Neonatal Seizures

3,101 views

Published on

Published in: Health & Medicine, Sports
0 Comments
4 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,101
On SlideShare
0
From Embeds
0
Number of Embeds
15
Actions
Shares
0
Downloads
270
Comments
0
Likes
4
Embeds 0
No embeds

No notes for slide
  • Neonatal Seizures

    1. 1. Neonatal Seizures Amy Kao, M.D. Division of Neurology Doernbecher Children’s Hospital
    2. 2. Objectives <ul><li>Review the clinical presentation and differential diagnosis </li></ul><ul><li>Discuss pathophysiologic implications on clinical presentation </li></ul><ul><li>Review etiology </li></ul><ul><li>Apply this information to evaluation and treatment </li></ul><ul><li>Discuss prognosis </li></ul>
    3. 3. Clinical Classification <ul><li>Focal/Multifocal Clonic </li></ul><ul><ul><li>Not generalized </li></ul></ul><ul><ul><li>Migratory </li></ul></ul><ul><ul><li>Not necessarily focal etiology </li></ul></ul><ul><li>Focal Tonic </li></ul><ul><ul><li>Not usually generalized </li></ul></ul><ul><li>Generalized Myoclonic </li></ul>
    4. 4. Clinical Classification <ul><li>Subtle (“Hypomotor”) </li></ul><ul><ul><li>Motor activity arrest </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Eye deviation </li></ul></ul><ul><ul><li>Autonomic changes </li></ul></ul><ul><li>Motor automatisms </li></ul><ul><ul><li>Oral-buccal-lingual movements </li></ul></ul><ul><ul><li>Swimming </li></ul></ul><ul><ul><li>Bicycling </li></ul></ul>
    5. 5. The Definition of a Seizure <ul><ul><li>“ paroxysmal discharge of cerebral neurons sufficient to cause clinically detectable events that are apparent either to the subject or to an observer” </li></ul></ul>
    6. 6. Definition of a Seizure in a Neonate? <ul><li>Excitatory activity predominates </li></ul><ul><li>No paroxysmal discharge on EEG? </li></ul><ul><ul><li>True seizure </li></ul></ul><ul><ul><ul><li>The cortex is undeveloped </li></ul></ul></ul><ul><ul><ul><li>Deeper origin </li></ul></ul></ul><ul><ul><li>“ Brainstem release phenomena” </li></ul></ul>
    7. 7. Definition of a Seizure in a Neonate… <ul><li>Clinically detectable events? </li></ul><ul><ul><li>Subtle </li></ul></ul><ul><ul><li>Truly only electrographic </li></ul></ul><ul><ul><ul><li>Iatrogenic paralysis </li></ul></ul></ul><ul><ul><ul><li>High doses AEDs </li></ul></ul></ul><ul><ul><ul><li>Encephalopathy or subcortical/spinal cord damage </li></ul></ul></ul>
    8. 8. If It Isn’t a Seizure, Then What Is It?? <ul><li>Possible clues </li></ul><ul><ul><li>Stimulus-induced </li></ul></ul><ul><ul><li>Suppressable </li></ul></ul><ul><ul><li>No associated autonomic changes (usually not bradycardia) </li></ul></ul>
    9. 9. W eird B aby M ovements <ul><ul><li>Jitteriness </li></ul></ul><ul><ul><ul><li>Stimulus-sensitive </li></ul></ul></ul><ul><ul><ul><li>“ Tremor” </li></ul></ul></ul><ul><ul><ul><li>Suppressable </li></ul></ul></ul><ul><ul><li>Benign neonatal sleep myoclonus </li></ul></ul><ul><ul><li>Spinal myoclonus </li></ul></ul><ul><ul><li>Apnea of non-neurologic etiology </li></ul></ul><ul><ul><ul><li>bradycardia </li></ul></ul></ul>
    10. 10. Causes of Neonatal Seizures <ul><li>Within first 24 hours of life </li></ul><ul><ul><li>Hypoxic ischemic encephalopathy </li></ul></ul><ul><ul><li>Meningitis/sepsis </li></ul></ul><ul><ul><li>Subdural/Subarachnoid/Interventricular hemorrhage </li></ul></ul><ul><ul><li>Intrauterine infection </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Pyridoxine dependency </li></ul></ul><ul><ul><li>Drug effect/withdrawal </li></ul></ul>
    11. 11. Causes…. <ul><li>24-72 hours </li></ul><ul><ul><li>Meningitis/sepsis </li></ul></ul><ul><ul><li>In premature infants: IVH </li></ul></ul><ul><ul><li>In full-term infants: infarction, venous thrombosis </li></ul></ul><ul><ul><li>Cerebral dysgenesis </li></ul></ul>
    12. 12. Causes…. <ul><li>72 hours to 1 week </li></ul><ul><ul><li>Above causes </li></ul></ul><ul><ul><li>Inborn errors of metabolism </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Familial neonatal seizures </li></ul></ul><ul><li>1 week to 4 weeks </li></ul><ul><ul><li>Above causes </li></ul></ul><ul><ul><li>HSV </li></ul></ul>
    13. 13. Other Syndromes <ul><li>Benign idiopathic neonatal convulsions (BINC or Fifth-day fits) </li></ul><ul><li>Benign familial neonatal convulsions (BFNC) </li></ul><ul><li>Early myoclonic encephalopathy (EME) </li></ul><ul><li>Early infantile epileptic encephalopathy (EIEE) </li></ul><ul><li>Glucose transporter type I </li></ul>
    14. 14. Evaluation of Neonatal Seizures <ul><li>Serum lytes (gluc, Ca, Mg, Na) </li></ul><ul><li>CSF </li></ul><ul><li>Head ultrasound </li></ul><ul><li>EEG (B6?) </li></ul><ul><li>Tox screen </li></ul><ul><li>CT or MRI of brain </li></ul><ul><li>?metabolic w/u, congenital infection w/u </li></ul>
    15. 15. Treatment of Electroclinical Seizures <ul><li>Phenobarbital 20 mg/kg </li></ul><ul><ul><li>10 mg/kg boluses until 40-50 microgm/ml </li></ul></ul><ul><li>Phenytoin 20 mg/kg </li></ul><ul><li>Lorazepam 0.1 mg/kg </li></ul><ul><li>Pyridoxine 50-100 mg IV with EEG </li></ul>
    16. 16. Outcome <ul><li>45 % controlled after either phenobarb or phosphenytoin </li></ul><ul><li>60 % controlled with both </li></ul><ul><li>30% of survivors develop epilepsy </li></ul><ul><li>WORSE: HIE, meningitis, dysplasia </li></ul><ul><li>WORSE: electrographic seizures </li></ul><ul><li>BETTER : hypoCa, BINC, BIFC, stroke </li></ul>

    ×