Dreams interrupted: characteristics of REM sleep-associated seizures and status epilepticus

Seizures are rare in rapid eye movement (REM) sleep. However, seizures sometimes occur in REM sleep, and a small number of focal epilepsy patients display their maximum rate of interictal epileptiform discharges in REM sleep. We sought to systematically identify and characterize seizures in REM sleep.

We reviewed all admissions to the epilepsy monitoring unit at the Winnipeg Health Sciences Center over 12 months in 2014-2015. American Academy of Sleep Medicine sleep-stage scoring was initially applied in the standard 30-second epochs. Then, to capture sudden changes in sleep-wake state on shorter timescales that are associated with seizure formation and propagation, we rescored ictal and peri-ictal electroencephalography epochs every 1 second. Patients found to have seizures in REM sleep were subject to chart review spanning 3 years pre- and postadmission.

REM sleep seizures occurred in 3 of 63 patients admitted to the epilepsy monitoring unit. Notably, 1 patient exhibited continuous epileptiform activity, consistent with focal nonconvulsive electrographic status epilepticus, throughout REM sleep cycles for each night of her admission. Otherwise, discrete REM sleep seizures constituted a small fraction of the other patients' total seizures (range 5.0-8.3%), occurred shortly after REM sleep onset from stage N2 sleep, and were manifest as minor epileptic arousals.

Our results confirm that REM sleep seizures are rare, while highlighting outliers who widen the known spectrum of heterogeneous sleep effects on seizures/epilepsy. We also report, to our knowledge, the first case of paradoxical status epilepticus in REM sleep.

McLeod GA, Szelemej PA, Toutant D, McKenzie MB, Ng MC. Dreams interrupted: characteristics of REM sleep-associated seizures and status epilepticus. J Clin Sleep Med. 2025;21(1):23-32.