Neonatal seizures recent advances

treatment on neonatal seizure

1. Neonatal seizures Recent advance Dr MANDAR HAVAL DCH. DNB. Fellow In Neonatology(NNF)

2. INTRODUCTION Seizures is defined clinically as a paroxysmal alteration in clinical function i.e motor , behavior and autonomic function

3. Types Clonic movement (focal, multifocal, genralised ) Myoclonus ( multifocal, genralised ) Tonic movement ( focal, genralised ) Motor (automatism and subtle seizure)

4. Interesting Evidence Subtle and generalized seizure had a significantly higher prevalance of epilepsy , mental retardation and cerebral palsy as compare to other seizure type

5. Neonatal seizures are not stimulus sensitive not abolished by restraint or repositioning and often associated with autonomic changes and ocular phenomenon, are usually stereotypic and repetitive , and the interictal examination is often abnormal .

6. Common cause of neonatal seizure HIE Intracranial Infection Metabolic disorder (Hypoglycemia, Hyponatrimia , Hypocaemia ) Intracranial Hemorrhages (ICH) Inborn Error Of Metabolism Epileptic syndrome

7. Interesting evidence Study in PGI chandigarh found HIE is the commonest cause of seizure followed by meningitis

8. Investigation following seizure Cbc , Crp , Procalcitonin , Blood Culture, Csf Sr.Electrolyte (Na, iCa ) and BSL EEG Neuroimaging (MRI and cranial USG) Coagulation profile ABG with An ionic gap Lactate and Pyruate level TMS and HPLC

9. Recommendation for investigation 1 st line ( BSL, iCa , Na, ABG) 2 nd line - Add on Situational A) Sick Neonate With Seizure B) Intracranial Infection C) Intracranial Hemorrhage D) IEM workup

10. (EEG) Newborn frequently demonstrate electrographic seizure without clinical movement and vice versa

11. Interesting Evidance Focal clonic , some form of Myoclonic seizures, focal tonic seizure where associated with EEG changes Most Subtle seizure, all Generalized tonic seizures and some form of M yoclonic seizure where eighter not associated with EEG changes or had inconsistent relationship. Only 21% of seizure are seen on EEG

12. TYPE OF EEG CONVENTIONAL EEG using international 10 -20 system(channels) modified for neonate with concurrent video is the gold standered aEEG compared with conventional eeg shows 76% sensitivity and 78% positive predictive value for detection of neonatal seizure

13. EEG For Prognosis purpose Neurological sequelae are unusual when EEG correlates occur on normal background In contrast sever background activity are associated with neurological sequelae in 90% of case

14. LUMBAR PUNTURE Lumbar puncture is done in neonatal seizures to rule out bacterial and viral infection. Rare disease Nonketotic hyperglycemia GLUT1 deficiency deficiency is like to get diagnosed

15. Neuroimaging (Recommendation) All sick looking neonate with seizure should undergo bedside cranial USG ( rule out intracranial hemorrhage, major malformation and abscess ) In term infant with seizures and encephalopathy , significant birth trauma, and evidence of low hematocrit and /or coagulopathy , a non contrast CT scan should be performed (Hemorrhage)

16. Treatment of neonatal seizure Followed in four step 1) Stabilization 2) Identification 3) Specific Treatment 4) Prevention of recurrence

17. Flow Chart

18. If Seizure Persist Calcium step is consider in case of IDM , IUGR , preterm and sick neonate

19. Seizure persist Dextrose and Ca normal In neonate with hepatic dysfunction the max dose should be restricted to 20mg/kg

20. IF Seizure Persist * OR * Consider using pyridoxine at these step

21. If Seizure persist Consider alternate drug 1) Levateracetam 2) Topiramate

22. Suggested guidelines for weaning AED Yes No No Yes

23. Cont.. NORMAL ABNORMAL

24. After 1 month of repeat neurological exam

25. EEG

26. Follow up sequelae Early infancy (12 to 18 mt follow up recognise most babies with major disability) cerebral palsy, mental retardation or hearing problem. School age and older age learning and behavioral problem

27. Study of infant discharge wit neonatal seizure over 12 yrs 24% had seizure recurrence and 16% had multiple recurrence treated as epilepsy In other study 25% cerebral palsy, 20% mental retardation, 27% learning disorder

28. Interesting Evidance A pure clonic seizure without facial involvement in term infant suggestive of favorable outcome Whereas generalized myoclonic seizure in preterm infant where associated with increase risk of mortality

29. Factor Associated With Poor Prognosis Severe HIE Cerebral dysgenesis IVH Seizure within 12hr of life Seizure lasting more than 30 min to one hour Recurrent seizure for more than 48 hr Generalized myoclonic , generalized tonic and subtle seizure with severe background abnormalities on EEG

30. Thanks! ALL THE BEST