Sleep-Related Seizures in Children: Cohort Study from a Tertiary Center

Sleep-Related Seizures in Children: Cohort Study from a Tertiary Center | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sleep-Related Seizures in Children: Cohort Study from a Tertiary Center Christine Salama, Marian Girgis, Hala Elhabashy, Mona Kamel, Yara Shahin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6220612/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Aug, 2025 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted 4 You are reading this latest preprint version Abstract Background and objective: Sleep-related epilepsy (SRE) is nocturnal seizures that manifest during the sleep state. It affects 12%-20% of epileptic patients, specifically those suffering from focal epilepsy. SRE is often misdiagnosed as a sleep disorder, especially in cases where the seizures manifest exclusively during sleep. This work aimed to study SRE, etiology, semiology, and electroencephalogram (EEG) characters and to determine their outcome regarding seizure control on properly selected anti-seizure medications (ASMs). Methodology: This study enrolled one hundred patients who fulfilled the inclusion criteria. All of them were subjected to history taking, full examination, seizure semiology analysis, inter-ictal EEG recordings, and magnetic resonance imaging (MRI). Results: Patients with self-limited epilepsy with centro-temporal spikes (SeLECTS) were the most common epilepsy syndrome (52%), followed by sleep-related hypermotor seizures (SHE) (33%), then patients with self-limited epilepsy with autonomic symptoms (SeLEAS). Around 79% of the patients had sleep seizures, while 21% had seizures during sleep and wakefulness. Also, oxcarbazepine (OXC) was the most used first ASM in 62% of our patients, followed by levetiracetam (LEV) in 28% of the patients. Conclusion: SeLECTS, SHE, and SeLEAS are three of the most frequently implicated epilepsy syndromes occurring during the sleep state. Oxcarbazepine was the most effective drug to control seizures. Sleep-related epilepsy Epilepsy syndrome Seizures semiology EEG brain MRI Anti-seizure medications Figures Figure 1 Figure 2 Introduction The relationship between sleep and epilepsy is intricate and influenced by multiple factors. Sleep is divided into two main phases. The stages of sleep can influence both the activation and inhibition of epileptic activity in the brain, with NREM sleep facilitating epileptic activity while REM sleep inhibits it [ 1 ]. Additionally, sleep has the potential to provoke seizures, and a lack of sleep heightens the likelihood of seizures by increasing cortical excitability and lowering the seizure threshold [ 2 ]. Epilepsy can interfere with the structure and quality of sleep, resulting in sleep disturbance and additional comorbidities such as sleep apnea and restless legs syndrome. It also plays a role in causing significant daytime drowsiness and tiredness, effects that can be worsened by the sedative properties of seizure medications (ASMs) [ 2 ]. Sleep-related epilepsy (SRE) is a form of epilepsy where seizures primarily happen during sleep. This condition is recognized as a specific category of epilepsy syndromes and is defined by a strong connection between the occurrence of seizures and sleep-wake patterns. Seizures that happen solely at night make up about 12–20% of all seizures [ 3 ]. While the fundamental mechanisms of SRE remain incompletely understood, one potential contributing factor may be the impact of sleep-associated neuronal and physiological changes on seizure threshold and excitability. Fluctuations in neurotransmitter levels, shifts in neuronal synchronization, and variations in cortical excitability during sleep can increase the likelihood of seizures in vulnerable individuals [ 4 ]. Over the past decade, the discovery of numerous pre-disposing genes and the availability of advanced diagnostic tools have shed more light on the nature of SRE [ 5 ]. Distinguishing nocturnal seizures from non-epileptic parasomnia can be challenging. A careful clinical history, knowledge of key features of seizure syndromes and parasomnia, and video-electroencephalogram (EEG) monitoring are helpful in avoiding misdiagnosis or redundant treatment with ASMs [ 6 ]. Thus, the current work aimed to study sleep-related epilepsy epidemiology, etiology, and syndromic classification according to seizure semiology and EEG characteristics and to correlate their outcome with seizure control on properly selected ASMs. Patients and methods This is a prospective cohort observational study that included 100 patients who were diagnosed as SRE recruited from Neuro-pediatric outpatient clinics in the Pediatric department of a tertiary university-based pediatric hospital from February 2023 to July 2024 to discuss the predominance of SRE, semiology, and EEG characteristics in children presenting with sleep-related seizures and to determine their outcome regarding seizure control on properly selected ASMs. Patients recruited prospectively were followed for a period of at least 6 months. The study included children younger than 18 years old who were diagnosed with SRE and had nocturnal epilepsy evidenced by seizure semiology taken from history and proved by home video, including Sleep-related hypermotor seizures (SHE), Self-limited epilepsy with centro-temporal spikes (SeLECTS), Self-limited epilepsy with autonomic symptoms (SeLEAS), as well as awakening epilepsy, e.g., Juvenile myoclonic epilepsy (JME). The study excluded patients who are non-compliant with ASMs, patients who have hypoxic-ischemic encephalopathy, patients with inborn metabolic abnormalities (genetic or acquired), and those with cardiac, renal, or any other systemic illnesses. Sample size: The sample size to study the results of the current study with a significant P < 0.05 is calculated with reference to Ashry et al. [7] and according to the formulan ≥ [Z 2 1- α /2 x p (1-p)] / d 2 , Z 1-α/2 = 1.96, p = 0.05, d (absolute error) = 0.05. So, n = 259. By adding 35% as a drop-out rate, at least 100 participants should be recruited. Ethics approval and consent to participate: The study protocol was reviewed and approved by the institutional Ethical Research Committee (Code MD-78-2023). The procedure and the aim of the study were clearly explained to the study participants/ their legal guardians. Before enrollment in the study, written informed consent was obtained from the participants’ legal guardians with an explanation of the benefits and drawbacks of the procedure. The subject was free to withdraw from the study at any moment; participation was entirely voluntary. In accordance with the Declaration of Helsinki, all steps of data collecting, entry, and analysis were conducted in a highly confidential and private manner. History was taken from all patients’ mothers, including sociodemographic data, present, past, perinatal, developmental, and family histories, with an emphasis on the seizure's timing, type, and semiology as well as ASM and compliance to them. The syndromic classification was attempted for every patient according to the semiology of seizures into sleep-related hypermotor epilepsy (SHE), probably self-limited epilepsy with centrotemporal spike (SeLECTS), self-limited epilepsy with autonomic seizures (SeLEAS), and juvenile myoclonic epilepsy (JME). A sleep behavior questionnaire was also done. All study participants were subjected to thorough general and neurological examinations, as well as other systemic examinations, to exclude any generalized systemic illness and identify any associated central nervous system (CNS) disorders. Radiological investigations were conducted, including EEG monitoring to assess seizure semiology, inter-ictal epileptiform discharge, and ictal video-EEG if possible [8]. If the type of nocturnal events the patient experienced was uncertain, video-EEG monitoring was performed [4]. Seizure semiology was described according to the new International League Against Epilepsy (ILAE) classification 2017 [9]. All study participants were subjected to brain magnetic resonance- imaging (MRI); In cases resistant to treatment, an optimized epilepsy protocol with adequate spatial resolution and multiplanar reformatting was essential [10]. Blinding: The subjects included were blindly submitted to seizure semiology analysis by two neurologists who were not aware of the original preassessment diagnosis. Statistical methods: Data entry was carried out using SPSS (Statistical Package for Social Science) version 24.0 (IBM ® , SPSS, USA). Variables were examined for normality. Categorical variables were expressed in numbers and percentages; Chi-square and Fisher’s exact tests were applied as appropriate. Continuous variables were expressed using mean and standard deviation or median for normally distributed data and interquartile range for not normally distributed data; the T-test, Mann Whitney, and other tests of significance were used for comparison as appropriate. P value <0.05 was considered significant. Results The current study included 100 patients who fulfilled the inclusion criteria. The mean age of the patients was 10.23±3.11 years, with a minimum age of 3 years and a maximum of 17 years. The males were predominant, with 65%. Notably, 68 patients (68%) were born by elective CS. The majority (92%) were full-term, and 18 patients (18%) were admitted to the neonatal intensive care unit (NICU). Almost half of the cases (47%) had a relevant family history of epilepsy, and 22% had positive consanguinity. Only one patient showed delayed mental development, and two patients had delayed motor development. Regarding seizure characterization, 92 patients (92%) had idiopathic etiology, while only 8% considered symptomatic cases of underlying etiology. The mean ± standard deviation (SD) duration of active fits among the study patients was 2.52±2.24 years. The frequency of fits among the study participants had a median of 0.3 with an interquartile range (IQR) of 0.15-1 fits/month with a median (IQR) duration of 3 (1-7) minutes per fit. A significant majority of the patients (78%) experienced controllable seizures. Of the 22 uncontrollable cases, 13 patients had SHE, seven patients had SeLECTS, one patient had JME, and another patient had focal symptomatic epilepsy. The most common type was focal seizures, representing 52% of the study cohort. Most patients reported seizures during sleep only, at the start of sleep, and once per night (70%, 79 and 81%, respectively). Only 36 patients of the study cohort had specific associated symptoms, but a patient may have more than one symptom. Salivation was the most common (25%), followed by vomiting (19.4%) ( Figure 1 ) . Seizure-associated behavioral changes occurred in 52 patients (52%), 43 of whom (83%) were irritable, 4 (8%) were hyperactive, and 5 (9%) were both irritable and hyperactive. The inter-ictal EEGs of the studied patients revealed abnormalities in 84% of the cases. However, MRI findings were abnormal in only 14% of the cases (Table 1). Table (1): Characteristics of abnormal inter-ictal EEG findings of the studied population. Studied Patients N % Inter-ictal EEG (n=84) Side Right 27 32% Left 37 44% Bilateral 17 20% Generalized 3 4% Affected lobe (n=81) Frontal 15 18.5% Occipital 4 5% Centro- temporal 52 64.2% Fronto- temporal 10 12.3% Brain MRI (n=14) Focal cortical dysplasia 3 21.5% Gliosis 2 14.5% Mesial sclerosis 1 7% Gyration anomaly 1 7% Frontal patchy area of increased signal 1 7% Other findings not related to the symptomatic etiology* 6 43% * Periventricular leukomalacia, temporal arachnoid cyst, colpocephaly with attenuation of the body of corpus callosum, and an old infarction. Regarding the first-line ASM, Oxcarbazepine was the most frequently prescribed, used by 62 patients (62%), followed by Levetiracetam, prescribed to 28 patients (28%). In contrast, the second-line ASM, Levetiracetam, was used in 15 patients (15%), and Oxcarbazepine was used in 12 patients (12%). As regards the third-line ASM, Oxcarbazepine was used in 3 patients (3%). A minority of patients used Lacosamide, Lamotrigine, Clonazepam, Perampanel, and Topiramate. Concerning sleep behavior, the mean amount of sleep for all patients was 8.92±1.11 hours, ranging from 6 to 13 hours. As for the effect of seizures on sleep quality, 42 patients (42%) experienced decreased sleep, while 58 patients (58%) had normal sleep quality. A variety of sleep-related phenomena were observed among the studied patients. Specifically, 36 patients (36%) were identified as grinding their teeth nocturnally, 30 patients (30%) were reported to have significant movement during sleep, 14 patients (14%) exhibited sleep talking, while five patients (5%) demonstrated sleepwalking behavior. Additionally, the occurrence of screaming and sweating during sleep was noted in 11 patients (11%). These findings highlight the prevalence of diverse sleep disturbances within this population. The study also showed a statistically significant relation (p-value = 0.012) between the etiology and control of seizures. Hence, when the cause is symptomatic, controlling the seizures is more difficult (Table 2) . Table (2): Comparison between the etiology of seizures and various aspects as regards control and timing of seizures and the number of anti-seizure medications (ASMs) Etiology of Seizures P- value Idiopathic (n= 92) Symptomatic (n= 8) N % N % Control of seizures Yes (n=78) 75 81.5% 3 37.5% 0.012 No (n= 22) 17 18.5% 5 62.5% Occurrence of seizures Sleep (n=79) 73 79.3% 6 75.0% 0.673 Sleep and awake (n=21) 19 20.7% 2 25.0% Number of ASMs 1 drug (n=60) 58 63.0% 2 25.0% 0.05 > 1 drug (n=40) 34 37.0% 6 75.0% P-value 0.05). However, a statistically significant relation (P-value= 0.028) between the presence of frontal epileptic activity and difficulty in controlling the seizures was found. On relating the number of ASMs used and the type of seizures, no statistically significant difference was found (p-value >0.05). Comparing various epilepsy syndromes and the first ASM used in all studied patients, shown in Table 3, a statistically significant (p-value= 0.045) relation was found. Oxcarbazepine was commonly used in patients diagnosed with SeLECTS, SHE, and SeLEAS, while Levetiracetam was commonly used in patients diagnosed with SHE and JME. In contrast, when the response to the 2nd ASM (Add-on) was compared in all studied patients, no statistically significant (p-value= 0.649) relation was found. On comparing seizure control using various drugs as the 1 st ASM, a statistically significant difference was found (p-value= 0.008) where Oxcarbazepine was the most effective drug to control the seizures and Sodium Valproate was the least effective drug. Table (3): Relation between various epilepsy syndromes and 1 st ASM (anti-seizure medication) used in all studied patients. Epilepsy syndromes SeLECTS (n=52) SHE (n=33) SeLEAS (n=7) JME (n=5) P- value Oxcarbazepine 43 82.7% 14 42.4% 5 71.4% 0 0% 0.045 Levetiracetam 6 11.5% 15 45.5% 1 14.3% 4 80% Valproate 0 0% 3 9.1% 0 0% 1 20% Carbamazepine 2 3.8% 0 0% 1 14.3% 0 0% Lamotrigine 0 0% 1 3% 0 0% 0 0% Eslazepine 1 1.9% 0 0% 0 0% 0 0% SeLECTS: self-limited epilepsy with centrotemporal spikes; SHE: sleep-related hypermotor seizures; SeLEAS: self-limited epilepsy with autonomic symptoms; JME: juvenile myoclonic epilepsy; p-value < 0.05 is considered significant. Comparable characteristics were found between SeLECTS patients and SHE patients, as shown in Table 4 . Among SeLECTS, 33 patients (63.5%) were males. Moreover, seven patients (13.5%) had positive consanguinity, and 22 patients (42.3%) had relevant family history. Table (4): Demographic data, seizures characterization, and seizure semiology in participants diagnosed with SeLECTS and SHE SeLECTS (n=52) SHE (n=33) Age: mean ±sd (range) 10.2 ± 2.6 (5-13) 10.5 ± 3.4 (3-17) Gender Male, n (%) 33 (63.50%) 23 (69.70%) Female, n (%) 19 (36.50%) 10 (30.30%) Positive consanguinity, n (%) 7 (13.50%) 12 (36.40%) Relevant family history, n (%) 22 (42.30%) 16 (48.50%) Frequency (n o of fits/month), mean ± SD (range) 0.51 ± 0.8 (0.01-4) 1, 0.25:10* (0.01-120) Duration (min), median (IQR) 2.5 (1:8.5) 5 (1:5) Time of occurrence of seizures Sleep, n (%) 45 (86.50%) 21 (63.60%) Sleep + awake, n (%) 7 (13.50%) 12 (36.40%) Time of seizures at night Start, n (%) 38 (73.10%) 23 (69.70%) Mid, n (%) 4 (7.70%) 15 (45.50%) End, n (%) 12 (23.10%) 11 (33.30%) On awakening, n (%) 6 (11.50%) 13 (39.40%) Number of attacks per one night Once, n (%) 50 (96.20%) 16 (48.50%) Twice, n (%) 2 (3.80%) 6 (18.20%) Several attacks, n (%) 0 (0.00%) 11 (33.30%) Type of seizures Focal, n (%) 25 (48.10%) 18 (54.50%) GTCS, n (%) 11 (21.20%) 5 (15.20%) Focal to bilateral tonic-clonic, n (%) 9 (17.30%) 9 (27.30%) Both, n (%) 7 (13.50%) 1 (3%) IQR: Interquartile range, SeLECTS: self-limited epilepsy with centrotemporal spikes; GTCS: generalized tonic-clonic seizure. Seventeen patients (32.7%) had associated seizure symptoms in the patients with SeLECTS versus 11 patients (33.3%) with SHE. The most common associated symptoms in SeLECTS were salivation in 9 patients (17.3%), followed by numbness in 5 patients (7.7%), headache in 4 patients (7.7%), and dysarthria in 3 patients (5.8%). The most associated symptoms in SHE patients were fear in 5 patients (15.2%) and hallucinations in 2 patients (6.1%). Twenty-six (50%) had seizure-associated behavioral changes in SeLECTS patients (19 patients (73.1%) of them had irritability, four patients (15.4%) had hyperactivity, and three patients (11.5%) had both irritability and hyperactivity). As regards SHE patients, 20 patients (60.6%) had associated behavioral changes, 19 patients (95%) from them had irritability, and one patient (5%) had both irritability and hyperactivity. EEG findings in the patients with SeLECTS and SHE are shown in Figure 2. As regards the focus of epileptic activity, all patients with SeLECTS (100%) had centro-temporal spikes on their EEG. When considering the aspect of epileptic activity of SeLECTS, 22 patients (42.3%) had right-sided epileptic activity, 20 patients (38.5%) had left-sided epileptic activity, and 10 patients (19.2%) had bilateral epileptic activity. As regards the focus of epileptic activity in SHE patients; 15 patients (45.5%) had frontal epileptic activity, eight patients (24.2%) had fronto-temporal epileptic activity while 10 patients (30.3%) had normal EEG findings. Regarding the aspect of the epileptic activity in SHE patients, 14 patients (60.9%) had right-sided epileptic activity, five patients (21.7%) had left-sided epileptic activity, and four patients (17.4%) had bilateral epileptic activity. Referring to SeLECTS patients, Oxcarbazepine was the most common first-line ASM used in 43 patients (82.7%). As a second-line ASM, 10 patients (62.5%) used Levetiracetam. As regards the ASMs used in the patients diagnosed with SHE, Levetiracetam was the most commonly used first-line ASM (15; 45.5%), followed by Oxcarbazepine (14; 42.4%). Oxcarbazepine was the most used second-line ASM (add-on) (9; 40.9%). Discussion Sleep-related epilepsy (SRE) represents a significant proportion of all epilepsies [11]. Idiopathic childhood focal and generalized epilepsies are classically defined by their specific focal EEG findings and clinical correlates. They are assumed to have a commonly shared genetic background [12]. This study aims to define the etiology, semiology, and neurophysiological findings in children presenting with sleep-related seizures and to determine their outcome regarding seizure control on properly selected anti-seizure medications (ASMs). One hundred patients who fulfilled the inclusion criteria were enrolled in this study. The majority, 97 patients (97%), were classified as epilepsy syndromes. However, a specific syndrome wasn’t identified in 3 cases; among the studied patients, 52 (52%) were diagnosed with SeLECTS, 33 patients (33 %) diagnosed with SHE, seven patients (7%) were diagnosed with SeLEAS and five patients (5%) were diagnosed with juvenile myoclonic epilepsy (JME). SeLECTS is the most frequently diagnosed form of self-limited epilepsy syndrome with a peak age of SeLECTS onset of 7 years and is closely associated with sleep [13]. In the current study, more than half of the cases were SeLECTS. Of these, 33 patients (63.5%) were males, and 19 (36.5%) were females. Moreover, seven patients (13.5%) had positive consanguinity, and 22 (42.3%) had relevant family history. Similarly, previous studies found that children with SeLECTS had a slight male predominance, 63% of their 70 patients diagnosed with SeLECTS. However, a positive family history of epilepsy was reported in no more than half of the patients in these studies [14-16]. The mean frequency of fits per month in SeLECTS patients included in the present study was 0.51±0.8, with a minimum frequency between 1 and 4 fits per month. The median duration of fits in minutes was 2.5 minutes, with a maximum duration of 8.5 minutes. In concordance, recent studies found that, according to their parents’ reports, the duration of seizures was less than 5 minutes in most cases while reaching more than 30 minutes in a small number of cases [12,16]. In our study, regarding the time of occurrence of seizures in SeLECTS, 45 patients (86.5%) had seizures only during sleep, and seven patients (13.5%) had seizures during sleep and wakefulness. According to Jiang et al.'s study, which enrolled 107 patients with SeLECTS, 17.8% of patients experienced seizures during wakefulness, while 88 (82.2%) experienced seizures during sleep [13]. Similarly, a study in 2023 found that seizures in SeLECTS patients occurred only during sleep, especially in the early morning hours in 15 (79%) children and during sleep and wakefulness in 4 children (21%) [17]. Seizure semiology describes the evolution of symptoms and signs during epileptic seizures. Semiology is a simple and cost-effective tool that allows localization of the epileptogenic zone [18]. In the current study, regarding the type of seizures in SeLECTS patients, 25 patients (48.1%) had focal seizures, among other types, including generalized tonic-clonic seizure (GTCS), bilateral tonic-clonic, and both focal with GTCS. This comes in agreement with the literature reporting the same types within their SeLECT cohort [19,17]. However, a study by Jiang et al. revealed that generalized and partial seizures, respectively, affected (57.01%) and (42.99%) of SeLECTS patients [13]. In the present research, 17 patients with SeLECTS (32.7%) had seizure-associated symptoms. The most common associated symptoms were salivation in 9 patients (17.3), numbness in 5 (9.6%), headache in 4 (7.7%) and dysarthria in 3 patients (5.8%). These findings align with earlier research documenting hypersalivation and speech arrest as the most common symptoms, along with loss of consciousness, facial and oropharyngeal manifestations as well as dysarthria [20,21]. In our study, the frequency of attention deficit hyperactivity disorder (ADHD) was seven patients (13.5%) in children with SeLECTS. Patients with SeLECTS exhibit characteristic EEG changes, including a normal background with centrotemporal stereotyped spikes or sharp waves followed by slow waves, unilaterally or bilaterally, which can be asynchronized or synchronized on both sides. The epileptiform activities can migrate from side to side and even extend to adjacent brain regions, such as the frontal or occipital areas [22]. In the present study, 42 patients (80.7%) diagnosed with SeLECTS had unilateral epileptic activity in the EEG, while 10 patients (19.2%) had bilateral epileptic activity. This comes in agreement with multiple earlier studies, which revealed 60%-75% of their patients had unilateral features [23-26] However, a study by Hewawitharana et al. revealed that bilateral discharges in the Rolandic region were the most common (51%) EEG findings, followed by typical unilateral changes in 38% of patients [21]. Our study found that all patients with SeLECTS exhibited centro-temporal spikes on their EEG, consistent with Ross et al. [15]. Tang et al. studied 52 children with SeLECTS, dividing them into isolated and recurrence groups [27]. They found that 50% showed frontal paroxysmal abnormalities, with frontal spikes significantly more common in the recurrence group. In the past, ASMs were not recommended in children with SeLECTS due to their benign nature. However, with the current understanding of the disease entity, many children with SeLECTS are on ASMs [28]. All patients of the present study received at least one ASM, which is supported by previous studies [20,29]. However, others found only half of SeLECTS patients were given at least one ASM [15]. In our study, oxcarbazepine was the most common ASM used as monotherapy in 43 patients (82.7%) diagnosed with SeLECTS. This is in accordance with researchers who found that oxcarbazepine and carbamazepine are widely used among SeLECTS patients [20,23]. In contrast to our study, some reported that oxcarbazepine monotherapy was ineffective in SeLECTS cases [30]. Furthermore, others found levetiracetam to be the most prevalent treatment method and an alternative to carbamazepine [29,16]. Moreover, recent studies by Hewawitharana et al. and Varesio et al. revealed that sodium valproate was the most used drug in SeLECTS cases [21,14]. Sleep‐related hypermotor epilepsy (SHE) is a focal epilepsy syndrome characterized by motor events occurring predominantly in clusters during non–rapid eye movement sleep. The distinctive pattern of ictal manifestations consists of hyperkinetic seizures associated with possible asymmetric‐tonic attacks [31]. There were 33 patients diagnosed with SHE in the current study; their mean age was 10.5±3.4 years, with a male predominance of 69.7%. Twelve of them (36.4%) had positive consanguinity, and 16 patients (48.5%) had a relevant family history of epilepsy. Our patient characteristics agreed with previous ones, reporting the same age criteria and slight male predominance [32,31]. We found that the median number of fits per month in the patients diagnosed with SHE was higher, ranging from 1 to 120 fits with a mean duration of 5 minutes. In concordance, it was documented that SHE seizures could reach 300 fits per month, especially in patients resistant to ASMs [33,34]. However, the mean duration reported was 30 seconds for some studies, and the duration range reached a maximum of a few minutes [33,35]. Our study found that 21 SHE patients (63.6%) had seizures only during sleep. This comes in agreement with Licchetta et al., where most cases (67.9%) had seizures exclusively during sleep [31]. Analysis of the ictal episode revealed variable semiology, likely due to the complexity of frontal lobe networks. In our study, 54.5% of patients experienced focal motor seizures with sudden arousal, head deviation, or hyperkinetic movements. Some had focal to bilateral tonic-clonic seizures or GTCS, with associated symptoms including fear (15.2%) and hallucinations (6.1%). Kishk et al. also reported hypermotor movements in 42.3% of patients, with tonic/dystonic posturing in 57.7% [32]. Tao et al. found that 69.6% of their drug-resistant SHE patients experienced auras, with agitation common among many [34]. In our study, the predominant epileptic focus was frontal in 45.5% of patients, while 30.3% had normal EEG findings. Kishk et al. reported normal interictal EEG in 34.6% of patients, while 65.4% had interictal epileptiform discharges [32]. Provini et al. found that 51% had normal EEGs, and 45% showed focal abnormalities, primarily in frontal and temporal areas [36]. The current work identifies a significant correlation (P-value = 0.028) between frontal epileptic activity and difficulty controlling seizures, with 40% of patients experiencing uncontrolled seizures on ASMs associated with this activity. This aligns with Sinclair et al., who reported that only half of their patients (11/22) achieved seizure control on ASMs and noted that four intractable cases underwent epilepsy surgery, highlighting the challenges of managing frontal lobe seizures [37]. In the present research, Levetiracetam was the most commonly used ASM, prescribed to 45.5% of SHE patients, followed by oxcarbazepine (42.4%) and valproate (9.1%). Similarly, Kanemura et al. noted greater benefits from Levetiracetam in SHE patients [38]. Raju et al. found that oxcarbazepine was effective and well-tolerated, with complete cessation of nocturnal seizures [39]. Most sleep-related seizures are focal, often non-lesional, and typically have a benign outcome with a good response to anti-seizure medications (ASMs). Treatment should start with effective drugs for focal epilepsies, such as oxcarbazepine, levetiracetam, carbamazepine, and lacosamide. If a patient is drug-resistant, epilepsy surgery may be considered [40]. Our study shows a significant correlation (p-value=0.008) between the first ASM used and seizure control, with oxcarbazepine being the most effective (controlled in 51 patients, 65.4%), compared to levetiracetam (21 patients, 26.9%), carbamazepine (3 patients, 3.8%), and valproate (1 patient, 1.3%). This aligns with Franzoni et al., who observed that oxcarbazepine led to seizure freedom in 58.3% of patients [41]. Beydoun et al. affirmed oxcarbazepine’s Class I efficacy as initial monotherapy for focal-onset seizures in children and as adjunctive therapy alongside drugs like gabapentin and lamotrigine [42]. This is consistent with the National Institute of Health and Care Excellence (NICE) guidelines recommending carbamazepine, lamotrigine, and oxcarbazepine as first-line treatments for newly diagnosed focal-onset childhood seizures. It is estimated that 80% of children with epilepsy could respond to carbamazepine [43]. In contrast, Hur found better seizure outcomes for lamotrigine compared to oxcarbazepine in pediatric patients with normal MRI findings [44]. Limitation This 18-month study may have benefited from a longer duration for more comprehensive data. However, we believe that an extended study with a larger population would not have significantly altered the findings related to SRE incidences. Our case series reflects a heterogeneous SRE population with varied and often unknown etiology. In addition, the absence of genetic studies limited our results regarding genetic links. Conclusion The etiology of SRE was mostly idiopathic. Patients with SeLECTS had the highest prevalence of epilepsy syndromes, followed by SHE and SeLEAS, with male predominance. Seizure semiology and EEG analysis provided valuable insights for classifying SRE, showing concordance between the interictal focus and seizure semiology. Regarding treatment, Oxcarbazepine was the most effective treatment for SRE and was frequently used for SeLECTS, SHE, and SeLEAS, while levetiracetam was preferred for JME. Finally, controlling seizures is more challenging when sleep-related seizures have a symptomatic cause. Recommendations Efforts should be made to identify and treat SRE for better outcomes. Neuroimaging is essential to exclude structural, inflammatory, or metabolic causes of seizures. Moreover, pediatric neurologists should be aware of selecting ASMs based on the type of epileptic syndrome, seizures, patient characteristics, and drug pharmacokinetics to reduce reliance on valproate and levetiracetam in focal onset seizures. Abbreviations ADHD: Attention deficit hyperactivity disorder ASMs: Anti-seizure medications CNS: Central nervous system EEG: Electroencephalogram GTCS: Generalized tonic-clonic seizure ILAE: International League Against Epilepsy IQR: Interquartile range JME: Juvenile myoclonic epilepsy LEV: Levetiracetam MRI: Magnetic resonance- imaging NICE: National Institute of Health and Care Excellence NICU: Neonatal intensive care unit NREM: Non-rapid eye movement OXC: Oxcarbazepine REM: Rapid eye movement SD: Standard deviation SeLEAS: Self-limited epilepsy with autonomic symptoms SeLECTS: Self-limited epilepsy with centro-temporal spikes SHE: Sleep-related hypermotor seizures SPSS: Statistical Package for Social Science SRE: Sleep-related epilepsy USA: United States of America. Declarations Ethics approval and consent to participate: The study protocol was reviewed and approved by the institutional Ethical Research Committee (Code MD-78-2023). The procedure and the aim of the study were clearly explained to the study participants/ their legal guardians. Before enrollment in the study, written informed consent was obtained from the participants’ legal guardians with an explanation of the benefits and drawbacks of the procedure. The subject was free to withdraw from the study at any moment; participation was entirely voluntary. In accordance with the Declaration of Helsinki, all steps of data collecting, entry, and analysis were conducted in a highly confidential and private manner. Funding: None. References Nobili, L., Frauscher, B., Eriksson, S., Gibbs, S. A., Halasz, P., Lambert, I., Manni, R., Peter‐Derex, L., Proserpio, P., Provini, F., de Weerd, A., & Parrino, L. (2022). Sleep and epilepsy: A snapshot of knowledge and future research lines. Journal of Sleep Research, 31(4). Kim, K. M., & Yang, K. I. (2023). Sleep and Epilepsy. Sleep Medicine Research, 14(2), 61–65. Kumar, J., Solaiman, A., Mahakkanukrauh, P., Mohamed, R., & Das, S. (2018). Sleep-Related Epilepsy and Pharmacotherapy: An Insight. Frontiers in Pharmacology, 9. Moore, J. L., Carvalho, D. Z., St Louis, E. K., and Bazil, C. (2021). Sleep and epilepsy: a focused review of pathophysiology, clinical syndromes, co-morbidities, and therapy. Neurotherapeutics, 18, 170–180. Tchopev, Z. N., Yeh, P.-H., Morgan, G. W., Meyer, E., Wolf, J. M., Ollinger, J. M., Riedy, G. P., & Young, L. C. (2018). Acquired Sleep-Related Hypermotor Epilepsy with Disrupted White Matter Tracts Assessed by Multishell Diffusion Magnetic Resonance Imaging. Frontiers in Neurology, 9. Schmitt, B. (2015). Sleep and epilepsy syndromes. Neuropediatrics, 46(3), 171–179. Ashry, A. A. M. M., Farwiz, H. M., & Abdelrasoul, R. B. (2021). Semiology of epileptic seizures: Assiut University Hospital-based study. Journal of Current Medical Research and Practice , 6 (2), 128. ‏ Smith, S. J. M. (2005). EEG in the diagnosis, classification, and management of patients with epilepsy. Journal of Neurology, Neurosurgery & Psychiatry, 76(suppl_2), ii2–ii7. Fisher, R. S. (2017). The new classification of seizures by the International League Against Epilepsy 2017. Current Neurology and Neuroscience Reports, 17, 1–6. Cendes, F., Theodore, W. H., Brinkmann, B. H., Sulc, V., and Cascino, G. D. (2016). Neuroimaging of epilepsy (pp. 985–1014). Nobili, L., de Weerd, A., Rubboli, G., Beniczky, S., Derry, C., Eriksson, S., Halasz, P., Högl, B., Santamaria, J., and Khatami, R. (2020). Standard procedures for the diagnostic pathway of sleep‐related epilepsies and comorbid sleep disorders: A European Academy of Neurology, European Sleep Research Society and International League against Epilepsy‐Europe consensus review. Journal of Sleep Research, 29(6), e13184. Vargas, R., Beltrán, L., Lizama, R., Valenzuela, G. R., and Caraballo, R. (2018). Benign rolandic epilepsy and generalized paroxysms: A study of 13 patients, Seizure, 57, 27-31. Jiang, N., Yang, C., Wang, J. Le, Ye, X., & Yang, B. (2024). The Association Between Sleep Problems and Attentional Network Functions in Patients with Self-Limited Epilepsy with Centrotemporal Spikes. Nature and Science of Sleep, Volume 16, 751–760. Varesio, C., Zanaboni, M. P., Salmin, E. C., Totaro, C., Totaro, M., Ballante, E., Pasca, L., Veggiotti, P., & De Giorgis, V. (2020). Childhood Epilepsy with Centrotemporal Spikes: Clinical and Neuropsychological Outcomes 5 Years after Remission. Diagnostics, 10(11), 931. Ross, E. E., Stoyell, S. M., Kramer, M. A., Berg, A. T., & Chu, C. J. (2020). The natural history of seizures and neuropsychiatric symptoms in childhood epilepsy with centrotemporal spikes (CECTS). Epilepsy & Behavior, 103, 106437. Badem, M., Sarikaya Uzan, G., & Hiz Kurul, S. (2023). Electroclinical and Demographic Evaluation of Cases with Selflimited Epilepsy with Centrotemporal Spikes. Forbes Journal of Medicine, 4(1), 21–27. T Valoor, H. A. R. S. H. A., Jose, J., & Gafoor, A. (2023). Clinical features, electroencephalogram findings and treatment of self-limited focal epilepsies of childhood. Asian J Pharm Clin Res, 16(11), 141-143. Tufenkjian, K., & Lüders, H. O. (2012). Seizure Semiology: Its Value and Limitations in Localizing the Epileptogenic Zone. Journal of Clinical Neurology, 8(4), 243. Weir, E., Gibbs, J., & Appleton, R. (2018). Panayiotopoulos syndrome and benign partial epilepsy with centro-temporal spikes: A comparative incidence study. Seizure, 57, 66–69. Sable, S., Sable, R., Tamhankar, P., & Tamhankar, V. (2021). Clinical profile of patients with rolandic epilepsy at a clinic in rural Maharashtra. Journal of Family Medicine and Primary Care, 10(3), 1263–1266. Hewawitharana, G., Munasinghe, T. M., Kodithuwakku, A., Suriyaarachchi, S. R., & Kankananarachchi, I. (2023). Clinical profile and electroencephalogram characteristics of children with self-limited epilepsy with centro-temporal spikes attending paediatric neurology clinic, Teaching Hospital, Karapitiya, Sri Lanka. Sri Lanka Journal of Child Health, 52(1), 33. Callenbach, P. M. C., Bouma, P. A. D., Geerts, A. T., Arts, W. F. M., Stroink, H., Peeters, E. A. J., van Donselaar, C. A., Peters, A. C. B., & Brouwer, O. F. (2010). Long term outcome of benign childhood epilepsy with centrotemporal spikes: Dutch Study of Epilepsy in Childhood. Seizure, 19(8), 501–506. Liu, M.-J., Su, X., MD, X.-Y. S., Wu, G., Zhang, Y., Gao, L., Wang, W., Liao, J., Wang, H., Mai, J., Gao, J., Shu, X., Huang, S., Zhang, L., & Zou, L.-P. (2017). Clinical features of benign epilepsy of childhood with centrotemporal spikes in chinese children. Medicine, 96(4), e5623. Bedoin, N., Herbillon, V., Lamoury, I., Arthaud-Garde, P., Ostrowsky, K., De Bellescize, J., Kéo Kosal, P., Damon, G., & Rousselle, Ch. (2006). Hemispheric lateralization of cognitive functions in children with centrotemporal spikes. Epilepsy & Behavior, 9(2), 268–274. Riva, D., Vago, C., Franceschetti, S., Pantaleoni, C., D’Arrigo, S., Granata, T., & Bulgheroni, S. (2007). Intellectual and language findings and their relationship to EEG characteristics in benign childhood epilepsy with centrotemporal spikes. Epilepsy & Behavior, 10(2), 278–285. Zhao, X., Chi, Z., Chi, L., Shang, W., & Liu, X. (2007). Clinical and EEG characteristics of benign rolandic epilepsy in Chinese patients. Brain and Development, 29(1), 13–18. Tang, H., Wang, Y., Hua, Y., Wang, J., Jing, M., & Hu, X. (2019). Analysis of serial electroencephalographic predictors of seizure recurrence in Rolandic epilepsy. Child’s Nervous System, 35(9), 1579–1583. Dryżałowski, P., Jóźwiak, S., Franckiewicz, M., & Strzelecka, J. (2018). Benign epilepsy with centrotemporal spikes – Current concepts of diagnosis and treatment. Neurologia i Neurochirurgia Polska, 52(6), 677–689. Kessi, M., Yan, F., Pan, L., Chen, B., Olatoutou, E., Li, D., He, F., Rugambwa, T., Yang, L., Peng, J., & Yin, F. (2021). Treatment for the Benign Childhood Epilepsy With Centrotemporal Spikes: A Monocentric Study. Frontiers in Neurology, 12. Kwon, S., Hwang, T. G., Lee, J., Kim, D.-K., & Seo, H.-E. (2013). Benign Childhood Epilepsy with Centrotemporal Spikes: To Treat or Not to Treat. Journal of Epilepsy Research, 3(1), 1–6. Licchetta, L., Vignatelli, L., Zenesini, C., Mostacci, B., Ferri, L., Provini, F., Tinuper, P., and Bisulli, F. (2019). Sleep‐related hypermotor epilepsy: A prediction cohort study on sleep/awake patterns of seizures. Epilepsia, 60(11), e115–e120. Kishk, N. A., Nawito, A. M., Ebraheim, A. M., & Rizk, H. (2019). Insights into sleep-related hyper-motor epilepsy: an Egyptian case series. Neurological Research, 41(9), 771–779. Rheims, S., Ryvlin, P., Scherer, C., Minotti, L., Hoffmann, D., Guenot, M., Mauguière, F., Benabid, A., & Kahane, P. (2008). Analysis of clinical patterns and underlying epileptogenic zones of hypermotor seizures. Epilepsia, 49(12), 2030–2040. Tao, Y., Guojun, Z., Yuping, W., Lixin, C., Wei, D., & Yongjie, L. (2010). Surgical treatment of patients with drug‐resistant hypermotor seizures. Epilepsia, 51(10), 2124–2130. Alqadi, K., Sankaraneni, R., Thome, U., & Kotagal, P. (2016). Semiology of hypermotor (hyperkinetic) seizures. Epilepsy & Behavior, 54, 137–141. Provini, F. (1999). Nocturnal frontal lobe epilepsy: A clinical and polygraphic overview of 100 consecutive cases. Brain, 122(6), 1017–1031. Sinclair, D. B., Wheatley, M., & Snyder, T. (2004). Frontal lobe epilepsy in childhood. Pediatric Neurology, 30(3), 169–176. Kanemura, H., Sano, F., Sugita, K., & Aihara, M. (2013). Effects of levetiracetam on seizure frequency and neuropsychological impairments in children with refractory epilepsy with secondary bilateral synchrony. Seizure, 22(1), 43–47. Raju, G. P., Sarco, D. P., Poduri, A., Riviello, J. J., Bergin, A. M. R., & Takeoka, M. (2007). Oxcarbazepine in Children with Nocturnal Frontal-Lobe Epilepsy. Pediatric Neurology, 37(5), 345–349. Carreño, M., & Fernández, S. (2016). Sleep-Related Epilepsy. Current Treatment Options in Neurology, 18(5), 23. Franzoni, E., Garone, C., Sarajlija, J., Gualandi, S., Malaspina, E., Cecconi, I., Moscano, F. C., & Marchiani, V. (2006). Open prospective study on oxcarbazepine in epilepsy in children: A preliminary report. Seizure, 15(5), 292–298. Beydoun, A., DuPont, S., Zhou, D., Matta, M., Nagire, V., and Lagae, L. (2020). Current role of carbamazepine and oxcarbazepine in the management of epilepsy. Seizure, 83, 251–263. Jones, K. E. A., Howells, R., Mallick, A. A., Paul, S. P., & Dey, I. (2023). NICE guideline review: Epilepsies in children, young people and adults NG217. Archives of Disease in Childhood - Education & Practice Edition, 108(6), 416–421. Hur, Y. J. (2018). Comparison of lamotrigine and oxcarbazepine monotherapy for pediatric focal epilepsy: An observational study. Seizure, 60, 123–126. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Aug, 2025 Read the published version in Egyptian Pediatric Association Gazette → Version 1 posted Editorial decision: Revision requested 21 Mar, 2025 Editor assigned by journal 20 Mar, 2025 Submission checks completed at journal 20 Mar, 2025 First submitted to journal 13 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6220612","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":431191948,"identity":"77bcaf29-3c9d-4ab8-8132-f1d0da59ede7","order_by":0,"name":"Christine Salama","email":"data:image/png;base64,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","orcid":"","institution":"Cairo University","correspondingAuthor":true,"prefix":"","firstName":"Christine","middleName":"","lastName":"Salama","suffix":""},{"id":431191949,"identity":"f8deb89a-e9b6-481f-b043-196b9289c2a7","order_by":1,"name":"Marian Girgis","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Marian","middleName":"","lastName":"Girgis","suffix":""},{"id":431191950,"identity":"e9f9e4cc-4e5a-423c-ab18-2c49ecd960fb","order_by":2,"name":"Hala Elhabashy","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Hala","middleName":"","lastName":"Elhabashy","suffix":""},{"id":431191951,"identity":"55602eaf-82b1-45ab-8774-8feb7ba64cec","order_by":3,"name":"Mona Kamel","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"","lastName":"Kamel","suffix":""},{"id":431191952,"identity":"4902e3d4-3ec8-4657-a323-eb8a559e885b","order_by":4,"name":"Yara Shahin","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Yara","middleName":"","lastName":"Shahin","suffix":""}],"badges":[],"createdAt":"2025-03-13 13:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6220612/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6220612/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43054-025-00409-z","type":"published","date":"2025-08-05T15:57:21+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":78888384,"identity":"393a9469-ba8b-440d-9ce5-c0849feba64b","added_by":"auto","created_at":"2025-03-20 10:00:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":50652,"visible":true,"origin":"","legend":"\u003cp\u003ePercentage of associated symptoms among study participants (n=100)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6220612/v1/d2e8a7518e0920a01cd8bd49.png"},{"id":78889132,"identity":"6e585c39-9449-4a9e-b202-30390ec44bc8","added_by":"auto","created_at":"2025-03-20 10:08:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":44886,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of EEG findings for patients diagnosed with SeLECTS and SHE.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6220612/v1/55e4952fb8b230dfb846331d.png"},{"id":88814125,"identity":"3b96df11-c14f-4927-b17f-3eda30ba38dd","added_by":"auto","created_at":"2025-08-11 16:07:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1314199,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6220612/v1/1c402bb3-7161-4965-8c79-57052812e720.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sleep-Related Seizures in Children: Cohort Study from a Tertiary Center","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe relationship between sleep and epilepsy is intricate and influenced by multiple factors. Sleep is divided into two main phases. The stages of sleep can influence both the activation and inhibition of epileptic activity in the brain, with NREM sleep facilitating epileptic activity while REM sleep inhibits it [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Additionally, sleep has the potential to provoke seizures, and a lack of sleep heightens the likelihood of seizures by increasing cortical excitability and lowering the seizure threshold [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEpilepsy can interfere with the structure and quality of sleep, resulting in sleep disturbance and additional comorbidities such as sleep apnea and restless legs syndrome. It also plays a role in causing significant daytime drowsiness and tiredness, effects that can be worsened by the sedative properties of seizure medications (ASMs) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSleep-related epilepsy (SRE) is a form of epilepsy where seizures primarily happen during sleep. This condition is recognized as a specific category of epilepsy syndromes and is defined by a strong connection between the occurrence of seizures and sleep-wake patterns. Seizures that happen solely at night make up about 12\u0026ndash;20% of all seizures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the fundamental mechanisms of SRE remain incompletely understood, one potential contributing factor may be the impact of sleep-associated neuronal and physiological changes on seizure threshold and excitability. Fluctuations in neurotransmitter levels, shifts in neuronal synchronization, and variations in cortical excitability during sleep can increase the likelihood of seizures in vulnerable individuals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver the past decade, the discovery of numerous pre-disposing genes and the availability of advanced diagnostic tools have shed more light on the nature of SRE [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDistinguishing nocturnal seizures from non-epileptic parasomnia can be challenging. A careful clinical history, knowledge of key features of seizure syndromes and parasomnia, and video-electroencephalogram (EEG) monitoring are helpful in avoiding misdiagnosis or redundant treatment with ASMs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, the current work aimed to study sleep-related epilepsy epidemiology, etiology, and syndromic classification according to seizure semiology and EEG characteristics and to correlate their outcome with seizure control on properly selected ASMs.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003eThis is a\u0026nbsp;prospective cohort observational\u0026nbsp;study that included 100 patients who were diagnosed as SRE recruited from Neuro-pediatric outpatient clinics in the Pediatric department of a tertiary university-based pediatric hospital\u0026nbsp;from February 2023 to July 2024 to\u0026nbsp;discuss the predominance of SRE, semiology, and EEG characteristics in children presenting with sleep-related\u0026nbsp;seizures and to determine their outcome regarding seizure control on properly selected ASMs. Patients recruited prospectively were followed for a period of at least 6 months.\u003c/p\u003e\n\u003cp\u003eThe study included children younger than 18 years old who were diagnosed with SRE and had nocturnal epilepsy evidenced by seizure semiology taken from history and proved by home video, including Sleep-related hypermotor seizures (SHE), Self-limited epilepsy with centro-temporal spikes (SeLECTS), Self-limited epilepsy with autonomic symptoms (SeLEAS), as well as awakening epilepsy, e.g., Juvenile myoclonic epilepsy (JME).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study excluded patients who are non-compliant with ASMs, patients who have hypoxic-ischemic encephalopathy, patients with inborn metabolic abnormalities (genetic or acquired), and those with cardiac, renal, or any other systemic illnesses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSample size:\u003c/u\u003e\u003c/strong\u003eThe sample size to study the results of the current study with a significant P \u0026lt; 0.05 is calculated with reference to Ashry et al. [7] and according to the formulan ≥ [Z\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e1-\u003c/sub\u003e\u003csub\u003eα\u003c/sub\u003e\u003csub\u003e/2\u003c/sub\u003e x p (1-p)] / d\u003csup\u003e2\u003c/sup\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eZ\u003csub\u003e1-α/2\u003c/sub\u003e = 1.96, p = 0.05, d (absolute error) = 0.05. So, n = 259. By adding 35% as a drop-out rate, at least 100 participants should be recruited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate:\u003c/u\u003e\u003c/strong\u003e The study protocol was reviewed and approved by the institutional Ethical Research Committee (Code MD-78-2023). The procedure and the aim of the study were clearly explained to the study participants/ their legal guardians. Before enrollment in the study, written informed consent was obtained from the participants’ legal guardians with an explanation of the benefits and drawbacks of the procedure. The subject was free to withdraw from the study at any moment; participation was entirely voluntary. In accordance with the Declaration of Helsinki, all steps of data collecting, entry, and analysis were conducted in a highly confidential and private manner.\u003c/p\u003e\n\u003cp\u003eHistory was taken from all patients’ mothers, including sociodemographic data, present, past, perinatal, developmental, and family histories, with an emphasis on the seizure's timing, type, and semiology as well as ASM and compliance to them. The syndromic classification was attempted for every patient according to the semiology of seizures into sleep-related hypermotor epilepsy (SHE), probably self-limited epilepsy with centrotemporal spike (SeLECTS), self-limited epilepsy with autonomic seizures (SeLEAS), and juvenile myoclonic epilepsy (JME). \u003cstrong\u003eA sleep behavior questionnaire was also done.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll study participants were subjected to thorough general and neurological examinations, as well as other systemic examinations, to exclude any generalized systemic illness and identify any associated central nervous system (CNS) disorders.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRadiological investigations were conducted, including EEG monitoring to assess seizure semiology, inter-ictal epileptiform discharge, and ictal video-EEG if possible\u0026nbsp;[8].\u003c/p\u003e\n\u003cp\u003eIf the type of nocturnal events the patient experienced was uncertain, video-EEG monitoring was performed [4].\u003c/p\u003e\n\u003cp\u003eSeizure semiology was described according to the new International League Against Epilepsy (ILAE) classification 2017 [9].\u003c/p\u003e\n\u003cp\u003eAll study participants were subjected to brain magnetic resonance- imaging (MRI);\u0026nbsp;In cases resistant to treatment, an optimized epilepsy protocol with adequate spatial resolution and multiplanar reformatting was essential\u0026nbsp;[10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eBlinding:\u003c/u\u003e\u003c/strong\u003e The subjects included were blindly submitted to seizure semiology analysis by two neurologists who were not aware of the original preassessment diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eStatistical methods:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData entry was carried out using SPSS (Statistical Package for Social Science) version 24.0 (IBM\u003csup\u003e®\u003c/sup\u003e, SPSS, USA). Variables were examined for normality. Categorical variables were expressed in numbers and percentages; Chi-square and Fisher’s exact tests were applied as appropriate. Continuous variables were expressed using mean and standard deviation or median for normally distributed data and interquartile range for not normally distributed data; the T-test, Mann Whitney, and other tests of significance were used for comparison as appropriate. P value \u0026lt;0.05 was considered significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe current study included 100 patients who fulfilled the inclusion criteria. The mean age of the patients was 10.23\u0026plusmn;3.11 years, with a minimum age of 3 years and a maximum of 17 years. The males were predominant, with 65%. Notably, 68 patients (68%) were born by elective CS. The majority (92%) were full-term, and 18 patients (18%) were admitted to the neonatal intensive care unit (NICU). Almost half of the cases (47%) had a relevant family history of epilepsy, and 22% had positive consanguinity. Only one patient showed delayed mental development, and two patients had delayed motor development.\u003c/p\u003e\n\u003cp\u003eRegarding seizure characterization, 92 patients (92%) had idiopathic etiology, while only 8% considered symptomatic cases of underlying etiology. The mean \u0026plusmn; standard deviation (SD) duration of active fits among the study patients was 2.52\u0026plusmn;2.24 years. The frequency of fits among the study participants had a median of 0.3 with an interquartile range (IQR) of 0.15-1 fits/month with a median (IQR) duration of 3 (1-7) minutes per fit. A significant majority of the patients (78%) experienced controllable seizures. Of the 22 uncontrollable cases, 13 patients had SHE, seven patients had SeLECTS, one patient had JME, and another patient had focal symptomatic epilepsy. The most common type was focal seizures, representing 52% of the study cohort. Most patients reported seizures during sleep only, at the start of sleep, and once per night (70%, 79 and 81%, respectively).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnly 36 patients of the study cohort had specific associated symptoms, but a patient may have more than one symptom. Salivation was the most common (25%), followed by vomiting (19.4%) (\u003cstrong\u003eFigure 1\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eSeizure-associated behavioral changes occurred in 52 patients (52%), 43 of whom (83%) were irritable, 4 (8%) were hyperactive, and 5 (9%) were both irritable and hyperactive.\u003c/p\u003e\n\u003cp\u003eThe inter-ictal EEGs of the studied patients revealed abnormalities in 84% of the cases. However, MRI findings were abnormal in only 14% of the cases \u003cstrong\u003e(Table 1).\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc182014801\"\u003e\u003cstrong\u003eTable (1):\u0026nbsp;\u003c/strong\u003eCharacteristics of abnormal inter-ictal EEG findings of the studied population.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"105%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 41px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudied Patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInter-ictal EEG (n=84)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSide\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e32%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBilateral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGeneralized\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAffected lobe\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=81)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrontal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccipital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCentro- temporal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e64.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFronto- temporal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e12.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBrain MRI (n=14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFocal cortical dysplasia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e21.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGliosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e14.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMesial sclerosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGyration anomaly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrontal patchy area of increased signal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther findings not related to the symptomatic etiology*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e43%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e* Periventricular leukomalacia, temporal arachnoid cyst, colpocephaly with attenuation of the body of corpus callosum, and an old infarction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the first-line ASM, Oxcarbazepine was the most frequently prescribed, used by 62 patients (62%), followed by Levetiracetam, prescribed to 28 patients (28%). In contrast, the second-line ASM, Levetiracetam, was used in 15 patients (15%), and Oxcarbazepine was used in 12 patients (12%). As regards the third-line ASM, Oxcarbazepine was used in 3 patients (3%). A minority of patients used Lacosamide, Lamotrigine, Clonazepam, Perampanel, and Topiramate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConcerning sleep behavior, the mean amount of sleep for all patients was 8.92\u0026plusmn;1.11 hours, ranging from 6 to 13 hours. As for the effect of seizures on sleep quality, 42 patients (42%) experienced decreased sleep, while 58 patients (58%) had normal sleep quality.\u003c/p\u003e\n\u003cp\u003eA variety of sleep-related phenomena were observed among the studied patients. Specifically, 36 patients (36%) were identified as grinding their teeth nocturnally, 30 patients (30%) were reported to have significant movement during sleep, 14 patients (14%) exhibited sleep talking, while five patients (5%) demonstrated sleepwalking behavior. Additionally, the occurrence of screaming and sweating during sleep was noted in 11 patients (11%). These findings highlight the prevalence of diverse sleep disturbances within this population.\u003c/p\u003e\n\u003cp\u003eThe study also showed a statistically significant relation (p-value = 0.012) between the etiology and control of seizures. Hence, when the cause is symptomatic, controlling the seizures is more difficult \u003cstrong\u003e(Table 2)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp id=\"_Toc182014816\"\u003e\u003cstrong\u003eTable (2):\u0026nbsp;\u003c/strong\u003eComparison between the etiology of seizures and various aspects\u0026nbsp;as regards control and timing of seizures and the number of anti-seizure medications (ASMs)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEtiology of Seizures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIdiopathic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n= 92)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSymptomatic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n= 8)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl of seizures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes (n=78)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e81.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e37.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e0.012\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (n= 22)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e18.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e62.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOccurrence of seizures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep (n=79)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e79.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e75.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep and awake (n=21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e20.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of ASMs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 drug (n=60)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e63.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt; 1 drug (n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e37.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e75.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eP-value \u0026lt; 0.05 is considered significant.\u003c/p\u003e\n\u003cp\u003eAnalyzing seizure control, the results show no statistically significant relation to the time of occurrence of seizures (p-value \u0026gt; 0.05). However, a statistically significant relation (P-value= 0.028) between the presence of frontal epileptic activity and difficulty in controlling the seizures was found.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn relating the number of ASMs used and the type of seizures, no statistically significant difference was found (p-value \u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003eComparing various epilepsy syndromes and the first ASM used in all studied patients, shown in \u003cstrong\u003eTable 3,\u003c/strong\u003e a statistically significant (p-value= 0.045) relation was found. Oxcarbazepine was commonly used in patients diagnosed with SeLECTS, SHE, and SeLEAS, while Levetiracetam was commonly used in patients diagnosed with SHE and JME.\u003c/p\u003e\n\u003cp\u003eIn contrast, when the response to the 2nd ASM (Add-on) was compared in all studied patients, no statistically significant (p-value= 0.649) relation was found.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn comparing seizure control using various drugs as the 1\u003csup\u003est\u003c/sup\u003e ASM, a statistically significant difference was found (p-value= 0.008) where Oxcarbazepine was the most effective drug to control the seizures and Sodium Valproate was the least effective drug.\u003c/p\u003e\n\u003cp id=\"_Toc182014825\"\u003e\u003cstrong\u003eTable (3):\u0026nbsp;\u003c/strong\u003eRelation between various epilepsy syndromes and 1\u003csup\u003est\u003c/sup\u003e ASM (anti-seizure medication) used in all studied patients.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"8\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEpilepsy syndromes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeLECTS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=52)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSHE\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeLEAS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=7)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJME\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=5)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP- value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOxcarbazepine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e82.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e42.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e71.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003e0.045\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevetiracetam\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e11.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e45.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e80%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValproate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e9.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarbamazepine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e3.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e14.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLamotrigine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEslazepine\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e1.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSeLECTS: self-limited epilepsy with centrotemporal spikes; SHE: sleep-related hypermotor seizures; SeLEAS: self-limited epilepsy with autonomic symptoms; JME: juvenile myoclonic epilepsy; p-value \u0026lt; 0.05 is considered significant.\u003c/p\u003e\n\u003cp\u003eComparable characteristics were found between SeLECTS patients and SHE patients, as shown in \u003cstrong\u003eTable 4\u003c/strong\u003e.\u0026nbsp;Among SeLECTS, 33 patients (63.5%) were males. Moreover, seven patients (13.5%) had positive consanguinity, and 22 patients (42.3%) had relevant family history.\u003c/p\u003e\n\u003cp id=\"_Toc182014796\"\u003e\u003cstrong\u003eTable (4):\u0026nbsp;\u003c/strong\u003eDemographic data, seizures characterization, and seizure semiology in participants diagnosed with\u0026nbsp;SeLECTS and SHE\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\" style=\"margin-right: calc(2%); width: 98%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeLECTS (n=52)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSHE (n=33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge: mean \u0026plusmn;sd (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e10.2 \u0026plusmn; 2.6 (5-13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e10.5 \u0026plusmn; 3.4 (3-17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 72.5959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e33 (63.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e23 (69.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e19 (36.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e10 (30.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePositive consanguinity, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e7 (13.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e12 (36.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelevant family history, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e22 (42.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e16 (48.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n\u003csup\u003eo\u003c/sup\u003e of fits/month),\u003cbr\u003e\u0026nbsp;mean \u0026plusmn; SD (range)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e0.51 \u0026plusmn; 0.8 (0.01-4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e1, 0.25:10* (0.01-120)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration (min), median (IQR)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e2.5 (1:8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e5 (1:5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 72.5959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of occurrence of seizures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e45 (86.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e21 (63.60%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSleep + awake, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e7 (13.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e12 (36.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 72.5959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime of seizures at night\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStart, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e38 (73.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e23 (69.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMid, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e4 (7.70%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e15 (45.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnd, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e12 (23.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e11 (33.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOn awakening, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e6 (11.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e13 (39.40%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 72.5959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of attacks per one night\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOnce, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e50 (96.20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e16 (48.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTwice, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e2 (3.80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e6 (18.20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeveral attacks, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e0 (0.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e11 (33.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 72.5959%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of seizures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFocal, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e25 (48.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e18 (54.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGTCS, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e11 (21.20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e5 (15.20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFocal to bilateral tonic-clonic, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e9 (17.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e9 (27.30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 36.2979%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoth, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17.0814%;\"\u003e\n \u003cp\u003e7 (13.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18.576%;\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIQR: Interquartile range, SeLECTS: self-limited epilepsy with centrotemporal spikes; GTCS: generalized tonic-clonic seizure.\u003c/p\u003e\n\u003cp\u003eSeventeen patients (32.7%) had associated seizure symptoms in the patients with SeLECTS versus 11 patients (33.3%) with SHE. The most common associated symptoms in SeLECTS were salivation in 9 patients (17.3%), followed by numbness in 5 patients (7.7%), headache in 4 patients (7.7%), and dysarthria in 3 patients (5.8%). The most associated symptoms in SHE patients were fear in 5 patients (15.2%) and hallucinations in 2 patients (6.1%).\u003c/p\u003e\n\u003cp\u003eTwenty-six (50%) had seizure-associated behavioral changes in SeLECTS patients (19 patients (73.1%) of them had irritability, four patients (15.4%) had hyperactivity, and three patients (11.5%) had both irritability and hyperactivity). As regards SHE patients, 20 patients (60.6%) had associated behavioral changes, 19 patients (95%) from them had irritability, and one patient (5%) had both irritability and hyperactivity.\u003c/p\u003e\n\u003cp\u003eEEG findings in the patients with SeLECTS and SHE are shown in \u003cstrong\u003eFigure 2.\u0026nbsp;\u003c/strong\u003eAs regards the focus of epileptic activity, all patients with SeLECTS (100%) had centro-temporal spikes on their EEG. When considering the aspect of epileptic activity of SeLECTS, 22 patients (42.3%) had right-sided epileptic activity, 20 patients (38.5%) had left-sided epileptic activity, and 10 patients (19.2%) had bilateral epileptic activity.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAs regards the focus of epileptic activity in SHE patients; 15 patients (45.5%) had frontal epileptic activity, eight patients (24.2%) had fronto-temporal epileptic activity while 10 patients (30.3%) had normal EEG findings. Regarding the aspect of the epileptic activity in SHE patients, 14 patients (60.9%) had right-sided epileptic activity, five patients (21.7%) had left-sided epileptic activity, and four patients (17.4%) had bilateral epileptic activity.\u003c/p\u003e\n\u003cp\u003eReferring to SeLECTS patients, Oxcarbazepine was the most common first-line ASM used in 43 patients (82.7%). As a second-line ASM, 10 patients (62.5%) used Levetiracetam.\u003c/p\u003e\n\u003cp\u003eAs regards the ASMs used in the patients diagnosed with SHE, Levetiracetam was the most commonly used first-line ASM (15; 45.5%), followed by Oxcarbazepine (14; 42.4%). Oxcarbazepine was the most used second-line ASM (add-on) (9; 40.9%).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSleep-related epilepsy (SRE) represents a significant proportion of all epilepsies [11]. Idiopathic childhood focal and generalized epilepsies are classically defined by their specific focal EEG findings and clinical correlates. They are assumed to have a commonly shared genetic background [12].\u003c/p\u003e\n\u003cp\u003eThis study aims to define the etiology, semiology, and neurophysiological findings in children presenting with sleep-related seizures and to determine their outcome regarding seizure control on properly selected anti-seizure medications (ASMs).\u003c/p\u003e\n\u003cp\u003eOne hundred patients who fulfilled the inclusion criteria were enrolled in this study. The majority, 97 patients (97%), were classified as epilepsy syndromes. However, a specific syndrome wasn’t identified in 3 cases; among the studied patients, 52 (52%) were diagnosed with SeLECTS, 33 patients (33 %) diagnosed with SHE, seven patients (7%) were diagnosed with SeLEAS and five patients (5%) were diagnosed with juvenile myoclonic epilepsy (JME).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeLECTS is the most frequently diagnosed form of self-limited epilepsy syndrome with a peak age of SeLECTS onset of 7 years and is closely associated with sleep [13].\u003c/p\u003e\n\u003cp\u003eIn the current study, more than half of the cases were SeLECTS. Of these, 33 patients (63.5%) were males, and 19 (36.5%) were females. Moreover, seven patients (13.5%) had positive consanguinity, and 22 (42.3%) had relevant family history.\u003c/p\u003e\n\u003cp\u003eSimilarly, previous studies found that children with SeLECTS had a slight male predominance, 63% of their 70 patients diagnosed with SeLECTS. However, a positive family history of epilepsy was reported in no more than half of the patients in these studies [14-16].\u003c/p\u003e\n\u003cp\u003eThe mean frequency of fits per month in SeLECTS patients included in the present study was 0.51±0.8, with a minimum frequency between 1 and 4 fits per month. The median duration of fits in minutes was 2.5 minutes, with a maximum duration of 8.5 minutes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn concordance, recent studies found that, according to their parents’ reports, the duration of seizures was less than 5 minutes in most cases while reaching more than 30 minutes in a small number of cases [12,16].\u003c/p\u003e\n\u003cp\u003eIn our study, regarding the time of occurrence of seizures in SeLECTS, 45 patients (86.5%) had seizures only during sleep, and seven patients (13.5%) had seizures during sleep and wakefulness.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to Jiang et al.'s study, which enrolled 107 patients with SeLECTS, 17.8% of patients experienced seizures during wakefulness, while 88 (82.2%) experienced seizures during sleep [13].\u003c/p\u003e\n\u003cp\u003eSimilarly, a study in 2023 found that seizures in SeLECTS patients occurred only during sleep, especially in the early morning hours in 15 (79%) children and during sleep and wakefulness in 4 children (21%) [17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeizure semiology describes the evolution of symptoms and signs during epileptic seizures. Semiology is a simple and cost-effective tool that allows localization of the epileptogenic zone [18].\u003c/p\u003e\n\u003cp\u003eIn the current study, regarding the type of seizures in SeLECTS patients, 25 patients (48.1%) had focal seizures, among other types, including\u0026nbsp;generalized tonic-clonic seizure (GTCS), bilateral tonic-clonic, and both focal with GTCS. This comes in agreement with the literature reporting the same types within their SeLECT cohort [19,17].\u003c/p\u003e\n\u003cp\u003eHowever, a study by Jiang et al. revealed that generalized and partial seizures, respectively, affected (57.01%) and (42.99%) of SeLECTS patients [13].\u003c/p\u003e\n\u003cp\u003eIn the present research, 17 patients with SeLECTS (32.7%) had seizure-associated symptoms. The most common associated symptoms were salivation in 9 patients (17.3), numbness in 5 (9.6%), headache in 4 (7.7%) and dysarthria in 3 patients (5.8%).\u003c/p\u003e\n\u003cp\u003eThese findings align with earlier research documenting hypersalivation and speech arrest as the most common symptoms, along with loss of consciousness, facial and oropharyngeal manifestations as well as dysarthria [20,21].\u003c/p\u003e\n\u003cp\u003eIn our study, the frequency of\u0026nbsp;attention deficit hyperactivity disorder (ADHD) was seven patients (13.5%) in children with SeLECTS.\u003c/p\u003e\n\u003cp\u003ePatients with SeLECTS exhibit characteristic EEG changes, including a normal background with centrotemporal stereotyped spikes or sharp waves followed by slow waves, unilaterally or bilaterally, which can be asynchronized or synchronized on both sides. The epileptiform activities can migrate from side to side and even extend to adjacent brain regions, such as the frontal or occipital areas [22].\u003c/p\u003e\n\u003cp\u003eIn the present study, 42 patients (80.7%) diagnosed with SeLECTS had unilateral epileptic activity in the EEG, while 10 patients (19.2%) had bilateral epileptic activity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis comes in agreement with multiple earlier studies, which revealed 60%-75% of their patients had unilateral features [23-26]\u003c/p\u003e\n\u003cp\u003eHowever, a study by Hewawitharana et al. revealed that bilateral discharges in the Rolandic region were the most common (51%) EEG findings, followed by typical unilateral changes in 38% of patients [21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study found that all patients with SeLECTS exhibited centro-temporal spikes on their EEG, consistent with Ross et al. [15]. Tang et al. studied 52 children with SeLECTS, dividing them into isolated and recurrence groups [27]. They found that 50% showed frontal paroxysmal abnormalities, with frontal spikes significantly more common in the recurrence group.\u003c/p\u003e\n\u003cp\u003eIn the past, ASMs were not recommended in children with SeLECTS due to their benign nature. However, with the current understanding of the disease entity, many children with SeLECTS are on ASMs [28].\u003c/p\u003e\n\u003cp\u003eAll patients of the present study received at least one ASM, which is supported by previous studies [20,29]. However, others found only half of SeLECTS patients were given at least one ASM [15].\u003c/p\u003e\n\u003cp\u003eIn our study, oxcarbazepine was the most common ASM used as monotherapy in 43 patients (82.7%) diagnosed with SeLECTS. This is in accordance with researchers who found that oxcarbazepine and carbamazepine are widely used among SeLECTS patients [20,23].\u003c/p\u003e\n\u003cp\u003eIn contrast to our study, some reported that oxcarbazepine monotherapy was ineffective in SeLECTS cases [30]. Furthermore, others found levetiracetam to be the most prevalent treatment method and an alternative to carbamazepine [29,16]. Moreover, recent studies by Hewawitharana et al. and Varesio et al. revealed that sodium valproate was the most used drug in SeLECTS cases [21,14].\u003c/p\u003e\n\u003cp\u003eSleep‐related hypermotor epilepsy (SHE) is a focal epilepsy syndrome characterized by motor events occurring predominantly in clusters during non–rapid eye movement sleep. The distinctive pattern of ictal manifestations consists of hyperkinetic seizures associated with possible asymmetric‐tonic attacks [31].\u003c/p\u003e\n\u003cp\u003eThere were 33 patients diagnosed with SHE in the current study; their mean age was 10.5±3.4 years, with a male predominance of 69.7%. Twelve of them (36.4%) had positive consanguinity, and 16 patients (48.5%) had a relevant family history of epilepsy. Our patient characteristics agreed with previous ones, reporting the same age criteria and slight male predominance [32,31].\u003c/p\u003e\n\u003cp\u003eWe found that the median number of fits per month in the patients diagnosed with SHE was higher, ranging from 1 to 120 fits with a mean duration of 5 minutes.\u003c/p\u003e\n\u003cp\u003eIn concordance, it was documented that SHE seizures could reach 300 fits per month, especially in patients resistant to ASMs [33,34].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the mean duration reported was 30 seconds for some studies, and the duration range reached a maximum of a few minutes [33,35].\u003c/p\u003e\n\u003cp\u003eOur study found that 21 SHE patients (63.6%) had seizures only during sleep. This comes in agreement with Licchetta et al., where most cases (67.9%) had seizures exclusively during sleep [31].\u003c/p\u003e\n\u003cp\u003eAnalysis of the ictal episode revealed variable semiology, likely due to the complexity of frontal lobe networks. In our study, 54.5% of patients experienced focal motor seizures with sudden arousal, head deviation, or hyperkinetic movements. Some had focal to bilateral tonic-clonic seizures or GTCS, with associated symptoms including fear (15.2%) and hallucinations (6.1%). Kishk et al. also reported hypermotor movements in 42.3% of patients, with tonic/dystonic posturing in 57.7% [32].\u003c/p\u003e\n\u003cp\u003eTao et al. found that 69.6% of their drug-resistant SHE patients experienced auras, with agitation common among many [34]. In our study, the predominant epileptic focus was frontal in 45.5% of patients, while 30.3% had normal EEG findings. Kishk et al. reported normal interictal EEG in 34.6% of patients, while 65.4% had interictal epileptiform discharges [32]. Provini et al. found that 51% had normal EEGs, and 45% showed focal abnormalities, primarily in frontal and temporal areas [36].\u003c/p\u003e\n\u003cp\u003eThe current work identifies a significant correlation (P-value = 0.028) between frontal epileptic activity and difficulty controlling seizures, with 40% of patients experiencing uncontrolled seizures on ASMs associated with this activity. This aligns with Sinclair et al., who reported that only half of their patients (11/22) achieved seizure control on ASMs and noted that four intractable cases underwent epilepsy surgery, highlighting the challenges of managing frontal lobe seizures [37].\u003c/p\u003e\n\u003cp\u003eIn the present research, Levetiracetam was the most commonly used ASM, prescribed to 45.5% of SHE patients, followed by oxcarbazepine (42.4%) and valproate (9.1%). Similarly, Kanemura et al. noted greater benefits from Levetiracetam in SHE patients [38]. Raju et al. found that oxcarbazepine was effective and well-tolerated, with complete cessation of nocturnal seizures [39].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost sleep-related seizures are focal, often non-lesional, and typically have a benign outcome with a good response to anti-seizure medications (ASMs). Treatment should start with effective drugs for focal epilepsies, such as oxcarbazepine, levetiracetam, carbamazepine, and lacosamide. If a patient is drug-resistant, epilepsy surgery may be considered [40].\u003c/p\u003e\n\u003cp\u003eOur study shows a significant correlation (p-value=0.008) between the first ASM used and seizure control, with oxcarbazepine being the most effective (controlled in 51 patients, 65.4%), compared to levetiracetam (21 patients, 26.9%), carbamazepine (3 patients, 3.8%), and valproate (1 patient, 1.3%). This aligns with Franzoni et al., who observed that oxcarbazepine led to seizure freedom in 58.3% of patients [41].\u003c/p\u003e\n\u003cp\u003eBeydoun et al. affirmed oxcarbazepine’s Class I efficacy as initial monotherapy for focal-onset seizures in children and as adjunctive therapy alongside drugs like gabapentin and lamotrigine [42].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis is consistent with the\u0026nbsp;National Institute of Health and Care Excellence (NICE) guidelines recommending carbamazepine, lamotrigine, and oxcarbazepine as first-line treatments for newly diagnosed focal-onset childhood seizures. It is estimated that 80% of children with epilepsy could respond to carbamazepine [43].\u003c/p\u003e\n\u003cp\u003eIn contrast, Hur found better seizure outcomes for lamotrigine compared to oxcarbazepine in pediatric patients with normal MRI findings [44].\u0026nbsp;\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eThis 18-month study may have benefited from a longer duration for more comprehensive data. However, we believe that an extended study with a larger population would not have significantly altered the findings related to SRE incidences. Our case series reflects a heterogeneous SRE population with varied and often unknown etiology. In addition, the absence of genetic studies limited our results regarding genetic links.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe etiology of SRE was mostly idiopathic. Patients with SeLECTS had the highest prevalence of epilepsy syndromes, followed by SHE and SeLEAS, with male predominance.\u003c/p\u003e\n\u003cp\u003eSeizure semiology and EEG analysis provided valuable insights for classifying SRE, showing concordance between the interictal focus and seizure semiology. Regarding treatment, Oxcarbazepine was the most effective treatment for SRE and was frequently used for SeLECTS, SHE, and SeLEAS, while levetiracetam was preferred for JME. \u0026nbsp; Finally, controlling seizures is more challenging when sleep-related seizures have a symptomatic cause. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eRecommendations\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEfforts should be made to identify and treat SRE for better outcomes. Neuroimaging is essential to exclude structural, inflammatory, or metabolic causes of seizures. Moreover, pediatric neurologists should be aware of selecting ASMs based on the type of epileptic syndrome, seizures, patient characteristics, and drug pharmacokinetics to reduce reliance on valproate and levetiracetam in focal onset seizures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADHD: Attention deficit hyperactivity disorder\u003c/p\u003e\n\u003cp\u003eASMs: Anti-seizure medications\u003c/p\u003e\n\u003cp\u003eCNS: Central nervous system\u003c/p\u003e\n\u003cp\u003eEEG: Electroencephalogram\u003c/p\u003e\n\u003cp\u003eGTCS: Generalized tonic-clonic seizure\u003c/p\u003e\n\u003cp\u003eILAE: International League Against Epilepsy\u003c/p\u003e\n\u003cp\u003eIQR: Interquartile range\u003c/p\u003e\n\u003cp\u003eJME: Juvenile myoclonic epilepsy\u003c/p\u003e\n\u003cp\u003eLEV: Levetiracetam\u003c/p\u003e\n\u003cp\u003eMRI: Magnetic resonance- imaging\u003c/p\u003e\n\u003cp\u003eNICE: National Institute of Health and Care Excellence\u003c/p\u003e\n\u003cp\u003eNICU: Neonatal intensive care unit\u003c/p\u003e\n\u003cp\u003eNREM: Non-rapid eye movement\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOXC: Oxcarbazepine\u003c/p\u003e\n\u003cp\u003eREM: Rapid eye movement\u003c/p\u003e\n\u003cp\u003eSD: Standard deviation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeLEAS: Self-limited epilepsy with autonomic symptoms\u003c/p\u003e\n\u003cp\u003eSeLECTS: Self-limited epilepsy with centro-temporal spikes\u003c/p\u003e\n\u003cp\u003eSHE: Sleep-related hypermotor seizures\u003c/p\u003e\n\u003cp\u003eSPSS: Statistical Package for Social Science\u003c/p\u003e\n\u003cp\u003eSRE: Sleep-related epilepsy\u003c/p\u003e\n\u003cp\u003eUSA: United States of America.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate:\u003c/u\u003e\u003c/strong\u003eThe study protocol was reviewed and approved by the institutional Ethical Research Committee (Code MD-78-2023). The procedure and the aim of the study were clearly explained to the study participants/ their legal guardians. Before enrollment in the study, written informed consent was obtained from the participants’ legal guardians with an explanation of the benefits and drawbacks of the procedure. The subject was free to withdraw from the study at any moment; participation was entirely voluntary. In accordance with the Declaration of Helsinki, all steps of data collecting, entry, and analysis were conducted in a highly confidential and private manner.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding:\u003c/u\u003e\u003c/strong\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNobili, L., Frauscher, B., Eriksson, S., Gibbs, S. A., Halasz, P., Lambert, I., Manni, R., Peter‐Derex, L., Proserpio, P., Provini, F., de Weerd, A., \u0026amp; Parrino, L. (2022). Sleep and epilepsy: A snapshot of knowledge and future research lines. 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Nature and Science of Sleep, Volume 16, 751\u0026ndash;760.\u003c/li\u003e\n\u003cli\u003eVaresio, C., Zanaboni, M. P., Salmin, E. C., Totaro, C., Totaro, M., Ballante, E., Pasca, L., Veggiotti, P., \u0026amp; De Giorgis, V. (2020). Childhood Epilepsy with Centrotemporal Spikes: Clinical and Neuropsychological Outcomes 5 Years after Remission. Diagnostics, 10(11), 931.\u003c/li\u003e\n\u003cli\u003eRoss, E. E., Stoyell, S. M., Kramer, M. A., Berg, A. T., \u0026amp; Chu, C. J. (2020). The natural history of seizures and neuropsychiatric symptoms in childhood epilepsy with centrotemporal spikes (CECTS). Epilepsy \u0026amp; Behavior, 103, 106437.\u003c/li\u003e\n\u003cli\u003eBadem, M., Sarikaya Uzan, G., \u0026amp; Hiz Kurul, S. (2023). Electroclinical and Demographic Evaluation of Cases with Selflimited Epilepsy with Centrotemporal Spikes. Forbes Journal of Medicine, 4(1), 21\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eT Valoor, H. A. R. S. H. A., Jose, J., \u0026amp; Gafoor, A. (2023). Clinical features, electroencephalogram findings and treatment of self-limited focal epilepsies of childhood. Asian J Pharm Clin Res, 16(11), 141-143.\u003c/li\u003e\n\u003cli\u003eTufenkjian, K., \u0026amp; L\u0026uuml;ders, H. O. (2012). Seizure Semiology: Its Value and Limitations in Localizing the Epileptogenic Zone. Journal of Clinical Neurology, 8(4), 243.\u003c/li\u003e\n\u003cli\u003eWeir, E., Gibbs, J., \u0026amp; Appleton, R. (2018). Panayiotopoulos syndrome and benign partial epilepsy with centro-temporal spikes: A comparative incidence study. Seizure, 57, 66\u0026ndash;69.\u003c/li\u003e\n\u003cli\u003eSable, S., Sable, R., Tamhankar, P., \u0026amp; Tamhankar, V. (2021). Clinical profile of patients with rolandic epilepsy at a clinic in rural Maharashtra. Journal of Family Medicine and Primary Care, 10(3), 1263\u0026ndash;1266.\u003c/li\u003e\n\u003cli\u003eHewawitharana, G., Munasinghe, T. M., Kodithuwakku, A., Suriyaarachchi, S. R., \u0026amp; Kankananarachchi, I. (2023). Clinical profile and electroencephalogram characteristics of children with self-limited epilepsy with centro-temporal spikes attending paediatric neurology clinic, Teaching Hospital, Karapitiya, Sri Lanka. Sri Lanka Journal of Child Health, 52(1), 33.\u003c/li\u003e\n\u003cli\u003eCallenbach, P. M. C., Bouma, P. A. D., Geerts, A. T., Arts, W. F. M., Stroink, H., Peeters, E. A. J., van Donselaar, C. A., Peters, A. C. B., \u0026amp; Brouwer, O. F. (2010). Long term outcome of benign childhood epilepsy with centrotemporal spikes: Dutch Study of Epilepsy in Childhood. Seizure, 19(8), 501\u0026ndash;506.\u003c/li\u003e\n\u003cli\u003eLiu, M.-J., Su, X., MD, X.-Y. S., Wu, G., Zhang, Y., Gao, L., Wang, W., Liao, J., Wang, H., Mai, J., Gao, J., Shu, X., Huang, S., Zhang, L., \u0026amp; Zou, L.-P. (2017). Clinical features of benign epilepsy of childhood with centrotemporal spikes in chinese children. Medicine, 96(4), e5623.\u003c/li\u003e\n\u003cli\u003eBedoin, N., Herbillon, V., Lamoury, I., Arthaud-Garde, P., Ostrowsky, K., De Bellescize, J., K\u0026eacute;o Kosal, P., Damon, G., \u0026amp; Rousselle, Ch. (2006). Hemispheric lateralization of cognitive functions in children with centrotemporal spikes. Epilepsy \u0026amp; Behavior, 9(2), 268\u0026ndash;274.\u003c/li\u003e\n\u003cli\u003eRiva, D., Vago, C., Franceschetti, S., Pantaleoni, C., D\u0026rsquo;Arrigo, S., Granata, T., \u0026amp; Bulgheroni, S. (2007). Intellectual and language findings and their relationship to EEG characteristics in benign childhood epilepsy with centrotemporal spikes. Epilepsy \u0026amp; Behavior, 10(2), 278\u0026ndash;285.\u003c/li\u003e\n\u003cli\u003eZhao, X., Chi, Z., Chi, L., Shang, W., \u0026amp; Liu, X. (2007). Clinical and EEG characteristics of benign rolandic epilepsy in Chinese patients. Brain and Development, 29(1), 13\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eTang, H., Wang, Y., Hua, Y., Wang, J., Jing, M., \u0026amp; Hu, X. (2019). Analysis of serial electroencephalographic predictors of seizure recurrence in Rolandic epilepsy. Child\u0026rsquo;s Nervous System, 35(9), 1579\u0026ndash;1583.\u003c/li\u003e\n\u003cli\u003eDryżałowski, P., J\u0026oacute;źwiak, S., Franckiewicz, M., \u0026amp; Strzelecka, J. (2018). Benign epilepsy with centrotemporal spikes \u0026ndash; Current concepts of diagnosis and treatment. Neurologia i Neurochirurgia Polska, 52(6), 677\u0026ndash;689.\u003c/li\u003e\n\u003cli\u003eKessi, M., Yan, F., Pan, L., Chen, B., Olatoutou, E., Li, D., He, F., Rugambwa, T., Yang, L., Peng, J., \u0026amp; Yin, F. (2021). Treatment for the Benign Childhood Epilepsy With Centrotemporal Spikes: A Monocentric Study. Frontiers in Neurology, 12.\u003c/li\u003e\n\u003cli\u003eKwon, S., Hwang, T. G., Lee, J., Kim, D.-K., \u0026amp; Seo, H.-E. (2013). Benign Childhood Epilepsy with Centrotemporal Spikes: To Treat or Not to Treat. Journal of Epilepsy Research, 3(1), 1\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eLicchetta, L., Vignatelli, L., Zenesini, C., Mostacci, B., Ferri, L., Provini, F., Tinuper, P., and Bisulli, F. (2019). Sleep‐related hypermotor epilepsy: A prediction cohort study on sleep/awake patterns of seizures. Epilepsia, 60(11), e115\u0026ndash;e120.\u003c/li\u003e\n\u003cli\u003eKishk, N. A., Nawito, A. M., Ebraheim, A. M., \u0026amp; Rizk, H. (2019). Insights into sleep-related hyper-motor epilepsy: an Egyptian case series. Neurological Research, 41(9), 771\u0026ndash;779.\u003c/li\u003e\n\u003cli\u003eRheims, S., Ryvlin, P., Scherer, C., Minotti, L., Hoffmann, D., Guenot, M., Maugui\u0026egrave;re, F., Benabid, A., \u0026amp; Kahane, P. (2008). Analysis of clinical patterns and underlying epileptogenic zones of hypermotor seizures. Epilepsia, 49(12), 2030\u0026ndash;2040.\u003c/li\u003e\n\u003cli\u003eTao, Y., Guojun, Z., Yuping, W., Lixin, C., Wei, D., \u0026amp; Yongjie, L. (2010). Surgical treatment of patients with drug‐resistant hypermotor seizures. Epilepsia, 51(10), 2124\u0026ndash;2130.\u003c/li\u003e\n\u003cli\u003eAlqadi, K., Sankaraneni, R., Thome, U., \u0026amp; Kotagal, P. (2016). Semiology of hypermotor (hyperkinetic) seizures. Epilepsy \u0026amp; Behavior, 54, 137\u0026ndash;141.\u003c/li\u003e\n\u003cli\u003eProvini, F. (1999). Nocturnal frontal lobe epilepsy: A clinical and polygraphic overview of 100 consecutive cases. Brain, 122(6), 1017\u0026ndash;1031.\u003c/li\u003e\n\u003cli\u003eSinclair, D. B., Wheatley, M., \u0026amp; Snyder, T. (2004). Frontal lobe epilepsy in childhood. Pediatric Neurology, 30(3), 169\u0026ndash;176.\u003c/li\u003e\n\u003cli\u003eKanemura, H., Sano, F., Sugita, K., \u0026amp; Aihara, M. (2013). Effects of levetiracetam on seizure frequency and neuropsychological impairments in children with refractory epilepsy with secondary bilateral synchrony. Seizure, 22(1), 43\u0026ndash;47.\u003c/li\u003e\n\u003cli\u003eRaju, G. P., Sarco, D. P., Poduri, A., Riviello, J. J., Bergin, A. M. R., \u0026amp; Takeoka, M. (2007). Oxcarbazepine in Children with Nocturnal Frontal-Lobe Epilepsy. Pediatric Neurology, 37(5), 345\u0026ndash;349.\u003c/li\u003e\n\u003cli\u003eCarre\u0026ntilde;o, M., \u0026amp; Fern\u0026aacute;ndez, S. (2016). Sleep-Related Epilepsy. Current Treatment Options in Neurology, 18(5), 23.\u003c/li\u003e\n\u003cli\u003eFranzoni, E., Garone, C., Sarajlija, J., Gualandi, S., Malaspina, E., Cecconi, I., Moscano, F. C., \u0026amp; Marchiani, V. (2006). Open prospective study on oxcarbazepine in epilepsy in children: A preliminary report. Seizure, 15(5), 292\u0026ndash;298.\u003c/li\u003e\n\u003cli\u003eBeydoun, A., DuPont, S., Zhou, D., Matta, M., Nagire, V., and Lagae, L. (2020). Current role of carbamazepine and oxcarbazepine in the management of epilepsy. Seizure, 83, 251\u0026ndash;263.\u003c/li\u003e\n\u003cli\u003eJones, K. E. A., Howells, R., Mallick, A. A., Paul, S. P., \u0026amp; Dey, I. (2023). NICE guideline review: Epilepsies in children, young people and adults NG217. Archives of Disease in Childhood - Education \u0026amp; Practice Edition, 108(6), 416\u0026ndash;421.\u003c/li\u003e\n\u003cli\u003eHur, Y. J. (2018). Comparison of lamotrigine and oxcarbazepine monotherapy for pediatric focal epilepsy: An observational study. Seizure, 60, 123\u0026ndash;126.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Sleep-related epilepsy, Epilepsy syndrome, Seizures semiology, EEG, brain MRI, Anti-seizure medications","lastPublishedDoi":"10.21203/rs.3.rs-6220612/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6220612/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground and objective:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e \u003c/em\u003eSleep-related epilepsy (SRE) is nocturnal seizures that manifest during the sleep state. It affects 12%-20% of epileptic patients, specifically those suffering from focal epilepsy. SRE is often misdiagnosed as a sleep disorder, especially in cases where the seizures manifest exclusively during sleep. This work aimed to study SRE, etiology, semiology, and electroencephalogram (EEG) characters and to determine their outcome regarding seizure control on properly selected anti-seizure medications (ASMs).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eThis study enrolled one hundred patients who fulfilled the inclusion criteria. All of them were subjected to history taking, full examination, seizure semiology analysis, inter-ictal EEG recordings, and magnetic resonance imaging (MRI).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003ePatients with self-limited epilepsy with centro-temporal spikes (SeLECTS) were the most common epilepsy syndrome (52%), followed by sleep-related hypermotor seizures (SHE) (33%), then patients with self-limited epilepsy with autonomic symptoms (SeLEAS). Around 79% of the patients had sleep seizures, while 21% had seizures during sleep and wakefulness. Also, oxcarbazepine (OXC) was the most used first ASM in 62% of our patients, followed by levetiracetam (LEV) in 28% of the patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eSeLECTS, SHE, and\u003cstrong\u003e \u003c/strong\u003eSeLEAS are three of the most frequently implicated epilepsy syndromes occurring during the sleep state. Oxcarbazepine was the most effective drug to control seizures.\u003c/p\u003e","manuscriptTitle":"Sleep-Related Seizures in Children: Cohort Study from a Tertiary Center","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-20 10:00:39","doi":"10.21203/rs.3.rs-6220612/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-21T06:23:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-21T02:47:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-21T02:45:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Egyptian Pediatric Association Gazette","date":"2025-03-13T13:36:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"egyptian-pediatric-association-gazette","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"epag","sideBox":"Learn more about [Egyptian Pediatric Association Gazette](https://epag.springeropen.com)","snPcode":"43054","submissionUrl":"https://submission.springernature.com/new-submission/43054/3?","title":"Egyptian Pediatric Association Gazette","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"b3b8d8c8-a296-4b54-8607-d2a7171e906c","owner":[],"postedDate":"March 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T16:00:29+00:00","versionOfRecord":{"articleIdentity":"rs-6220612","link":"https://doi.org/10.1186/s43054-025-00409-z","journal":{"identity":"egyptian-pediatric-association-gazette","isVorOnly":false,"title":"Egyptian Pediatric Association Gazette"},"publishedOn":"2025-08-05 15:57:21","publishedOnDateReadable":"August 5th, 2025"},"versionCreatedAt":"2025-03-20 10:00:39","video":"","vorDoi":"10.1186/s43054-025-00409-z","vorDoiUrl":"https://doi.org/10.1186/s43054-025-00409-z","workflowStages":[]},"version":"v1","identity":"rs-6220612","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6220612","identity":"rs-6220612","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}