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Objective There is evidence for central nervous system complications of coronavirus disease 2019 (COVID-19) infection, including encephalopathy. Encephalopathy caused by or arising from seizures, especially nonconvulsive seizures (NCS), often requires electroencephalography (EEG) monitoring for diagnosis. The prevalence of seizures and other EEG abnormalities among COVID-19-infected patients is unknown. Methods Medical records and EEG studies of patients hospitalized with confirmed COVID-19 infections over a 2-month period at a single US academic health system (four hospitals) were reviewed to describe the distribution of EEG findings including epileptiform abnormalities (seizures, periodic discharges, or nonperiodic epileptiform discharges). Factors including demographics, remote and acute brain injury, prior history of epilepsy, preceding seizures, critical illness severity scores, and interleukin 6 (IL-6) levels were compared to EEG findings to identify predictors of epileptiform EEG abnormalities. Results Of 111 patients monitored, most were male (71%), middle-aged or older (median age 64 years), admitted to an intensive care unit (ICU; 77%), and comatose (70%). Excluding 11 patients monitored after cardiac arrest, the most frequent EEG finding was moderate generalized slowing (57%), but epileptiform findings were observed in 30% and seizures in 7% (4% with NCS). Three patients with EEG seizures did not have epilepsy or evidence of acute or remote brain injury, although all had clinical seizures prior to EEG. Only having epilepsy (odds ratio [OR] 5.4, 95% confidence interval [CI] 1.4-21) or seizure(s) prior to EEG (OR 4.8, 95% CI 1.7-13) was independently associated with epileptiform EEG findings. Significance Our study supports growing evidence that COVID-19 can affect the central nervous system, although seizures are unlikely a common cause of encephalopathy. Seizures and epileptiform activity on EEG occurred infrequently, and having a history of epilepsy or seizure(s) prior to EEG testing was predictive of epileptiform findings. This has important implications for triaging EEG testing in this population.

Children with cleft and craniofacial conditions commonly present with concurrent airway anomalies, which often manifest as sleep disordered breathing. Craniofacial surgeons and members of the multidisciplinary team involved in the care of these patients should appreciate and understand the scope of airway pathology as well as the proper means of airway assessment. This review article details the prevalence and assessment of sleep disordered breathing in patients with craniofacial anomalies, with emphasis on indications, limitations, and interpretation of polysomnography.

Introduction During the first surge of the COVID-19 pandemic in New York City, as New Yorkers were enjoined by authorities to stay-at-home, patient encounters were transitioned from office visits to telemedicine consultations. It was thought that increased stress during the pandemic would worsen rates of insomnia, and concerns regarding use of positive airway pressure (PAP) therapy during a respiratory pandemic would affect compliance. We sought to describe telemedicine success rates, the distribution of sleep problems evaluated remotely by telemedicine, and PAP compliance in our patient population. Methods Telemedicine encounters from March 16th through May 31st, 2020, were reviewed for show-rates, patient characteristics and clinician impressions, and were compared to administrative data from the 2.5 months prior to the stay-at-home period (the “control period”). PAP compliance was analyzed for forty randomly selected patients established on PAP therapy between January 1st and October 1st, 2019, and whose machines transmitted data to a digital management system between October 1st and December 31st, 2019. Compliance reports and AHI were compared between the stay-at-home- and control- periods for this randomly selected group of patients. Results The telemedicine show rate was 89.37% (compared to a 91.91% in-office show-rate during the control period); all these encounters were successfully completed. Sleep apnea was the predominant diagnosis during the stay-at-home period (44.33% of encounters), followed by insomnia (23.16%). Insomnia complaints were significantly higher during the stay-at-home period compared to the control period (23.16% versus 14.6% of encounters; p < .05), and among new- versus follow-up- patients (41.76% versus 35.99%). PAP compliance and AHI, however, were not statistically different for forty randomly selected patients between the control and stay-at-home periods. Conclusion Most stay-at-home period telemedicine encounters were successful. Sleep apnea, then insomnia, were common findings among new and follow-up patients during the stay-at-home period, and insomnia rates increased during the pandemic. PAP compliance and AHI were similar in a random cohort when compared between the stay-at-home and control periods. Support (if any)

Introduction The 2020 Coronavirus disease 19 (COVID-19) pandemic has infected and killed millions of persons. To avoid virus spread, stay-at-home orders and social distancing measures were implemented worldwide. These measures have caused changes in work schedules and, subsequently, sleep habits. This study aims to examine sleep disturbances, anxiety and depression in a random community in Havana, Cuba during the pandemic lockdown period. Methods This a descriptive cross-sectional study performed in a randomly selected neighbourhood, via direct door-to-door survey. We applied four different surveys:1) Pittsburgh Sleep Quality Index (PSQI);2) Insomnia Severity Index (ISI);3) Epworth Sleepiness Scale (ESS) and 4) Hospital Anxiety and Depression Scales (HADS) questionnaire. Descriptive statistics will be applied using StatSoft, Inc. (2011) STATISTICA (data analysis software system), version 10. HYPERLINK “http://www.statsoft.com” www.statsoft.com Results A total of 366 adult subjects were surveyed and abnormal values were observed in the following percentages: 60.65% in the PSQI, 34.51% in the ISI, 14.74% in the ESS and 36.61% in the HADS for depression and 40.43% in the HADS for anxiety. Poorer sleepers and depression were more common women and elderly (p Conclusion There were sleep quality disruption in large percentage of subjects during the COVID-19 pandemic lockdown. Poor sleep and depression were worse in women and the elderly. Insomnia and anxiety were seen more in younger subjects that continue to work during this time. Support (if any)

Objective Recent data suggest that both disordered sleep and low serum iron occur more frequently in children with autism compared with children with typical development. Iron deficiency has been linked to specific sleep disorders. The goal of the current study was to evaluate periodic limb movements in sleep and iron status in a group of children with autism compared with typically developing children and children with nonautism developmental delay to determine if iron status correlated with polysomnographic measures of latency and continuity and periodic limb movements in sleep. Methods A total of 102 children (68 with autism, 18 typically developing, 16 with developmental delay) aged 2 to 7 years underwent a one-night modified polysomnography study and phlebotomy at the National Institutes of Health to measure serum markers of iron status (ferritin, iron, transferrin, percent transferrin saturation). Results No serum iron marker was associated with periodic limb movements of sleep or any other sleep parameter; this did not differ among the diagnostic groups. No significant differences among groups were observed on serum iron markers or most polysomnogram parameters: periodic limb movements in sleep, periodic limb movements index, wake after sleep onset, or sleep efficiency. Children in the autism group had significantly less total sleep time. Serum ferritin was uniformly low across groups. Conclusions This study found no evidence that serum ferritin is associated with polysomnogram measures of latency or sleep continuity or that young children with autism are at increased risk for higher periodic limb movements index compared with typically developing and developmental delay peers.

Background Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia. Methods We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Results Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy. Conclusions Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.

Narcolepsy is a neurologic disorder characterized by excessive daytime sleepiness and manifestations of disrupted rapid eye movement sleep stage. The pathologic hallmark is loss of hypocretin neurons in the hypothalamus likely triggered by environmental factors in a susceptible individual. Patients with narcolepsy, in addition to excessive daytime sleepiness, can present with cataplexy, sleep paralysis, sleep fragmentation, and hypnagogic/hypnopompic hallucinations. Approximately 60% to 90% of patients with narcolepsy have cataplexy, characterized by sudden loss of muscle tone. Only 15% of patients manifest all of these symptoms together. Narcolepsy can be misdiagnosed as a psychiatric disorder or even epilepsy. An appropriate clinical history, polysomnogram, Multiple Sleep Latency Test, and, at times, cerebrospinal fluid hypocretin levels are necessary for diagnosis. The treatment of narcolepsy is aimed toward the different symptoms that the patient manifests. Excessive daytime sleepiness is treated with amphetamine-like or non-amphetamine-like stimulants. Cataplexy is treated with sodium oxybate, tricyclic antidepressants, or selective serotonin and norepinephrine reuptake inhibitors. Sleep paralysis, hallucinations, and fragmented sleep may be treated with benzodiazepine hypnotics or sodium oxybate. Patients with narcolepsy should avoid sleep deprivation, sleep at regular hours, and, if possible, schedule routine napping.

Rapid eye movement (REM) sleep is greatest in the developing brain, is driven by acetylcholine, and may represent a protected time for neuroplasticity. Recently published data from our lab observed that children with autism spent significantly less time in this state during a single night recording than did typically developing children and those with developmental delay without autism. The objective of this study was to determine whether or not donepezil can increase the REM % in children with diagnosed autism spectrum disorder (ASD) found to have REM % values of at least two standard deviations below expected for age.Five subjects found to have an ASD (ages 2.5-6.9 years) and demonstrated deficits in REM sleep compared with within-lab controls were enrolled in a dose finding study of donepezil. Each subject was examined by polysomnography for REM sleep augmentation after drug administration.REM sleep as a percentage of Total Sleep Time was increased significantly and REM latency was decreased significantly after drug administration in all subjects. No other observed sleep parameter was changed significantly.Donepezil can increase the amount of time that children with an ASD spend in the REM sleep state. A double-blind, placebo-controlled trial is needed to assess the association between REM sleep augmentation and learning, cognition, and behavior in such children.

Objective Panayiotopoulos syndrome is a benign idiopathic childhood epilepsy characterized by altered autonomic activity at seizure onset. Methods Three siblings with Panayiotopoulos syndrome underwent 24-hour EEG recording and head-up tilt testing with continuous blood pressure and RR interval monitoring. Plasma catecholamines and vasopressin were measured while supine, upright, and during a typical seizure. Results Patient 1, a 12-year-old girl, had a history of involuntary lacrimation, abdominal pain, and recurrent episodes of loss of muscle tone and unresponsiveness followed by somnolence. Her EEG revealed bilateral frontotemporal spikes. Patient 2, a 10-year-old boy, had episodic headaches with pinpoint pupils, skin flushing of the face, trunk, and extremities, purple discoloration of hands and feet, diaphoresis, nausea, and vomiting. Tilt testing triggered a typical seizure after 9 minutes; there was a small increase in blood pressure (+ 5/4 mm Hg, systolic/diastolic) and pronounced increases in heart rate (+ 59 bpm) and norepinephrine (+ 242 pg/mL), epinephrine (+ 175 pg/mL), and vasopressin (+ 22.1 pg/mL) plasma concentrations. Serum glucose was elevated (206 mg/dL). His EEG revealed right temporal and parietal spikes. Patient 3, an 8-year-old boy, had a history of restless legs at night, enuresis, night terrors, visual hallucinations, cyclic abdominal pain, and nausea. His EEG showed bitemporal spikes. Conclusion Hypertension, tachycardia, and the release of vasopressin suggest activation of the central autonomic network during seizures in familial Panayiotopoulos syndrome. These autonomic and neuroendocrine features may be useful in the diagnosis and may have therapeutic implications.

To compare objective polysomnographic parameters between 3 cohorts: children with autism, typical development, and developmental delay without autism.Overnight polysomnographic recordings were scored for sleep architecture according to American Academy of Sleep Medicine criteria by a board-certified sleep medicine specialist blind to diagnosis for studies collected between July 2006 and September 2009.Subjects were evaluated in the pediatric ward in the Clinical Research Center of the National Institutes of Health.First 60 consecutive children with autism, 15 with typical development, and 13 with developmental delay matched for nonverbal IQ to the autism group, ranging in age from 2 to 13 years, selected without regard to the presence or absence of sleep problem behavior.Total sleep time, latencies to non-rapid eye movement (REM) and REM sleep, and percentages of total sleep time for stages 1 and 2 sleep, slow-wave sleep, and REM sleep.There were no differences between the typical vs developmental delay groups. Comparison of children with autism vs typical children revealed shorter total sleep time (P = .004), greater slow-wave sleep percentage (P = .001), and much smaller REM sleep percentage (14.5% vs 22.6%; P .001). Comparison of children with autism vs children with developmental delay revealed shorter total sleep time (P = .001), greater stage 1 sleep percentage (P .001), greater slow-wave sleep percentage (P .001), and much less REM sleep percentage (14.5% v 25%; P .001).A relative deficiency of REM sleep may indicate an abnormality in neural organization in young children with autism that is not directly associated with or related to inherent intellectual disability but may serve as a window into understanding core neurotransmitter abnormalities unique to this disorder.

SUMMARY : The EEG is helpful in the evaluation of patients with altered mental status and can provide clues for the underlying cause of certain entities. There are few descriptions of the EEG findings in patients with West Nile virus (WNV) infection. We describe the clinical presentation as well as the electroencephalographic findings in five patients with WNV encephalitis. Review of the records of all cases of WNV infection seen at the Mayo Clinic from 1999 to 2003, in which an EEG had been performed. Five patients with WNV encephalitis, in whom an EEG was performed, were found. All the patients had altered mental status and the EEG showed moderate to severe degrees of generalized slowing. Three of the patients had triphasic waves on the EEG. The patients did not have any metabolic disorder or electrolyte abnormalities that could account for these findings. EEG findings in WNV are consistent with an encephalopathic pattern and show varying degrees of generalized slow wave abnormalities and in some cases triphasic waves.

To determine the localizing value of electroencephalography (EEG) for seizures during sleep versus seizures during wakefulness, we compared scalp EEG for 58 seizures that occurred during sleep with 76 seizures during wake in 28 consecutive patients with temporal lobe epilepsy. Regression analysis showed that seizures during sleep are 2.5 times more likely to have focal EEG onset (p = 0.01) and 4 times more likely to correctly localize seizure onset (p = 0.04) than seizures during wake. EEG seizure onset preceded clinical onset by a longer duration in sleep seizures (mean, 4.69 s) than in wake seizures (mean, 1.23 s; p < 0.01). Sleep seizures showed fewer artifacts, but the difference was not significant (p = 0.07). For temporal lobectomy candidates undergoing video-EEG monitoring, the recording of seizures during sleep may be favored.

Sleep disorders are common in childhood. The prevalence of childhood sleep disorders is higher in chronic neurologic disorders, specifically epilepsy. Sleep needs, requirements, and structure are different in children compared with adults. These variables are disrupted severely in patients with epilepsy. Electroencephalogram abnormalities, nocturnal seizures, and medications may contribute further to sleep problems and affect daytime functioning. These sleep disturbances may worsen seizure control and affect quality of life. This article offers an overview of the normal sleep patterns in children, describes the interaction of electroencephalogram, sleep, and commonly found sleep disorders, and reviews the current literature of the main sleep disturbances found in children with epilepsy.

We used regression analysis to compare the semiologic features of temporal lobe seizures that occur during sleep (TLS-S) and wake (TLS-W) in the same patient. Most semiologic features correctly lateralized seizure activity during either sleep or wake. No significant differences were found between TLS-S and TLS-W in the 18 semiologic features analyzed. The diagnostic value of TLS-S semiology is similar to that of TLS-W semiology.

A 56-year-old woman presented with an acute confusional state and moderate global aphasia. Thyroperoxidase antibody level was elevated (3,890 IU/mL) and SREAT was diagnosed. MRI findings were normal. Cerebrospinal fluid examination revealed only a mildly increased protein. The initial electroencephalogram EEG showed slowing and markedly decreased amplitude over the left hemisphere and left temporal sharp waves. An EEG performed after treatment with intravenous steroids showed a significant improvement of the background slowing, which correlated with clinical improvement. One week later, the patient had an episode of forced head-turning and fencing posture to the right. The EEG shortly afterward showed slowing and a decreased amplitude over the right hemisphere. Continuous EEG monitoring was performed at the time of steroid treatment. Again, there was a significant improvement of the EEG after this treatment that correlated with the clinical condition. SREAT is characterized by fluctuations in mental status and variable EEG findings. These patients often show an excellent clinical improvement to immunosuppressive therapy, including corticosteroids. This case report documents the dramatic clinical and EEG improvement with steroid therapy.