Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Polysomnography in the evaluation of parasomnias and epilepsy

Jennifer L DeWolfe, DO
Section Editor
Susan M Harding, MD, FCCP, AGAF
Deputy Editor
Janet L Wilterdink, MD


Nocturnal behaviors can be complex and potentially injurious, and nocturnal video polysomnography (PSG) with extended electroencephalography (EEG) is often indicated to establish a definitive diagnosis, particularly when such behaviors arise in adulthood or when there is uncertainty about the etiology of the behaviors.

Common etiologies of nocturnal behaviors include non-rapid eye movement sleep (NREM) arousal parasomnias such as sleepwalking and confusional arousals, rapid eye movement sleep (REM) parasomnias, sleep-related seizures, sleep-related psychiatric events, and post-arousal behaviors associated with other primary sleep disorders (eg, obstructive sleep apnea) [1]. (See "Approach to abnormal movements and behaviors during sleep".)

This topic reviews the PSG monitoring techniques used to diagnose REM sleep behavior disorder (RBD), NREM arousal parasomnias, and epileptic seizures during sleep. The clinical features, evaluation, diagnosis, and management of parasomnias in children and adults are presented separately. (See "Sleepwalking and other parasomnias in children" and "Disorders of arousal from non-rapid eye movement sleep in adults" and "Rapid eye movement sleep behavior disorder" and "Sleep-related epilepsy syndromes".)

Additional considerations on PSG technique in infants and children are also reviewed separately. (See "Overview of polysomnography in infants and children".)


Digital specifications and settings — The American Academy of Sleep Medicine (AASM) manual for scoring sleep and associated events outlines the digital specifications for polysomnography (PSG) recordings [2]. The recommended minimal digital resolution is 12 bits per sample (with the exception of the body position channel), and the maximum recommended electrode impedance for electroencephalography (EEG) and electrooculography (EOG) is 5 kilo-ohms. The latter should be re-evaluated when the recording appears artifactual.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Jul 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Dewolfe JL, Malow B, Huguenard J, et al. Sleep and epilepsy: a summary of the 2011 merritt-putnam symposium. Epilepsy Curr 2013; 13:42.
  2. Berry RB, Brooks R, Gamaldo CE, et al. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, version 2.4, American Academy of Sleep Medicine, Darien IL 2017.
  3. Jasper HH. The ten-twenty electrode system of the International Federation: Report on the Committee on Methods of Clinical Examination in Electroencephalography. Electroencephalogr Clin Neurophysiol 1958; 10:370.
  4. Grigg-Damberger MM. The AASM Scoring Manual four years later. J Clin Sleep Med 2012; 8:323.
  5. van Sweden B, Kemp B, Kamphuisen HA, Van der Velde EA. Alternative electrode placement in (automatic) sleep scoring (Fpz-Cz/Pz-Oz versus C4-A1). Sleep 1990; 13:279.
  6. Foldvary N, Caruso AC, Mascha E, et al. Identifying montages that best detect electrographic seizure activity during polysomnography. Sleep 2000; 23:221.
  7. Foldvary-Schaefer N, De Ocampo J, Mascha E, et al. Accuracy of seizure detection using abbreviated EEG during polysomnography. J Clin Neurophysiol 2006; 23:68.
  8. American Clinical Neurophysiology Society. Guideline 6: A proposal for standard montages to be used in clinical EEG. J Clin Neurophysiol 2006; 23:111.
  9. Grigg-Damberger M, Ralls F. Primary sleep disorders and paroxysmal nocturnal nonepileptic events in adults with epilepsy from the perspective of sleep specialists. J Clin Neurophysiol 2011; 28:120.
  10. Patrick R. Principles of Recording Biopotentials, Lippincott Williams & Wilkins, Philadelphia, PA 2007.
  11. Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005; 28:499.
  12. Yogarajah M, Powell HW, Heaney D, et al. Long term monitoring in refractory epilepsy: the Gowers Unit experience. J Neurol Neurosurg Psychiatry 2009; 80:305.
  13. DeWolfe JL, Malow BA. Approach to sleep-related seizure identification and management. In: Therapy in Sleep Medicine, Barkoukis TJ, Matheson JK, Ferber R, Doghramji K (Eds), Saunders, Philadelphia, PA 2012.
  14. Lagerlund TD, Cascino GD, Cicora KM, Sharbrough FW. Long-term electroencephalographic monitoring for diagnosis and management of seizures. Mayo Clin Proc 1996; 71:1000.
  15. Uhles M, Malhotra R. Movement disorders. In: Fundamentals of Sleep Technology, 2nd ed, Lee-chiong T (Ed), Lippincott Williams & Wilkins, Philadelphia, PA 2012. p.136.
  16. Schenck CH, Pareja JA, Patterson AL, Mahowald MW. Analysis of polysomnographic events surrounding 252 slow-wave sleep arousals in thirty-eight adults with injurious sleepwalking and sleep terrors. J Clin Neurophysiol 1998; 15:159.
  17. Mahowald MW, Cramer Bornemann MA, Schenck CH. State dissociation, human behavior, and consciousness. Curr Top Med Chem 2011; 11:2392.
  18. Derry CP, Duncan JS, Berkovic SF. Paroxysmal motor disorders of sleep: the clinical spectrum and differentiation from epilepsy. Epilepsia 2006; 47:1775.
  19. Bornemann MA, Mahowald MW, Schenck CH. Parasomnias: clinical features and forensic implications. Chest 2006; 130:605.
  20. Cascino GD. Clinical indications and diagnostic yield of video-electroencephalographic monitoring in patients with seizures and spells. Mayo Clin Proc 2002; 77:1111.
  21. Espa F, Ondze B, Deglise P, et al. Sleep architecture, slow wave activity, and sleep spindles in adult patients with sleepwalking and sleep terrors. Clin Neurophysiol 2000; 111:929.
  22. Mahowald MW, Schenck CH. Non-rapid eye movement sleep parasomnias. Neurol Clin 2005; 23:1077.
  23. Vetrugno R, Manconi M, Ferini-Strambi L, et al. Nocturnal eating: sleep-related eating disorder or night eating syndrome? A videopolysomnographic study. Sleep 2006; 29:949.
  24. Yeh SB, Schenck CH. Sleep-related eating disorder in a 29 year-old man: a case report with diagnostic polysomnographic findings. Acta Neurol Taiwan 2007; 16:106.
  25. Brion A, Flamand M, Oudiette D, et al. Sleep-related eating disorder versus sleepwalking: a controlled study. Sleep Med 2012; 13:1094.
  26. Perogamvros L, Baud P, Hasler R, et al. Active Reward Processing during Human Sleep: Insights from Sleep-Related Eating Disorder. Front Neurol 2012; 3:168.
  27. Pilon M, Montplaisir J, Zadra A. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology 2008; 70:2284.
  28. Gaudreau H, Joncas S, Zadra A, Montplaisir J. Dynamics of slow-wave activity during the NREM sleep of sleepwalkers and control subjects. Sleep 2000; 23:755.
  29. American Academy of Sleep Medicine. The International Classification of Sleep Disorders, 3rd ed, Chicago, IL 2014.
  30. Frauscher B, Iranzo A, Högl B, et al. Quantification of electromyographic activity during REM sleep in multiple muscles in REM sleep behavior disorder. Sleep 2008; 31:724.
  31. Frauscher B, Gabelia D, Biermayr M, et al. Validation of an integrated software for the detection of rapid eye movement sleep behavior disorder. Sleep 2014; 37:1663.
  32. Iranzo A, Frauscher B, Santos H, et al. Usefulness of the SINBAR electromyographic montage to detect the motor and vocal manifestations occurring in REM sleep behavior disorder. Sleep Med 2011; 12:284.
  33. Lapierre O, Montplaisir J. Polysomnographic features of REM sleep behavior disorder: development of a scoring method. Neurology 1992; 42:1371.
  34. Consens FB, Chervin RD, Koeppe RA, et al. Validation of a polysomnographic score for REM sleep behavior disorder. Sleep 2005; 28:993.
  35. Ferri R, Gagnon JF, Postuma RB, et al. Comparison between an automatic and a visual scoring method of the chin muscle tone during rapid eye movement sleep. Sleep Med 2014; 15:661.
  36. Frauscher B, Ehrmann L, Högl B. Defining muscle activities for assessment of rapid eye movement sleep behavior disorder: from a qualitative to a quantitative diagnostic level. Sleep Med 2013; 14:729.
  37. Burns JW, Consens FB, Little RJ, et al. EMG variance during polysomnography as an assessment for REM sleep behavior disorder. Sleep 2007; 30:1771.
  38. McCarter SJ, St Louis EK, Duwell EJ, et al. Diagnostic thresholds for quantitative REM sleep phasic burst duration, phasic and tonic muscle activity, and REM atonia index in REM sleep behavior disorder with and without comorbid obstructive sleep apnea. Sleep 2014; 37:1649.
  39. Frauscher B, Iranzo A, Gaig C, et al. Normative EMG values during REM sleep for the diagnosis of REM sleep behavior disorder. Sleep 2012; 35:835.
  40. Foldvary-Schaefer N, Alsheikhtaha Z. Complex nocturnal behaviors: nocturnal seizures and parasomnias. Continuum (Minneap Minn) 2013; 19:104.
  41. Bazil CW, Walczak TS. Effects of sleep and sleep stage on epileptic and nonepileptic seizures. Epilepsia 1997; 38:56.
  42. Ng M, Pavlova M. Why are seizures rare in rapid eye movement sleep? Review of the frequency of seizures in different sleep stages. Epilepsy Res Treat 2013; 2013:932790.
  43. Okanari K, Baba S, Otsubo H, et al. Rapid eye movement sleep reveals epileptogenic spikes for resective surgery in children with generalized interictal discharges. Epilepsia 2015; 56:1445.
  44. Tezer FI, Rémi J, Erbil N, et al. A reduction of sleep spindles heralds seizures in focal epilepsy. Clin Neurophysiol 2014; 125:2207.
  45. Bisulli F, Vignatelli L, Naldi I, et al. Increased frequency of arousal parasomnias in families with nocturnal frontal lobe epilepsy: a common mechanism? Epilepsia 2010; 51:1852.
  46. Provini F, Plazzi G, Tinuper P, et al. Nocturnal frontal lobe epilepsy. A clinical and polygraphic overview of 100 consecutive cases. Brain 1999; 122 ( Pt 6):1017.
  47. Derry CP, Harvey AS, Walker MC, et al. NREM arousal parasomnias and their distinction from nocturnal frontal lobe epilepsy: a video EEG analysis. Sleep 2009; 32:1637.
  48. Hofstra WA, Spetgens WP, Leijten FS, et al. Diurnal rhythms in seizures detected by intracranial electrocorticographic monitoring: an observational study. Epilepsy Behav 2009; 14:617.
  49. Malow BA, Lin X, Kushwaha R, Aldrich MS. Interictal spiking increases with sleep depth in temporal lobe epilepsy. Epilepsia 1998; 39:1309.
  50. Clemens B, Majoros E. Sleep studies in benign epilepsy of childhood with rolandic spikes. II. Analysis of discharge frequency and its relation to sleep dynamics. Epilepsia 1987; 28:24.
  51. Schmitt B. Sleep and epilepsy syndromes. Neuropediatrics 2015; 46:171.
  52. Loddenkemper T, Fernández IS, Peters JM. Continuous spike and waves during sleep and electrical status epilepticus in sleep. J Clin Neurophysiol 2011; 28:154.
  53. Singhal NS, Sullivan JE. Continuous Spike-Wave during Slow Wave Sleep and Related Conditions. ISRN Neurol 2014; 2014:619079.
  54. Zarowski M, Loddenkemper T, Vendrame M, et al. Circadian distribution and sleep/wake patterns of generalized seizures in children. Epilepsia 2011; 52:1076.
  55. Stern JM. Interictal Epileptiform Patterns, 2nd ed, Lippincott Williams & Wilkins, Philadelphia, PA 2013.
  56. Neurological monitoring techniques, 4th ed, Malow BA (Ed), Elsevier, St. Louis, MO 2005.
  57. Benbadis SR, Rielo DA. EEG Artifacts [online]. Available at: http://emedicine.medscape.com/article/1140247-overview#showall. (Accessed on September 14, 2015).
  58. Misulis KE, Head TC. Essentials of Clinical Neurophysiology, Normal Electroencephalographic Patterns, Butterworth Heinemann, Burlington, MA 2003.
  59. Priyadharsini SS, Rajan SE. Evolutionary computing based approach for the removal of ECG artifact from the corrupted EEG signal. Technol Health Care 2014; 22:835.
  60. Siddiqui F, Osuna E, Walters AS, Chokroverty S. Sweat artifact and respiratory artifact occurring simultaneously in polysomnogram. Sleep Med 2006; 7:197.
  61. Reuber M, Fernández G, Bauer J, et al. Interictal EEG abnormalities in patients with psychogenic nonepileptic seizures. Epilepsia 2002; 43:1013.
  62. Bayly J, Carino J, Petrovski S, et al. Time-frequency mapping of the rhythmic limb movements distinguishes convulsive epileptic from psychogenic nonepileptic seizures. Epilepsia 2013; 54:1402.
  63. El Shakankiry HM, Kader AA. Pattern sensitivity: a missed part of the diagnosis. Neuropsychiatr Dis Treat 2012; 8:313.
  64. Rogawski MA. Migraine and epilepsy-shared mechanisms within the family of episodic disorders. In: Jasper's Basic Mechanisms of the Epilepsies, Noebels JL, Avoli M, Rogawski MA, et al (Eds), National Center for Biotechnology Information (US), Bethesda, MD 2012.
  65. Liedorp M, Stam CJ, van der Flier WM, et al. Prevalence and clinical significance of epileptiform EEG discharges in a large memory clinic cohort. Dement Geriatr Cogn Disord 2010; 29:432.
Topic Outline