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NEONATAL SEIZURES

Trauma & Emergency System


Perinatologi Division.Department of Child
Health
Medical Faculty of Hasanuddin University

Definition
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
Failure of Na + -K + pump secondary to
adenosine triphosphate
Excess of excitatory neurotransmitter
(eg.glutamic acidexcessive excitation)

DISORDER
Hypoxemia, ischemia,
and hypoglycemia
Hypoxemia, ischemia
and hypoglycemia
Pyridoxine dependency

Deficit of inhibitory neurotransmitter


(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
Seizures

Clinical

Electroencephalographic

Classification
I. Clinical Seizure
Subtle
Tonic
Clonic
Myoclonic
II. Electroencephalographic
seizure
Epileptic
Non-epileptic

..Clinical Classification
1. Subttle
Usually 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

..Clinical Classification
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
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
4. Myoclonic
Focal, multifocal, or generalized
Focal 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

Electroencephalographic seizure
I. Epileptic
Consistently associated with electrocortical 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
seizures
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)

Relation between Clinical seizure and EEG seizure


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.

Does absence of EEG seizure


activity indicate that a clinical seizure
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 surfacerecorded EEG or inconsistently propagated to
the surface

Surface 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


Seizures
Jitteriness
Sleep apnea
Isolated sucking movements
Benign neonatal sleep myoclonus

Jitteriness Versus Seizure


CLINICAL FEATURE

JITTERINESS

SEIZURE

Abnormality of gaze or eye


movement
Movements exquisitely stimulus
sensitive
Predominant movement
Tremor

Movements cease with passive


flexion
Autonomic changes
The flexion and extension phases
are equal in amplitude
EEG abnormalities

Clonic jerking
-

+
+
-

+/-

------------------------------------------------------------------------------------------------------------------

......Jitteriness (cont)
often

seen in neonates with


hypoglycemia, drug withdrawal,
hypocalcemia, hypothermia and in (SGA)
neonates.
spontaneously resolve within few weeks.

Sleep Apnea
Not 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 Movements


Random, infrequent and not well
sustained sucking movements are not
seizures.

Benign 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 Seizures

HIE
Infections (TORCH, meningitis, septicemia)
Hypoglycemia, hypocalcemia,
hypomagnesemia
CNS bleed (intraventricular, subdural, trauma,
etc.)

Less 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 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
infections
Delivery 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
Postnatal history
Neonatal seizures in infants without uneventful
antenatal history and delivery may result from
postnatal cause
Tremulousness may be secondary to drug
withdrawal or hypocalcemia
Temperature and blood pressure instability may
suggest infection.

Laboratory 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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.Laboratory Investigations, cont


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
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Management of Seizures
Management goals
To minimize brain damage
Achieve systemic homeostasis
(airway, breathing and circulation).
Correct the underlying cause if
possible.

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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

Stopping Seizures with Anticonvulsants

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Stopping Seizures with Anticonvulsants

28

Stopping Seizures with Anticonvulsants

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When to Stop Anticonvulsant Drugs /


AEDS

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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When to Stop Anticonvulsant Drugs /


AEDS (cont)
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.

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Determinants of Duration of
anticonvulsant therapy for neonatal
seizures

Neonatal neurological examination

Cause of neonatal seizure

Electroencephalogram

Prognosis
Two most useful approaches in utilizing outcome

EEG

Recognition of the underlying neurological


disease

Complications

Cerebral palsy
Hydrocephalus
Epilepsy
Spasticity
Feeding difficulties

Consultations

Neurology consult needed for


- evaluation of seizures
- evaluation of EEG and video EEG
monitoring
- management of anticonvulsant
medications

Further 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

References
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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