Tuesday, November 3, 2015

CPAP and seizures

A 25-year-old man presented to Cleveland Clinic's Epilepsy Center in 2002 with epileptic seizures occurring as frequently as once a day and convulsions occurring about once a week. Diagnosed with epilepsy at age 15 years, he had never been able to work outside the home or drive a car.

The patient was evaluated for surgical therapy, because his seizures were not controlled by anti-epileptic medications (oxcarbazepine and levetiracetam, prescribed at another institution). Because we were unable to localize his seizures, he was not a candidate for resection. He did receive a vagus nerve stimulator (VNS), which also proved ineffective in controlling his seizures.


The patient did not display the classic symptoms of sleep apnea. He was not greatly overweight. He had mild, intermittent snoring, but his wife did not observe cessation of breathing during the night.

Nevertheless, we decided to conduct a sleep study because sleep apnea has been associated with worsening epileptic seizures. In the laboratory at the Cleveland Clinic Sleep Disorders Center, he was observed to have 17 episodes of breathing cessation per hour of sleep; 15 episodes is considered to be moderate sleep apnea, and 30 is classified as severe. The medical literature indicates that a frequency of 15 episodes per hour increases the risk for a variety of cardiovascular events, including heart attack and stroke.

In addition, the patient's oxygen saturation level dropped to 67% during the study, which is considered significant desaturation.


The patient was placed on continuous positive airway pressure (CPAP) therapy at a pressure level of 10 cm H2O, ensuring that his apnea episodes would occur fewer than five times per hour and his oxygen saturation level would exceed 90%. He continued medical therapy with antiseizure medications, which were adjusted over time as new drugs with fewer side effects became available. He now takes topiramate and lamotrigine.


After beginning CPAP therapy, the patient gradually experienced fewer and fewer seizures. Within about 2 months they had stopped altogether.

During a 10-year follow-up period, he remained seizure-free. Initially, we were not sure what role each of the treatments (CPAP therapy, VNS, and medications) played in his improvement. But when the VNS failed twice—the second time permanently—and the seizures did not recur, we concluded that the CPAP therapy had the most impact.

Eight years after beginning CPAP therapy, the patient returned to the Sleep Disorders Center with recurrent daytime sleepiness, but not seizures. In the sleep laboratory, we determined that he required a higher pressure from the CPAP machine (a common development for patients who have been on CPAP therapy for several years). After the pressure was increased, his sleepiness resolved.

This father of two can now drive a car, and he works full-time as a quality technician in the auto industry.


More sleep apnea screening is needed in epileptic patients. The association between obstructive sleep apnea and epilepsy is fairly well recognized. Our group recently published a study demonstrating the benefit of CPAP therapy in reducing seizures among patients with epilepsy.

Despite a growing body of evidence pointing to sleep apnea as an activator of seizures, few epilepsy providers refer their patients for sleep studies. Most patients who come to us have never had a discussion with their doctors about their sleep. We believe that every patient with epilepsy, and especially those whose seizures are poorly controlled, should be screened for sleep apnea. This is one of the ways in which we can greatly enhance the quality of life for these patients.


1 comment:

  1. Pornsriniyom D, Kim Hw, Bena J, Andrews ND, Moul D, Foldvary-Schaefer N.
    Effect of positive airway pressure therapy on seizure control in patients with
    epilepsy and obstructive sleep apnea. Epilepsy Behav. 2014 Aug;37:270-5.


    Previous studies suggest that treatment for obstructive sleep apnea (OSA) in patients with epilepsy can improve seizure control. We investigated the effect of positive airway pressure (PAP) therapy on seizures in adults with epilepsy referred to the Cleveland Clinic for polysomnography (PSG) from 1997 to 2010. Seizure outcome at baseline and 1 year later was compared in patients with no OSA (apnea-hypopnea index [AHI] <5), patients with PAP-treated OSA, and patients with untreated OSA. One hundred thirty-two subjects (age: 40.2±13 (18-76) years, 65.4% female) were included. Seventy-six (57.6%) subjects had OSA; of these, 43 (56.6%) were on PAP therapy, and 33 (43.4%) were not on PAP therapy (either PAP-intolerant or refused therapy). Of the group with PAP-treated OSA, 83.7% were adherent (use ≥4 h/night at least 5 nights/week). The percentage of subjects with ≥50% seizure reduction and the mean percentage of seizure reduction were significantly greater in the group with PAP-treated OSA (73.9%; 58.5%) than in subjects with untreated OSA (14.3%; 17.0%). There were significantly more subjects with successful outcomes (with ≥50% seizure reduction or seizure-free at both baseline and follow-up) in the group with PAP-treated OSA (83.7%) than in the groups with no OSA (53.6%) and untreated OSA (39.4%). After adjusting for age, gender, body mass index, AHI, and epilepsy duration, we found that the odds of successful outcomes in subjects in the group with PAP-treated OSA were 9.9 and 3.91 times those of the groups with untreated OSA and no OSA, respectively. The group with PAP-treated OSA had 32.3 times the odds of having a ≥50% seizure reduction compared with the group with untreated OSA and 6.13 times compared with the group with no OSA. Positive airway pressure therapy appears to produce beneficial effects on seizures in adult patients with epilepsy and OSA.