IntroductionThe neonatal period (birth to 28 days) is a highly vulnerable time for an infant, who is completing many of the physiologic adjustments required for extrauterine existence. The high neonatal morbidity and mortality rates attest to the fragility of life during this period; of all deaths occurring in the 1st yr of life in the USA, two thirds are in the neonatal period.

IntroductionA seizure is a transient occurrence of signs and/or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain.

Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition.

IntroductionSeizure disorder is a general term that is usually used to include any one of several disorders including epilepsy and seizures 2ry to metabolic, infectious, or other etiologies (hypocalcemia, meningitis).

An epileptic syndrome is a disorder that manifests one or more specific seizure types and has a specific age of onset and a specific prognosis.

An epileptic encephalopathy is an epilepsy syndrome in which the severe EEG abnormality is thought to result in cognitive and other impairments in the patient.

Epidemiology•Seizures are the most important and common indicator of significant neurologic dysfunction in the neonatal period.

•Seizure incidence is higher during this period than in any other period in life:

57.5/1,000 in infants with birth weights <1,500 g 2.8/1,000 in infants weighing between 2,500 and 3,999 g have seizures.

Pathophysiology

•Immature brain

•More excitable

•More liable for seizures

PathophysiologyDefective balance between excitatory and inhibitory neurotransmission

+VE

-VE

Types of neonatal Seizures5 main types:

1.Subtle2.Tonic 3.Clonic4.Spasms5.myoclonic

1. Subtle Seizures:Subtle seizures include: 1.Transient eye deviations, nystagmus, blinking, 2.mouthing, 3.abnormal extremity movements (rowing, swimming, bicycling, pedaling, and stepping), 4.fluctuations in heart rate, hypertension episodes.5.apnea.

Subtle seizures occur more commonly in premature than in full-term infants.

2.Tonic Seizures:•Tonic seizures can be focal or generalized (generalized are more common). •Focal tonic seizures include persistent posturing of a limb or neck in an asymmetric way often with persistent horizontal eye deviation. •Generalized tonic seizures are bilateral tonic limb extension or tonic flexion of upper extremities often associated with tonic extension of lower extremities.

3. Clonic Seizures:•Clonic seizures can be focal or multifocal. •Multifocal clonic seizures incorporate several body parts and are migratory in nature. •Generalized clonic seizures, which are bilateral, symmetrical, and synchronous, are uncommon in the neonatal period .

4. SpasmSpasms are sudden generalized jerks lasting 1-2 sec that are distinguished from generalized tonic spells by their shorter duration and by the fact that spasms are usually associated with a single, very brief, generalized discharge.

5. Myoclonic Seizures:•Myoclonic seizures are divided into focal, multifocal, and generalized types. •Myoclonic seizures can be distinguished from clonic seizures by the rapidity of the jerks and by their lack of rhythmicity. •Focal myoclonic seizures affect the flexor muscles of the upper extremities. •Multifocal myoclonic movements involve asynchronous twitching of several parts of the body.•Generalized myoclonic seizures involve bilateral jerking

Etiology:•3 periods:

(1-4) days

1.Hypoxic-ischemic encephalopathy2.Drug withdrawal or toxicity3.Intraventricular hemorrhage

4.Acute metabolic disorders: •hypocalcemia, •hypoglycemia,•hypomagnesemia and •hypo or hyper natremia)

5.Inborn errors of metabolism (ex. Galactosemia)

6.Pyridoxine deficiency.

Etiology:•3 periods:

(4-14) days

1. Infection ( meningitis , encephalitis)

2. Metabolic ( hypocalcemia, persistent hypoglycemia)

3. Benign neonatal convulsion.

4.Kernectirus5. Drug withdrawal6. Developmental delay, epilepsy, neonatal diabetes.

Etiology:•3 periods:

(2-8) wks

1. Infection ( meningitis , encephalitis)

2. Head injury( subdural hemorrhage, child abuse)

3. Inherited disorders of metabolism (ex. Aminoaciduria).

4. Malformation of cortical development (ex lissencephaly)

5. Tuberous sclerosis.6. Sturge weber syndrome.

Put them all together..

1. Hypoxic ischemic encephalopathy (50-60)%.. Most common cause of neonatal seizure.

2. Vascular events (10 -20) %3. Intracranial infection (5-10)%4. Brain malformation (5-10)%5. Metabolic disturbances (↓glycemia, Ca, Mg, ↓ ↓

Na)↓↑6. Drugs ( withrawal or toxicity)7. Neonatal seizure syndromes : rare . AD.

Management1. HISTORY: PRENATAL & POSTNATAL

• History of fetal distress, maternal infection (TORCH) , preeclampsia and diabetes.

• Delivery history: type, duration, APGAR score, temperature and b. sugar instability.

• Family history may suggest a genetic syndrome (BFNC).

Management2. EXAMINATION:

• Neurological examination.• Ophthalmological exam: chorioretinitis, coloboma.• Skin : café au lait spots, shagreen patch, adenoma

sebaceoum.

Management3. INVESTIGATIONS:

*Lab investigation: Complete blood count. Serum level of: GlucoseCalciumMagnesiumSodiumBilirubinBlood urea nitrogen

Blood and urine culture

Serological tests for TORCH infection

Specific test for inborn errors of metabolism if suspected.

Management3. INVESTIGATIONS:

*Lumbar Puncture: - is indicated in virtually all neonates with seizures,

unless the cause is obviously related to a metabolic disorder such as hypoglycemia or hypocalcemia which usually respond promptly to appropriate therapy.

- LP may reveal features of meningitis.. Bloody CSF may indicate SAH

Management3. INVESTIGATIONS:

*EEG: EEG is considered the

main tool for diagnosis.

*other investigations:Cranial US, CT and MRI.

Management4. Differential Diagnosis: • Startle or Moro reflex.• Jitteriness.• Sleep myoclonus .

Jitteriness:Fast and fineTremor No eye deviationStimulus sensitivityHR and BP normalEEG normal

Management5. TREATMENT: Control Convulsion!Immediate: give O2, maintain airway, insert IV, treat

underlying cause.

Anticonvulsants: When to start anticonvulsants is controversial because risks and benefits of treatment have not been properly evaluated;

usual indication is >3 seizures/hr or single seizure lasting >3–5min.

ManagementA. Phenobarbital: drug of choice:• 20 ml/kg over 5-10 min up to 40 ml/kg.B. Phenytoin & Fosphenytoin:• 15-20 ml/kg phenytoin or 15- 20 PE/kg fosphenytoin.C. Lorazepam :• 0.05 – 0.1 mg/kgD. Diazepam and Midazolam:• 0.1 – 0.3 mg/kg over 3-5 min. Diazepam.• 0.05 – 0.1 mg/kg . Midazolam.

Management• Treat Underlying Cause:•Hypoglycemia : Glucose infusion 2 ml per kg of 10% glucose, through an I.V. line is given over 2-3 min

•Hypomagnesemia: MgSO4(0.4-0.8 mEq/kg); given IV every 12 hours until Mg level is normal.

•Infection: Appropriate antibiotics•Hypocalcemia: I.V administration of 2 ml/kg of Calcium gluconate given over 5 min.•Pyridoxine deficiency: IV administration of 50 mg pyridoxine is effective.

Prognosis•Mortality ↓ed from 40 to 20%.•Dep. on EEG and underlying causes:HIE …. 50% chance of normal development.Seizure 2ry to hypocalcemia …. Much better prognosis