Impact of sleep on the localizing value of video EEG in patients with refractory focal seizures – A prospective video-EEG with EOG and submental EMG study

• Sleep may have important implications for presurgical assessment of refractory epilepsy.
• The relationship and the role sleep plays in the occurrence and spread of seizures is unclear.
• We comprehensively assess the role of sleep in Video Electroencephalography (VEEG) localization of seizures, which may help in the management of difficult presurgical cases.

ObjectivesTo examine the role of sleep and its stages on the localizing value of video EEG in the evaluation of refractory focal seizures.MethodsVideo-electroencephalographic (VEEG) evaluation with additional polygraphic recording was carried out for 70 consecutive patients with refractory focal epilepsy, undergoing pre-surgical evaluation, over a two-year period. Localization of video EEG for each seizure was made based on clinical, ictal and interictal data. Seizure localization in each patient was assessed for concordance with MRI and other imaging data (SPECT, PET) for both wake and sleep seizures. Interictal discharges in sleep and wake were similarly compared for concordance with imaging data.ResultsA total of 608 seizures were recorded in 70 patients, 289 in sleep. Overall, concordance with imaging data was found in 218 out of 322 wake seizures (67.8%) and in 157 out of 286 sleep seizures (54.8%) (p = 0.0314). On analyzing the subset of patients with seizures recorded in both wake and sleep states (total 279 seizures recorded, 113 out of sleep), concordance was observed in 93 out of 166 (56%) wake seizures and in 80 out of 113 (70.7%) sleep seizures (OR 2.03, 95% CI 1.17 to 3.56; p 0.007). Interictal discharges were more common and more precisely localizing in sleep, mostly in stage N2.ConclusionsThis prospective VEEG-PSG study demonstrates the role of sleep versus wake state in the localizing value of different components of long-term VEEG recording for patients with medically refractory epilepsy. Our findings show that while wake state ictal EEG has more localizing value in a mixed group of patients, sleep ictal and interictal EEG is significantly more useful in patients who have seizures recorded both during wake and sleep states. In addition, interictal discharges recorded during NREM sleep have high localizing value.SignificanceThis is only the second study elucidating the effect of sleep on the localizing value of video-electroencephalographic evaluation of patients with medically refractory focal epilepsy; mainly revealing high value of sleep interictal discharges and that sleep ictal recording has two times higher localizing value than wake ictal recording, among patients in whom seizures are recorded in both states.