NEONATAL

SEIZURES

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INTRODUCTION Paroxysmal alteration in neonatal behavior and (or)

motor, autonomic function initiated by

hypersynchronous activity of neurons in the brain.

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Neonatal Seizures: A Signal of

Neurological Disease

Most distinctive indicator of neurological problem

in newborn period

Common problem in the neonatal ICU that

evokes urgent reaction

Therefore, it is critical to

RECOGINZE neonatal seizures

DETERMINE ETIOLOGY

TREAT

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CORRELATION OF TIME OF

ONSET OF SEIZURES AND

AETIOLOGY

Most Frequent Time Aetiology of Seizures

< 48 Hrs. Hypoxic - ischaemic encephalopathy

Intra cranial haemorrhage

Hypoglycemia, Hypoelectrolytemia

Congenital Viral infections

Drug induced

Pyridoxine dependency

Non-ketotic Hyperglycemia

Urea cycle disorder

48-72 Hrs. Cerebral dysgenesis, Early sepsis, Urea cycle

disorder

7 days Organic acidemias, Amino acidopathies,

Bacterial meningitis, BFNC and BINS www.similima.com 4

CAUSES OF NEONATAL SEIZURES

– Contd.. Developmental brain abnormalities Cerebral malformation and dysgenesis and

chromosomal disorders.

Anoxic-Ischaemic Encephalopathy Resulting from prenatal, intrapartum and postnatal

factors

Other causes explained The impairment of potassium dependent

repolarisation is likely to cause this age specific epileptic syndrome.

Receptors families of Excitatory Amino-Acids (EAA) are over expressed at the stage of brain ontogenesis. www.similima.com 5

CLINICAL FEATURES SUBTLE SEIZURES

Eyes : Sustained Opening, Ocular Movements, Blinking, Tonic Horizontal Deviation

Oral : Chewing, Drooling, Sucking, Laughing

Apnea : Full Term ? Premature

Motor : Boxing, Hooking, Rotary Pedalling, Stepping movements of the Extremities

Autonomic : Elevated Blood Pressure & Heart Rate

In Premature Infants www.similima.com 6

NORMAL NEONATAL MOTOR ACTIVITY

COMMONLY MISTAKEN FOR SEIZURES

AWAKE or DROWSY

Roving eye movements

Nystagmoid jerks

Unsustained, Sucking, Puckering

SLEEP

Fragmentary myoclonic jerks

Isolate, generalized myoclonic jerks on arousal

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CLINICAL CHARACTERISTICS WHICH

DISTINGUISH JITTERINESS FROM

SEIZURES

CLINICAL FEATURES JITTERINESS SEIZURES

Stimulus – Sensitive

Movements

+ 0

Movements Cease with

Restraint

+ 0

Associated Abnormal Eye

Movements

0 +

Quality of Movement Tremor Clonic

Jerking

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CLINICAL SEIZURES - Contd..

II Clonic Seizures Focal : Involve face upper + /- lower extremities on

one site “axial structures (neck / trunk) : Usually associated with neuropathology

(i.e. Cerebral infarction and intra cerebral haemorrhage)

Multi focal : Involve several body parts and often migrate in a non-jacksonian (random) manner may also involve the face.

: Consider the neonatal equivalent of generalized tonic – clonic seizures.

: Clonic movement are rhythmic and slow movements of limbs (about 1-3 jerks / sec.) at the onset and lateral declines. www.similima.com 9

CLINICAL SEIZURES - Contd.. III Tonic Seizures

Focal : Sustained posturing of a limb or asymmetric posturing of the trunk and / or neck

Generalised :Decerebrate posturing

Decorticate posturing

Usually associated with apnoea and upward gaze of eyes

Most common in preemies and usually

indicates structural brain damage and IVH

IV Myoclonic seizures

Involve flexor muscles of an Upper extremity www.similima.com 10

CLINICAL SEIZURES - Contd..

Multifocal :Asynchronous twitching of several parts of body.

Generalized :Bilateral jerks of upper and some times lower limps

:Rapid movements of distal flexors All 3 types

of may occur during sleep in the new born.

:Characterised brief repeated extension and

flexion movements of the arms, legs or all limbs.

:Presence suggests severe diffuse brain

damage

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INVESTIGATIONS - Complete Hemogram

- Blood : Sugar, Calcium, Magnesium, Na+, K+ & HCO3 Elevated Ammonia,

Lactate Levels Culture & Sensitivity

- CSF : Analysis, Biochemical & C/s.

- EEG : Plays an important role www.similima.com 12

MANAGEMENT OF NEONATAL SEIZURES

DURING ACUTE PHASE

GENERAL MEASURES :

OPTIMISE : Ventilation, Circulation,

Electrolytes,

Acid-Base Balance

NONEPILEPTIC

EVENTS : Associated with No EEG

Seizure Activity. These

Types of Neonatal

Seizures Should not be Treated.

EPILEPTIC

EVENTS : Associated with EEG Seizure

Activity

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MANAGEMENT – Contd.. SPECIFIC MEASURES

Identify the Cause & Treat

IF HYPOGLYCEMIA IS PRESENT

↓

ADMINISTER BY I.V. 2-4 ml of 25% DEXTROSE

↓

If There Is No Seizures

Stop Further Management

Monitor Vital Signs

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MANAGEMENT – Contd.. If the Convulsions Persist

↓

Inj. Phenobarbitone 20mg/kg by IV

Given over to 10 mints.

↓

Wait for 30 Mts. if the convulsion

Still Persists

↓

Inj. Phenobarbitone 10mg/kg is given

As IInd Dose.

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MANAGEMENT – Contd.. If there is further convulsion repeat inj. Phenobarbitone

10mg/kg by I.V. as third Dose (Cumulative dose of 40 mg/kg) consider omission of this additional phenobarbitol if the infant is severely Asphyxiated.

+

Administer Inj. Phenytoin sodium concomitantly 15-20 Mg/kg diluted in Normal Saline (1mg/kg/mt) followed by Maintenance Dose of Inj. Phenytoin & Phenobarbitone Alternatively

↓

Even then if the convulsions persists inj. Lorazepam 0.05 to 0.1 mg/kg/by I.V. is Administered.

(Contd..) www.similima.com 16

MANAGEMENT – Contd.. (or)

Inj. Clonzepam Loading dose of 0.25 mg/kg followed by 0.01 to 0.03 mg/kg/orally given

(or)

Inj. Midazolam 0.02 to 0.1 mg/kg - I.V. can be given

DIAZEPAM : Not safe in neonates as it interferes with vital functions its sedative effect half life exceeds 24 hours

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MANAGEMENT – Contd..

I.V. DIAZEPAM

↓

Ends you in trouble

↓

answerable for three generations

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MANAGEMENT – Contd..

OTHER MEDICATIONS

Calcium : 10% Cal. Gluconate 2 ml/kg mixed

with equal amount of 10% dextrose given by

slow I.V. over 3 mts.

Magnesium : Hypomagnesimia is treated with

50% magnesium sulphate 0.2 ml/kg

administered by IM route.

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DIAGNOSIS & MANAGEMENT OF

PDE

Failure of conventional AEDs

Pyridoxine 100 mg iv

Caution: May cause severe hypotonia, bradycardia,

apnea

Treat with daily B6, 200 mg/ day

B6 withdrawal challenge to confirm dx

Seizure recur in 7 days to 3 weeks

Restart B6

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PROGNOSIS OF NEONATAL SEIZURES

IN RELATION TO ETIOLOGY

Etiology Normal Development (%)

Hypoxic Ischemic Encephalopathy

16-50

Hemorrhage

a) Intraventricular

b) Sub Arachnoid

0-10

85-90

Bacterial Meningitis 25-65

Development Defect 0-5

Hypocalcemia

Early Onset

Late Onset

42-50

91-100

Hypoglycemia 25-50

Unknown 50-62

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EEG BACKGROUND SCORES

Normal

Mildly abnormal

Moderately Abnormal

Low – Voltage Undifferentiated

Suppression – Burst Pattern

Electrocerebral Inactivity

Better

Worse

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DURATION OF ANTICONVULSANT

THERAPY GUIDELINES

NEONATAL PERIOD

- If neonatal Neurologic examination becomes normal, discontinue therapy.

- If Neonatal Neurologic examination is persistently abnormal, consider etiology & obtain EEG.

- In most such cases. - Continue Phenobarbital - Discontinue phenytoin - Re-evaluate in 1 month.

1 Month After Discharge

- If neurologic examination has become normal, discontinue Phenobarbital If neurologic examination is persistently abnormal, obtain EEG. If no seizure activity on EEG, discontinue Phenobarbital

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EPILEPSY AFTER NEONATAL

SEIZURES

Overall, 15 – 30% develop seizures later in life

Again, depends on the cause of neonatal

seizures

Hypoxic – ischemic brain injury 30%

Cortical dysgenesis 100%

Hypocalcemia, late 0%

Other factors include neurologic examination and

neonatal EEG

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CONCLUSION Neonates with seizures require unique

Diagnostic & Perspective considerations compared with Older Infants and Children. Neurophysiologic evaluation preferably with EEG / Video polygraphic monitoring is required for accurate Detection & Classification

Fetal (or) Neonatal Disease states may contribute to seizure Occurrence in later years. Hence the main aim should be to control the seizure with Anti-convulsants at any cost apart from treating the underlying cause.

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Thank you

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