NEONATAL SEIZURESNEONATAL SEIZURES
Trauma & Emergency SystemTrauma & Emergency SystemPerinatologi Division.Department of Child Perinatologi Division.Department of Child
HealthHealthMedical Faculty of Hasanuddin UniversityMedical Faculty of Hasanuddin University
DefinitionDefinition
Seizures are transient disturbances in brain function manifesting as episodic impairments in consciousness in association with abnormal motor or automatic activity.
Probable Mechanisms of Some Neonatal Seizures
PROBABLE MECHANISM DISORDER
Failure of Na + -K + pump secondary to Hypoxemia, ischemia, adenosine triphosphate and hypoglycemiaExcess of excitatory neurotransmitter (eg.glutamic acid—excessive excitation) Hypoxemia, ischemia and hypoglycemiaDeficit of inhibitory neurotransmitter Pyridoxine dependency (i.e., relative excess of excitatory neurotransmitter) Membrane alteration— Na + Hypocalcemia and Permeability hypomagnesemia
_________________________________________________________________Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4th ed.
Classification of Neonatal Classification of Neonatal SeizuresSeizures
Clinical
Electroencephalographic
Classification Classification I. Clinical Seizure Subtle Tonic Clonic Myoclonic
II. Electroencephalographic seizure
Epileptic Non-epileptic
……..Clinical Classification..Clinical Classification
1. SubttleUsually occurs in association with other
types of seizures and may manifest with: Stereotypic movements of the
extremities such as bicycling or swimming movements. Deviation or jerking of the eyes with
repetitive blinking Drooling, sucking or chewing
movements. Apnea or sudden changes in respiratory
patterns. Rhythmic fluctuations in vital signs More in preterm than in term
2. Tonic Primarily in Preterm May be focal or generalized Sustained extension of the upper and lower
limbs (mimics decerebrate posturing) Sustained flexion of upper with extension of
lower limbs (mimics decorticate posturing) Signals severe ICH in preterm infants In 85% of cases are not associated with any
autonomic changes such as increases in heart rate or blood pressure, or skin flushing.
……..Clinical Classification..Clinical Classification
3. Clonic
Consist of slow (1-3 /minute) rhythmic jerking movements of the extremities. They may be focal or multi-focal. Each movement is composed of a rapid phase followed by a slow one.
Changing the position or holding the moving limb does not suppress the movements.
Commonly seen in full-term neonates >2500 grams Consciousness may be preserved Signals focal cerebral injury, infarction or metabolic
disturbances.
……..Clinical Classification..Clinical Classification
……..Clinical Classification..Clinical Classification
4. Myoclonic
Focal, multifocal, or generalizedFocal myoclonic seizures typically
involve the flexor muscles of the extremities.
Multi-focal myoclonic seizures present as asynchronous twitching of several parts of the body.
Generalized myoclonic seizures present as massive flexion of the head and trunk with extension or flexion of the extremities. They are associated with diffuse CNS pathology
Electroencephalographic seizureElectroencephalographic seizure
I. Epileptic Consistently associated with electro-
cortical seizure activity on the EEG Cannot be provoked by tactile stimulation Cannot be suppressed by restraint of
involved limb or repositioning of the infant Related to hyper synchronous discharges of
a critical mass of neuron
Electroencephalographic Electroencephalographic seizuresseizures
II. Non-epileptic No electro-cortical signature: seizures
are initiated in the subcortical area and are not usually associated with any EEG changes.
Provoked by stimulation Suppressed by restraint or repositioning Brainstem release phenomena (reflex)
ELECTROENCEPHALOGRAPHIC SEIZURE
CLINICAL SEIZURE COMMON UNCOMMON
Subtle +*Clonic Focal + Multifocal +Tonic Focal + Generalized +Myoclonic Focal, multifocal + Generalized +---------------------------------------------------------------------------------------------------------------*Only specific varieties of subtle seizures are commonly associate with simultaneous Electroencephalographic seizure activity.
Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4 th ed.
Relation between Clinical seizure and EEG seizure
Does absence of EEG seizure Does absence of EEG seizure activity indicate that a clinical seizure activity indicate that a clinical seizure
is non- epileptic?is non- epileptic?
Certain clinical seizures in the human newborn originate from electrical seizures in deep cerebral structures (limbic regions), or in diencephalic, or brain stem structures and thereby are either not detected by surface-recorded EEG or inconsistently propagated to the surface
Surface EEG-Silent SeizureSurface EEG-Silent Seizure
Can “ surface EEG-silent ” seizure in the newborn result to brain injury?
Can this be eliminated by conventional anticonvulsant therapy?
Further investigation needed
Benign Movements that are Not Benign Movements that are Not SeizuresSeizures
JitterinessSleep apneaIsolated sucking movementsBenign neonatal sleep myoclonus
Jitteriness Versus Seizure
CLINICAL FEATURE JITTERINESS SEIZURE
Abnormality of gaze or eye - + movementMovements exquisitely stimulus + - sensitivePredominant movement Tremor Clonic jerking
Movements cease with passive + - flexionAutonomic changes - +The flexion and extension phases + -are equal in amplitudeEEG abnormalities - +/-------------------------------------------------------------------------------------------------------------------
often seen in neonates with hypoglycemia, drug withdrawal, hypocalcemia, hypothermia and in (SGA) neonates.
spontaneously resolve within few weeks.
......Jitteriness (cont)......Jitteriness (cont)
Sleep ApneaSleep ApneaNot associated with abnormal movements and is usually associated with bradycardia.
When seizures are present with apnea, abnormal movements, tachycardia and increased blood pressure are present as well.
Isolated Sucking MovementsRandom, infrequent and not well sustained sucking movements are not seizures.
Benign Neonatal Sleep MyoclonusBenign Neonatal Sleep Myoclonus
They differ from myoclonic seizures in the following:
– can be triggered by noise or motion.– suppressed by the waking state.– not associated with any autonomic changes.
Predominantly seen in preterm neonates during sleep. They can be focal, multi-focal, or generalized. They do not stop with restraint. Resolve spontaneously within a few minutes and require no medication.
Most Common Causes of SeizuresMost Common Causes of Seizures HIE Infections (TORCH, meningitis, septicemia) Hypoglycemia, hypocalcemia,
hypomagnesemia CNS bleed (intraventricular, subdural, trauma,
etc.)Less Common Causes of SeizuresLess Common Causes of Seizures
Congenital brain anomalies Inborn errors of metabolism Maternal drug withdrawal (heroin,
barbiturates, methadone, cocaine, etc.) Kernicterus Pyridoxine (B6) dependency, and
hyponatremia
Diagnosis of SeizuresDiagnosis of Seizures
Obtain a good maternal and obstetric history;Pregnancy history is important
Search for history that supports TORCH infections History of fetal distress, preeclampsia or maternal
infectionsDelivery history:
type of delivery and antecedent events Apgar scores offer some guidance : Low Apgar
score without the need for resuscitation and subsequent neonatal intensive care is unlikely to be associated with neonatal seizures
……..Diagnosis of Seizures..Diagnosis of Seizures
Postnatal historyNeonatal seizures in infants without uneventful antenatal history and delivery may result from postnatal causeTremulousness may be secondary to drug withdrawal or hypocalcemiaTemperature and blood pressure instability may suggest infection.
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Laboratory InvestigationsLaboratory Investigations
Primary tests Blood glucose Blood calcium and magnesium Complete blood count, differential
leukocytic count and platelet count Electrolytes Arterial blood gas Cerebral spinal fluid analysis and cultures Blood cultures
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TORCH titers, ammonia level, head sonogram and amino acids in urine.
EEG Normal in about 1/3 of cases
Cranial ultrasound For hemorrhage and scarring
CT To diagnose cerebral malformations and hemorrhage
…….Laboratory Investigations, cont.Laboratory Investigations, cont
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Management of SeizuresManagement of Seizures
Management goals To minimize brain damage Achieve systemic homeostasis
(airway, breathing and circulation). Correct the underlying cause if
possible.
Medical Management : 10% dextrose solution (2cc/kg IV) empirically to
any seizing neonate. Anticonvulsant drugs Calcium gluconate (200mg/kg IV), if
hypocalcemia is suspected . Magnesium sulfate 50%, 0.2ml/kg or 2 mEq/kg. In pyridoxine dependency give pyridoxine
50mg IV as a therapeutic trial. Seizures will stop within minutes.
Antibiotics in suspected sepsis. Be prepared to manage any complication
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Stopping Seizures with AnticonvulsantsStopping Seizures with Anticonvulsants
Drug Dose Comments Side Effects
Phenobarbital Loading dose: 10-20 mg/kg. Add 5 mg/kg to a maximum of 40 mg/kg
Maintenance:
3-5 mg/kg/day in divided doses every 12 hours.
It is the drug of choice.
Administer IV over 5 minutes.
Therapeutic level: 20-40 g/ml.
Administer IM, IV, or PO every 12 hours.
Begin therapy 12 hours after loading dose.
Hypotension Apnea Monitor
respiratory status during administration and assess IV site.
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Drug Dose Comments Side Effects When seizures are not controlled with phenobarbital alone.
Phenytoin
Loading dose: 15-20 mg/kg IV over 30 min.
Maintenance:
3-5 mg/kg/day.
Administer IV at a maximum rate of 0.5 mg/kg/min
Maintenance: 4-8 mg/kg/day by IV push or PO.
Divide total dose and administer IV every 12 hours.
Do not give IM. Toxicity is a
problem with this drug.
Cardiac arrhythmias
Cerebellar damage
Stopping Seizures with AnticonvulsantsStopping Seizures with Anticonvulsants
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Drug Dose Comments Side Effects For treatment of status epilepticus.
Benzodiazepines Lorazepam: 0.05 – 0.1 mg/kg
Diazepam: 0.1 – 0.3 mg/kg/dose.
Administer IV. Repeat every 15
minutes for 2-3 doses if needed.
Maximum dose is 2-5 mg.
It can be given once as a PO dose of 0.1-0.3 mg/kg.
Respiratory depression,
Interferes with bilirubin binding to albumin
Stopping Seizures with AnticonvulsantsStopping Seizures with Anticonvulsants
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When to Stop Anticonvulsant Drugs / When to Stop Anticonvulsant Drugs / AEDSAEDS
No specific practice guidelines for the timing for stopping these medications, however:
Stopping AEDs two weeks after last seizure episode is acceptable as prolonged medication can adversely affect the developing brain.
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Discontinuation before discharging from the neonatal unit is generally recommended unless the neonate demonstrates a significant brain lesion on head sonogram or CT, or abnormal neurological signs at the time of discharge.
When to Stop Anticonvulsant Drugs / When to Stop Anticonvulsant Drugs / AEDS (cont)AEDS (cont)
Determinants of Duration of Determinants of Duration of anticonvulsant therapy for neonatal anticonvulsant therapy for neonatal
seizuresseizures
Neonatal neurological examination
Cause of neonatal seizure
Electroencephalogram
PrognosisPrognosis
Two most useful approaches in utilizing outcome EEG
Recognition of the underlying neurological disease
ComplicationsComplications
Cerebral palsy Hydrocephalus Epilepsy Spasticity Feeding difficulties
ConsultationsConsultations
Neurology consult needed for - evaluation of seizures - evaluation of EEG and video EEG monitoring - management of anticonvulsant medications
Further Outpatient CareFurther Outpatient Care
Neurology outpatient evaluation Developmental evaluation for early
identification of physical or cognitive deficits Orthopedic evaluations if with joint
deformities Consider physical medicine/physical therapy
referral if indicated
ReferencesReferences
1.Volpe JJ.Neonatal seizures. In:Neurology of the newborn.4th ed.Philadelphia,Pa:WB Saunders's Co;2001:178-214
2.Hahn J,Olson D.Etiology of neonatal seizures.NeoReviews.2004;5:327-335
3.Riviello,J.Drug therapy for neonatal seizures:Part I.NeoReviews.2004;5:215-220
4.Riviello,J.Drug therapy for neonatal seizures:Part II.NeoReviews.2004;5:262-268
5.Fanaroff A,Martin R,Neonatal seizures.In:Neonatal-Perinatal Medicine-Diseases of the fetus and infant.6th ed.St.Louis,MO:Mosby-Yearbook Inc.1997:899-911
6.Sheth R, Neonatal seizures;Emedicine.com
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