Breakthrough spikes in rapid eye movement sleep from the epilepsy monitoring unit are associated with peak seizure frequency

Study Objectives Rapid eye movement sleep (REM) usually suppresses interictal epileptiform discharges (IED) and seizures. However, breakthrough IEDs in REM sometimes continue. We aimed to determine if the amount of IED and seizures in REM, or REM duration, is associated with clinical trajectories. Methods Continuous electroencephalogram (EEG) recordings from the epilepsy monitoring unit (EMU) were clipped to at least 3 h of concatenated salient findings per day including all identified REM. Concatenated EEG files were analyzed for nightly REM duration and the “REM spike burden” (RSB), defined as the proportion of REM occupied by IED or seizures. Patient charts were reviewed for clinical data, including patient-reported peak seizure frequency. Logistic and linear regressions were performed, as appropriate, to explore associations between two explanatory measures (duration of REM and RSB) and six indicators of seizure activity (clinical trajectory outcomes). Results The median duration of REM sleep was 43.3 (IQR 20.9–73.2) min per patient per night. 59/63 (93.7%) patients achieved REM during EMU admission. 39/59 (66.1%) patients had breakthrough IEDs or seizures in REM with the median RSB at 0.7% (IQR 0%–8.4%). Every 1% increase in RSB was associated with 1.69 (95% CI = 0.47–2.92) more seizures per month during the peak seizure period of one’s epilepsy (p = 0.007). Conclusions Increased epileptiform activity during REM is associated with increased peak seizure frequency, suggesting an overall poorer epilepsy trajectory. Our findings suggest that RSB in the EMU is a useful biomarker to help guide about what to expect over the course of one’s epilepsy.