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The FLEP scale in diagnosing nocturnal frontal lobe epilepsy, NREM and REM parasomnias: Data from a tertiary sleep and epilepsy unit
Open accessAbstract
PURPOSE: To test the usefulness of the FLEP scale in diagnosing nocturnal frontal lobe epilepsy (NFLE), arousal parasomnias, and REM sleep behavior disorder (RBD). METHODS: The FLEP scale was applied to 71 subjects (60 male; 11 female; aged 54 +/- 21) referred to an outpatient's sleep and epilepsy unit for diagnostic assessment of nocturnal motor-behavioral episodes, which turned to be arousal parasomnias (11 subjects), NFLE (14 subjects), or idiopathic RBD (46 subjects), based on the findings of in-lab full night video polysomnography with extended EEG montages. RESULTS: The sensitivity of the scale as a diagnostic test for NFLE was 71.4%, the specificity 100%, the positive predictive value 100%, and the negative predictive value 91.1%. The FLEP scale gave an incorrect diagnosis in 4/71 (5.6%) of the cases, namely NFLE patients with episodes of nocturnal wandering, and uncertain diagnostic indications in 22/71 subjects (30.9%). CONCLUSIONS: The FLEP scale shows high positive and negative predictive values in diagnosing NFLE versus arousal parasomnias and RBD. However, the scale is associated with a real risk of misdiagnosis in some patients and gives uncertain indications in about one-third of cases, mainly RBD. Our investigation highlights the inadequacy of some of the items in the scale. The item investigating wandering, as presently formulated, may be unable to distinguish nocturnal wandering from sleepwalking. The items about "recall" and "clustering" of the events throughout the night may increase the likelihood of mistaking RBD for seizures. Further testing of the reliability of the FLEP scale items appears to be needed.
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“A successive Italian validation of the same scale [37], in which the diagnoses were confirmed by in-lab VPSG, did not confirm these encouraging results. The scale gave an incorrect diagnosis in 5.6% of cases, which included patients with SHE seizures characterized by nocturnal wandering (mistaken for SW), while around one-third of cases had uncertain diagnostic indications, due to items associated”
From Diagnosis and Management of NREM Sleep Parasomnias in Children and Adults (2023) · cites this paper as [37]
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Sleep‐related hypermotor epilepsy—No longer controversial
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“A comprehensive examination and additional clinical scores like The Frontal Lobe Epilepsy and Parasomnias (FLEP) score were employed to distinguish parasomnias from frontal lobe epilepsy.[18]”
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“4%, specificity of 100%, and positive predictive value of 100%.(19) Incorrect diagnoses using the scale was found in 4 of 71 cases, particularly in subjects with REM behavior disorder and those with NFLE who had wandering as part of their event description.”
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Recording and Scoring Sleep-Related Movements
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Galbiati, A., Manni, R., Terzaghi, M., Rinaldi, F., & Zucconi, M. (2016) · Current Sleep Medicine Reports · doi:10.1007/s40675-016-0043-2 · Cited by 2
Differential Diagnosis and Related Disorders: RBD Mimics
Manni, R., & Terzaghi, M. (2018) · Springer eBooks · doi:10.1007/978-3-319-90152-7_26 · Cited by 1
Voges, B. R. (2018) · Clinical Epileptology · doi:10.1007/s10309-018-0224-8 · Cited by 1
“Quelle: [7, 8, 11, 12, 19, 24, 27, 31, 40, 53, 54] [20, 23, 34, 41, 43] [4, 5, 7, 8, 12–14, 26, 31, 37, 49]”
BackgroundSchreiner, S. J., & Stefani, A. (2025) · PSYCH up2date · doi:10.1055/a-2477-3568 · Cited by 1
Current Perspectives on Nonrapid Eye Movement Parasomnias
Irfan, M., & Schenk, C. H. (2025) · Seminars in Neurology · doi:10.1055/a-2565-3317 · Cited by 1
“Frontal lobe epilepsy and parasomnia scale (FLEP) 35 was developed to help differentiate sleep-related hypermotor epilepsy (SHE) from parasomnias, primarily DoA.”
Stal, V. (2009) · Médecine du Sommeil · doi:10.1016/j.msom.2009.05.001 · Cited by 1
Nocturnal Frontal Epilepsies: Diagnostic and Therapeutic Challenges for Sleep Specialists
Provini, F., Bisulli, F., & Tinuper, P. (2012) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2011.12.007 · Cited by 1
García-Huerta, L. G., Moctezuma, J. G., & Solórzano-Gómez, E. (2012) · Cited by 1
Sleep Terrors and Confusional Arousals in Children and Adolescents
Jain, S. V. (2013) · Springer eBooks · doi:10.1007/978-1-4614-7627-6_8 · Cited by 1
Voges, B. R., & Stodieck, S. R. G. (2017) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-017-0130-8 · Cited by 1
Kothare, S. V., & Pavkovic, I. M. (2022) · Springer eBooks · doi:10.1007/978-3-031-10494-7_13 · Cited by 1
Differentiating Seizures from Other Paroxysmal Nocturnal Events in Young and Older Adults
Derry, C. P. (2012) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2011.12.006 · Cited by 1
Miano, S. (2020) · Springer eBooks · doi:10.1007/978-3-030-54359-4_11 · Cited by 1
Williamson, A. A., & Mason, T. B. A. (2018) · Springer eBooks · doi:10.1007/978-3-319-98414-8_7 · Cited by 1
Sleep, Sleep Disorders, and Epilepsy
Carvalho, D. Z., Moore, J. L., & Louis, E. K. S. (2021) · Epilepsy · doi:10.1002/9781119431893.ch9 · Cited by 1
Sleep Terrors and Confusional Arousals in Adults
Pavlova, M. K., & Abdennadher, M. (2013) · Springer eBooks · doi:10.1007/978-1-4614-7627-6_7
McCandless, D. W. (2011) · Epilepsy · doi:10.1007/978-1-4614-0361-6_17
Kaleyias, J., Arora, R., & Kothare, S. V. (2013) · Springer eBooks · doi:10.1007/978-1-4614-7627-6_17
“The scale was found to be associated with a risk of misdiagnosis in some patients especially with ENW, which were misinterpreted as arousal parasomnias [59], indicating a low sensitivity of the scale.”
BackgroundFrontal Lobe Epilepsy and Parasomnias (FLEP) Scale
Shahid, A., Wilkinson, K., Marcu, S., & Shapiro, C. M. (2011) · Springer eBooks · doi:10.1007/978-1-4419-9893-4_38
Value of Polysomnography and Other Diagnostic Tools to Diagnose and Treat Parasomnias
Grigg-Damberger, M. M., & Ralls, F. M. (2013) · Elsevier eBooks · doi:10.1016/b978-0-12-378610-4.00446-0
Radhakrishnan, K. (2013)
PARASOMnIAS: SLEEP DISTURBAnCES WITH AUTOMATIC BEHAVIORS
Mutani, R., Chiarot, E., & Cicolin, A. (2009)
Vibha, D., & Tripathi, M. (2010) · Indian Journal of Sleep Medicine · doi:10.5005/ijsm-5-2-37
“4%) with a high specificity (100%) (39).”
Pearls & Oy-sters: Diagnostic challenges in nocturnal frontal lobe epilepsy
Cox, F. M. E., Lammers, G. J., Thijs, R. D., & Visser, G. H. (2016) · Neurology · doi:10.1212/wnl.0000000000002539
Metadata
- Authors
- Manni, R., Terzaghi, M., & Repetto, A.
- Affiliations
- Fondazione Istituto Neurologico Nazionale Casimiro Mondino (IT)
- Corresponding author
- Manni, Raffaele
- Venue
- Epilepsia
- Publisher
- Wiley
- Published
- 2008-09
- Volume
- 49
- Issue
- 9
- Pages
- 1581-1585
- ISSN
- 0013-9580 (ISSN-L)
- 1528-1167
- OpenAlex
- W2036750865
- Cited by
- 121
- References
- 22
- Citations by year
- 2026: 1 · 2025: 5 · 2024: 3 · 2023: 7 · 2022: 3 · 2021: 10 · 2020: 7 · 2019: 3 · 2018: 12 · 2017: 4 · 2016: 10 · 2015: 5 · 2014: 5 · 2013: 9 · 2012: 10
- FWCI
- 6.08
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Epilepsia (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Clinical Neurology › Epilepsy research and treatment
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Life Sciences › Neuroscience › Cognitive Neuroscience › Sleep and Wakefulness Research
- Keywords
- nocturnal frontal lobe epilepsy, REM sleep behavior disorder, nocturnal wandering, sleepwalking, misdiagnosis, diagnostic accuracy
- MeSH terms
- Adolescent, Adult, Aged, Arousal, Circadian Rhythm, Diagnosis, Differential, Electroencephalography, Female, Humans, Male, Middle Aged, Predictive Value of Tests, Sensitivity and Specificity, Sleep Stages, Sleep, REM, Videotape Recording, Epilepsy, Frontal Lobe, Polysomnography, Parasomnias
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