1062 Differentiating confusional parasomnias from nocturnal frontal lobe epilepsy

It can be clinically challenging to differentiate nocturnal frontal lobe epilepsy (NFLE) from parasomnias. Delays in effective treatment due to diagnostic error are not uncommon. A 66-year-old woman was referred for management of adult night terrors. Her first incident occurred in 2007 followed by further incidents every few months until an apparent remission from 2009–2012. The incidents, however, returned in 2012 and persisted. She would awaken from sleep complaining of abdominal pain. She would then scream and yell repeatedly “I am sick” while appearing confused. She could follow simple commands during the incidents. She was able to recall part of the event in the morning. These events occurred in the middle to late sleep period and could happen several times per night. She was hospitalized for these multiple times in 2007 and 2008 and told the episodes were caused by a peri-infectious psychosis due to a urinary tract infection. The episodes improved with oral antibiotics and lorazepam in 2009 but returned despite these medications in 2012. Polysomnography in 2013 and 2018 showed no sleep-related breathing disorder, electroencephalographic abnormality, or unusual behaviors. Routine electroencephalograms were normal. Imaging of the head with CT was normal. Physical and neurological exam showed only slightly decreased strength and sensation in the lower extremities. In 2018 she was admitted to our epilepsy monitoring unit. During this admission she had multiple partial seizures originating from the left frontotemporal region during sleep. She was placed on anti-seizure medication and no longer experiences the behavioral events out of sleep. NFLE and parasomnias can present with dramatic and bizarre behavior out of sleep. Diagnosis in an epilepsy monitoring inpatient unit (EMU) is expensive and may not have a high yield if episodes are infrequent. Misdiagnosis can occur in the absence of generalized tonic clonic seizures.