.

In view of the regulatory function of the thalamus in the sleep-wake cycle, the impact of deep brain stimulation (DBS) of the anterior nucleus thalami (ANT) on sleep was assessed in a small consecutive cohort of epilepsy patients with standardized polysomnography (PSG). In nine patients treated with ANT-DBS (voltage 5 V, frequency 145 Hz, cyclic mode), the number of arousals during stimulation and nonstimulation periods, neuropsychiatric symptoms (npS), and seizure frequency were determined. Electroclinical arousals were triggered in 14.0 to 67.0% (mean 42.4 ± SD 16.8%) of all deep brain stimuli. Six patients reported npS. Nocturnal DBS voltages were reduced in eight patients (one patient without npS refused) and PSGs were repeated. Electroclinical arousals occurred between 1.4 and 6.7 (mean 3.3 ± 1.7) times more frequently during stimulation periods compared to nonstimulation periods; the number of arousals positively correlated with the level of DBS voltage (range 1 V to 5 V) (Spearman's rank coefficient 0.53121; p < 0.05). No patient experienced seizure deterioration and four patients reported remission of npS. This case-cohort study provides evidence that ANT-DBS interrupts sleep in a voltage-dependent manner, thus putatively resulting in an increase of npS. Reduction of nocturnal DBS voltage seems to lead to improvement of npS without hampering efficacy of ANT-DBS.