**11. Effect of vagal nerve stimulator on sleep**

Vagus nerve stimulation [VNS] is used in some form of refractory epilepsy. VNS increases NREM N3 stage and reduces daytime sleepiness. VNS may worsen or increase risk for sleep-disordered breathing [67].

### **12. Effect of epilepsy surgery on sleep**

Epilepsy surgery has a positive effect on sleep. It improves total sleep time, decreases wake after sleep onset, increases REM sleep, and improves the subjective sleep quality. No changes were seen in the subjects who continued to have frequent seizures after surgery [67].

#### **13. Seizures and parasomnia**

Parasomnias are disorders with undesirable physical and mental events that occur mainly or exclusively during NREM and REM sleep, often accompanied by skeletal muscle activity and autonomic arousal. Mental phenomena may also occur, including emotions, thoughts, and images.

The NREM parasomnias are associated with central nervous system activation, skeletal muscle activity, and signs of autonomic arousal. Common examples of NREM parasomnias in children are confusion arousals, sleepwalking, and nocturnal terrors that present with different degree of motor and autonomic activation. The distinction between NREM parasomnias and seizures might requires the need for polysomnography with video recording and extended EEG leads.

REM sleep involves a highly energized state of brain activity with increased motor activation during REM where patients can enact the dreams. Patient scream, throw punches and kicks, show exploratory behaviors, involving staring, head rising, head turning, grasping, and searching; stalking imaginary prey, as well as episodic attack behavior; and locomotion. The mechanisms responsible for the oneiric behaviors are postulated to result from the disruption of brain neuronal organization during REM sleep. There is presumably disinhibition of motor pattern generators in the mesencephalic locomotor region, which results in phasic motor over-activation with behavioral release during REM sleep.
