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Neonatal Seizures

Bhavith Ravi
Medical Student
Objectives
Review the clinical presentation and
differential diagnosis
Discuss pathophysiologic implications on
clinical presentation
Review etiology
Apply this information to evaluation and
treatment
Discuss prognosis
Clinical Classification
Focal/Multifocal Clonic
Not generalized
Migratory
Not necessarily focal etiology
Focal Tonic
Not usually generalized
Generalized Myoclonic

Clinical Classification
Subtle (Hypomotor)
Motor activity arrest
Apnea
Eye deviation
Autonomic changes
Motor automatisms
Oral-buccal-lingual movements
Swimming
Bicycling
The Definition of a Seizure

paroxysmal discharge of cerebral neurons
sufficient to cause clinically detectable
events that are apparent either to the
subject or to an observer
Definition of a Seizure in a Neonate?
Excitatory activity predominates
No paroxysmal discharge on EEG?
True seizure
The cortex is undeveloped
Deeper origin
Brainstem release phenomena
Definition of a Seizure in a Neonate
Clinically detectable events?
Subtle
Truly only electrographic
Iatrogenic paralysis
High doses AEDs
Encephalopathy or subcortical/spinal
cord damage


Possible clues
Stimulus-induced
Suppressable
No associated autonomic changes
(usually not bradycardia)
Weird Baby Movements
Jitteriness
Stimulus-sensitive
Tremor
Suppressable
Benign neonatal sleep myoclonus
Spinal myoclonus
Apnea of non-neurologic etiology
bradycardia
Causes of Neonatal Seizures
Within first 24 hours of life
Hypoxic ischemic encephalopathy
Meningitis/sepsis
Subdural/Subarachnoid/Interventricular
hemorrhage
Intrauterine infection
Trauma
Pyridoxine dependency
Drug effect/withdrawal
Causes.
24-72 hours
Meningitis/sepsis
In premature infants: IVH
In full-term infants: infarction, venous
thrombosis
Cerebral dysgenesis

Causes.
72 hours to 1 week
Above causes
Inborn errors of metabolism
Hypocalcemia
Familial neonatal seizures
1 week to 4 weeks
Above causes
HSV
Other Syndromes
Benign idiopathic neonatal convulsions (BINC
or Fifth-day fits)
Benign familial neonatal convulsions (BFNC)
Early myoclonic encephalopathy (EME)
Early infantile epileptic encephalopathy (EIEE)
Glucose transporter type I
Evaluation of Neonatal Seizures
Serum lytes (gluc, Ca, Mg, Na)
CSF
Head ultrasound
EEG (B6?)

Tox screen
CT or MRI of brain
metabolic w/u, congenital infection w/u
Treatment
Phenobarbital 20 mg/kg
10 mg/kg boluses until 40-50 microgm/ml
Phenytoin 20 mg/kg
Lorazepam 0.1 mg/kg
Pyridoxine 50-100 mg IV with EEG
Outcome
45 % controlled after either phenobarb or
phosphenytoin
60 % controlled with both
30% of survivors develop epilepsy
WORSE: HIE, meningitis, dysplasia
WORSE: electrographic seizures
BETTER: hypoCa, BINC, BIFC, stroke