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Morning Report: Friday, February 3rd

Neonatal Seizures

An Introduction…

Neonatal seizures (NS) result from a rapid depolarization of brain cells excessive synchronous electrical activity

Brain cells of newborns are immature and vulnerable to insultsTherefore, neonatal seizures often

indicate an underlying neurologic disturbance REQUIRE IMMEDIATE ASSESSMENT TO

DETERMINE THE UNDERLYING CAUSE AND NECESSARY INTERVENTIONS!!!

Epidemiology

Incidence varies widelyGestational ageWeightCause of NS

Some statistics:Preterm infants <1,500g: 19-57.5/1000

live birthsPreterm/ term infants >2,500g: 2.8/1000

live births

*Causes

Hypoxic-ischemic encephalopathy Intracranial infections Intracranial hemorrhage

Non-accidental trauma Cortical (structural) brain

malformations Metabolic derangements Inborn errors of metabolism Genetic epileptic syndromes

Question A term 3500g male infant is admitted to the NICU

after precipitous vaginal delivery in the ED to a G34 P4 24 yo mother without PNC. On PE, the infant has normal VS, a HC of 35.5cm, and normal general examination findings. 12h after birth, the nurse notes brief jerking in one of the infant’s arms. Thirty minutes later, the other arm jerks, and the nurse places a hand on the arm, noting the jerking is not suppressible. Of the following, the most likely cause of the jerking is: A. Benign neonatal myoclonus B. Jitteriness due to drug withdrawl C. Seizure due to CMV infection D. Seizure due to hypocalcemia E. Seizure due to hypoxic-ischemic injury

Hypoxic-Ischemic Encephalopathy

Most common cause of NS50-60% of cases

*Seizures usually occur within the first 24h after birthSeverity can increase with

time *Majority of full term

newborn with NS secondary to asphyxia do NOT manifest long-term neurodevelopmental sequelae

Intracranial Infections

Account for 10-20% of NSMost common cause in developing countries

Seizures usually begin during the end of the first week of life

PathogensBacteria

Listeria GBS E.Coli

Viruses HSV CMV Rubella

Intracranial Hemorrhage

Accounts for ~10% of NS cases Preterm infants

Intraventricular hemorrhage Grade I-II usually asymptomatic Grade III-IV symptomatic• Seizures focal and persistant

Term infantsSubarachnoid hemorrhage

Most common type of ICH Birth trauma

Intracranial Hemorrhage

Term infantsSubarachnoid hemorrhage (con’t)

Not associated with long-term neurologic sequelae

Subdural hemorrhage Birth trauma Consider NAT in an infant who has been

d/ed from the hospital

Intraventricular hemorrhage

Subdural Hemorrhage

SubarachnoidHemorrhage

Cortical (Structual) Brain Malformations Seizures with variable onset Dysmorphic features, microcephaly

or cutaneous lesions may suggest this diagnosis

Metabolic Derangements

Electrolyte abnormalitiesHypoglycemiaHypocalemiaHyper or hyponatremia

At risk patients:IDM (hypoglycemia and hypocalcemia)Preterm infantsSGA infants

Inborn Errors of Metabolism Aminoacidopathies (PKU, MSUD) Urea cycle defects (OTC deficiency) Mitochondrial disorders Beta-oxidation defects (MCAD, LCAD) Pyridoxine dependency

Genetic Epileptic Syndromes Benign familial neonatal convulsions

May occur 15-20 times per dayOutgrown by 1 yo

“Fifth day fits”Observed in term infants during the first postnatal

weekResolve within 24h

Ohtahara syndrome (early infantile epileptic encephalopathy?Due to malformations in cortical developmentBrief, repetitive tonic spasmsProgressive neurologic deterioration and poor

prognosis

Question You are called to the nursery to evaluate a 12h old infant for

episodes of jerking. She had been born following a term pregnancy. Vaginal birth was attempted after a prior C/S. Fetal monitoring had shown an apparently reassuring HR and normal status PTD. After replacing the monitor following transport from the labor room to the delivery room, the tracing indicated an abrupt decrease in HR. A stat C/S revealed that the uterus had ruptured and the infant was out of the uterus and in the abdominal cavity. The baby required intubation and chest compressions (no epi). Apgars were 1, 1 and 5 at 1, 5, and 10 mins. You question the parents and nurse about any possible seizures. Of the following, the description that MOST likely indicates that the child is having a NS is: A. Episodes of apnea and bradycardia B. Fatiguing and vomiting during feeds C. Focal jerking in both arms simultaneously but asynchronously D. Limb jerking triggered by touching the child E. Spontaneous limb jerking that stops when a hand is placed on the

child

*Clinical Presentation

Preterm InfantsRoving eyesSustained eye opening or fixationBicyclingLip smackingUnresponsiveness

Term infantsSustained tonic horizontal eye deviation+/- Jerking+/- Apnea

*More on Movements…

Is It REALLY A Seizure?

Evaluation

Top priority is identifying an underlying etiologyNEONATAL SEIZURES ARE VERY RARELY

IDIOPATHIC!! Detailed history and PE

Maternal RFComplications of pregnancy, labor and

delivery

Evaluation (con’t)

Screening labsAcucheckElectrolytesAmmoniaBlood gasLP

Additional studiesNeuroimagingSerum AA, lactate, UOAViral titersKaryotypeTox screen

A Word on EEGs…

Due to the immature myelination of the neuronal networkSome behavioral or motor

manifestations of NS may not be detected on surface EEG

Surface EEG findings may be present when there are no observable clinical manifestations

Treatment

ABCs!! Treat underlyingproblem Treat seizures

Question… A term infant is delivered via emergency C/S

following the acute onset of maternal vaginal bleeding and profound fetal bradycardia. Apgars are 1, 2, and 3 at 1, 5, and 10 minutes, respectively. Resuscitation includes intubation and assisted ventilation, chest compressions, and IV epi. The infant is admitted to the NICU and has seizures at 6h of life. Of the following, a TRUE statement about infants who have seizures following perinatal asphyxia is that most: A. Develop epilepsy B. Develop microcephaly C. Do not have long-term neurodevelopmental delay D. Experience hearing loss E. Require multiple anticonvulsant medications

*Prognosis

Cause is the MOST important factor that determines the outcome of NSPatients with self-resolving conditions (i.e.:

“fifth day fits”) do wellPatients with underlying brain disorders are

more likely to have long-term sequelae Other factors that affect prognosis:

Gestational age and BW 60% of term infants >25oog with NS were

later found to be developmentally normal 20% of preterm infants <1500g with NS were

found to be normal

*Prognosis

Other factors that affect prognosis (con’t)Apgar scoresNeed for mechanical ventilationNeurologic findingsFindings on EEG and U/S

Overall, high incidence of:Early death (24 to 30 percent)Neurologic impairments (20 to 60 percent)Developmental delay (up to 55 percent)Postneonatal epilepsy (20 to 30 percent)

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Thanks for your attention!!