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Sleep associated seizures especially Nocturnal Frontal Lobe Epilepsy (NFLE) represents a spectrum of challenging clinical manifestations presenting as complex nocturnal movements/behaviors, making the diagnosis often difficult. Report of Case A 64 y/o male, with history of ongoing complex movements occurring during his sleep, with no history of strokes or neurological deficits. Had extensive neurologic workup (all negative) including routine electroencephalogram (EEG), prolonged inpatient EEG (12 hours), and MRI of the brain. Home sleep study showing moderate obstructive sleep apnea (OSA) AHI 24/hour successfully treated with CPAP therapy (residual AHI 1.7/hour) with improved nighttime symptoms initially. Wife recalls events as happening only at night while sleep, as patient often confused upon waking up in the morning, at times appear to sit up and smack his lips. No nighttime hallucinations, sleep paralysis, or acting out dreams were reported. Had two episodes associated with tongue biting and loss of bladder control. Another episode happened after a daytime nap, patient went outside and was mowing his lawn, went “completely blank “, appeared confused. No daytime or nighttime seizures were ever noticed. Patient do not recall any of the above events. Repeat EEG was normal. MRI/MRA of the head /neck showed small tiny focus in left frontoparietal lobe, suggesting remote cortical ischemic injury. Polysomnography (PSG) with seizure montage showed Interictal epileptic discharges (IEDs) foci recorded in the frontal/frontopolar leads without accompanying body movements. Interictal spike and wave activity seen during stage N2. Initially treated with carbamazepine (had skin reaction) switched to levetiracetam with complete resolution of his symptoms. Conclusion This case illustrates the importance of reviewing the clinical history, behavior semiology, and diagnostic ancillary testing such as polysomnography with EEG monitoring in distinguishing nocturnal epileptic seizures from other nocturnal complex behavior disorders and parasomnias.

1219 A CASE OF A NIGHT TIME AFFAIR