The diagnosis of complex nocturnal behaviors is among the most difficult to establish in sleep medicine clinics and laboratories. VPSG-EEG is indicated in the evaluation of patients with complex nocturnal behaviors when routine EEG is nondiagnostic. Ongoing research is necessary to fully elucidate the pathophysiology of these disorders, which share a host of clinical manifestations.
A 48-year-old athletic man with history of dyslipidemia and seconddegree atrioventricular block (Mobitz type I 2:1 atrioventricular block) endorses sleeprelated difficulties at his annual physical examination. Mobitz type I block was diagnosed 11 years earlier when the patient presented to his primary care physician with left-sided chest pain for 2 months. He was evaluated by cardiology, with a normal stress echocardiogram. The impression was that the chest pain was nonanginal. He describes sleeping for only a few hours at a time and has nighttime awakenings. He does not wake up feeling refreshed. He experiences passive daytime sleepiness and evening somnolence. He is very active, runs every day, and has participated in several half-marathons. He currently undergoes high-intensity interval training, including running and lifting. Per his wife, the patient snores loudly and has apneic episodes during sleep. One of his siblings has OSA. He denies excessive sleepiness, with an Epworth Sleepiness Scale score of 2.
This case illustrates diagnostic challenges in patients with epilepsy and suspected sleep disorders. Specifically, the symptomatic generalized epilepsy Lennox-Gastaut syndrome is an age-related epileptic encephalopathy characterized by developmental delay; multiple seizure types, including tonic seizures in drowsiness and sleep; and generalized slow spike-wave complexes on electroencephalography (EEG). Tonic seizures in sleep can be unrecognized or can be confused with sleep disorders such as sleep apnea. The case demonstrates how to identify generalized epileptic abnormalities and seizures on the limited EEG montage used in routine polysomnography and expanded EEG using the 10-20 system of electrode placement.
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