neonatal seizures and different modalities of treatment

neonatal seizures

1. NEONATAL SEIZURE Dr. Raksha S K

2. Competency covered PE 20.15 discuss the etiology, clinical features and management of neonatal seizures

3. INTRODUCTION Seizures are the main paroxysmal disorder of the newborn Seizures are the most common neurological emergency in the neonatal period, occurring in 1–5 per 1000 live births. In India incidence is 8.4/1000 live births

4. Pathophysiology

5. WHY SEIZURES ARE COMMON IN NEONATAL PERIOD

6. SEIZURE PATTERNS Seizures in newborns, especially in the premature , are poorly organized and difficult to distinguish from normal activity.

7. Seizure Patterns in Newborns

8. SUBTLE SEIZURES Most common type of seizures Called as subtle because clinical manifestations are mild and often missed OCULAR : tonic horizontal deviation of eyes or sustained eye opening with ocular fixation or cycled fluttering Oral-facial-lingual movements :chewing , tongue thrusting, lip smacking etc

9. 3.Limb movements : cycling ,pedaling, boxing etc 4. Autonomic phenomena: tachycardia or bradycardia 5. Apnea :apnea with tachycardia

10. Clonic seizures It can be focal or multiofocal This pattern may occur unilaterally, sequentially in different limbs, or simultaneously. The movement is rhythmic , biphasic with a fast-contraction phase and a slower relaxation. A clinical correlate may be present for only a small portion of the total duration of the electrographic seizure. Face, upper or lower limbs, eyes, or trunk may be involved.

11. Tonic seizures IT CAN BE FOCAL OR GENERALISED Patterns include a sustained posture of a single limb , tonic horizontal eye deviation or asymmetric tonic truncal postures. Focal tonic events are generally not accompanied by seizure patterns on EEG.

12. Myoclonic seizures IT CAN BE FOCAL, MULTIFOCAL AND GENERALISED These are characterized by a rapid movement usually of flexion. Of the varieties of myoclonus occurring in the newborn, generalized myoclonus, usually involving both upper limbs and less commonly the lower limbs, is most often associated with an EEG seizure pattern. Focal or multifocal myoclonic events are usually not associated with such patterns.

13. EEG CHANGES ARE SEEN IN

14. Etiology The majority of neonatal seizures are provoked by an acute illness or brain insult with an underlying etiology either documented or suspected, that is, these are acute provoked seizures (previously also called acute symptomatic seizures)

15. First 24 hours Perinatal asphyxia Structural abnormalities Intracranial bleeds Inadvertent IV injection of local anesthetics Hypoglycemia Hypocalcemia Pyridoxine deficiency Drug withdrawl

16. Birth to 7 days Hypoxic ischemic encephalopathy Metabolic disturbance s Meningitis Neonatal stroke/thrombosis Drug withdrawal IEMs Benign seizure syndromes

17. Beyond 7days Meningitis Metabolic disturbances IEMs

18. Apneic spells in an otherwise normal-appearing newborn is typically a sign of brainstem immaturity and not a pathological condition. The sudden onset of apnea and states of decreased consciousness, especially in premature newborns, suggests an intracranial hemorrhage with brainstem compression. Immediate ultrasound examination is in order. Prolonged apnea without bradycardia, and especially with tachycardia , is a seizure until proven otherwise

19. Movements That Resemble Neonatal Seizures Benign nocturnal myoclonus Jitteriness Nonconvulsive apnea Normal movement Opisthotonos

20. A clinical-only seizure has been defined as a sudden paroxysm of abnormal clinical changes without a definite EEG association, Currently there is no evidence that these clinical-only events are epileptic in nature

21. An electro-clinical seizure features definite clinical signs simultaneously coupled with an electrographic seizure

22. An electrographic-only seizure refers to the presence of an electrographic seizure seen on EEG that is not associated with any evident clinical signs ( clinically silent or subclinical seizures).

23. DIAGNOSIS HISTORY: Detailed history regarding the event should be asked Associated eye movements , restraint of episode by passive flexion of the affected limb , change in skin color , autonomic phenomena, and whether the neonate was conscious or sleeping at the time of seizures . If possible record the event to understand the nature of the seizures .

24. ANTENATAL HISTORY : History s/o intrauterine infection , maternal diabetes, narcotic addiction should be elicited H/O sudden increase in fetal movements s/o intrauterine convulsions.

25. PERINATAL HISTORY H/O fetal distress Decreased fetal movements Instrumental delivery Need for resuscitation in the labor room Apgar scores Abnormal cord Ph and base deficit

26. FEEDING HISTORY c/f like , lethargy, poor activity , drowsiness and vomiting after initiation of breast feeding s/o IEM Late onset hypocalcemia should be considered in the presence of top feedng with cows milk

27. FAMILY HISTORY H/O consanguinity in parents , family history of seizures or mental retardation and early fetal/neonatal deaths s/o IEM. H/O seizures in either parent or sibling in the neonatal period may suggest Benign familial neonatal convulsions

28. INVESTIGATIONS

29. DIAGNOSTIC FRAMEWORK OF SEIZURES IN NEONATAL PERIOD

30. Amplitude-integrated EEG ( aEEG ) is a bedside technique increasingly being used by neonatologists for neuromonitoring. The background EEG activity from a limited number of electrodes (usually 1–2 channels, 2–4 electrodes) is amplified, filtered, rectified, compressed (6 cm/hour), and displayed on a semi-logarithmic scale. One minute of EEG is thus represented by 1 mm of aEEG .

31. MANAGEMENT INITIAL MANAGEMENT: First step is to ensure airway, breathing and circulation and to nurse the baby in thermoneutral environment. Oxygen should be started, IV access should be secured and blood should be collected for glucose and other investigations

32. Seizures themselves and treatment with anticonvulsant medication may impair respiratory drive and the ability to maintain adequate circulation Therefore, supportive management to ensure maintenance of adequate ventilation and perfusion is imperative

33. WHEN TO STOP AED ? AS PER WHO In neonates with normal neurological examination and /or normal EEG ,consider stopping if baby is seizure free for more than 72 hrs. In acute stage : one can start weaning AED once no seizures observed for 3-5 days General consensus is to discontinue all the medications at discharge if clinical examination is normal irrespective of etiology and EEG

34. In patients on multiple AED, after a seizure free period 48-72 hrs , one should stop the drug first which is started last and stop phenobarbitone at last. RECURRENCE DEPENDS ON: 1)Neurological examination 2)Cause of neonatal seizure 3)EEG pattern

35. MOST COMMON TYPE OF SEIZURES : SUBTLE SEIZURE MOST COMMON CAUSE OF SEIZURE: HIE (50-75%) 2 ND MC CAUSE : STROKE( 15-20%) BEST PROGNOSIS: FOCAL CLONIC WORST PROGNOSIS: MYOCLONIC