20.neonatal convulsion

8/13/2019 20.Neonatal Convulsion

1/38

NEONATAL SEIZURES

Trauma & Emergency System

Perinatologi Division.Department of Child Health

Medical Faculty of Hasanuddin University


2/38

Definition

Seizures are transient disturbances in brain

function manifesting as episodic impairmentsin consciousness in association with abnormal

motor or automatic activity.


3/38

Probable Mechanisms of Some NeonatalSeizures

PROBABLE MECHANISM DISORDER

Failure of Na + -K + pump secondary to Hypoxemia, ischemia,

adenosine triphosphate and hypoglycemiaExcess of excitatory neurotransmitter

(eg.glutamic acidexcessive excitation) Hypoxemia, ischemia

and hypoglycemia

Deficit of inhibitory neurotransmitter Pyridoxine dependency

(i.e., relative excess of excitatory

neurotransmitter)

Membrane alterationNa + Hypocalcemia and

Permeability hypomagnesemia

_________________________________________________________________

Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4thed.


4/38


5/38

Classification

I. Clinical Seizure

Subtle

Tonic

Clonic

Myoclonic

II. Electroencephalographic seizure

Epileptic

Non-epileptic


6/38

..Clinical Classification

1. SubttleUsually 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 patterns.

Rhythmic fluctuations in vital signs

More in preterm than in term


7/38

2. Tonic Primarily in Preterm

May be focal or generalized

Sustained extension of the upper and lowerlimbs (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.



8/38

3. Clonic

Consist of slow (1-3 /minute) rhythmic jerkingmovements of the extremities. They may be focal or

multi-focal. Each movement is composed of a rapidphase followed by a slow one.

Changing the position or holding the moving limbdoes not suppress the movements.

Commonly seen in full-term neonates >2500 grams Consciousness may be preserved

Signals focal cerebral injury, infarction or metabolicdisturbances.



9/38


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 thebody.

Generalized myoclonic seizures present asmassive flexion of the head and trunk withextension or flexion of the extremities. They areassociated with diffuse CNS pathology


10/38

Electroencephalographic seizure

I. Epileptic

Consistently associated with electro-cortical

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


11/38

Electroencephalographic

seizures

II. Non-epileptic

No electro-cortical signature: seizures are

initiated in the subcortical area and are notusually associated with any EEG changes.

Provoked by stimulation

Suppressed by restraint or repositioning

Brainstem release phenomena (reflex)


12/38

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.4th

ed.

Relation between Clinical seizure and EEG seizure


13/38


14/38

Surface EEG-Silent Seizure

Can surface EEG-silent seizure in the

newborn result to brain injury?

Can this be eliminated by conventionalanticonvulsant therapy?

Further investigation needed


15/38

Benign Movements that are Not

Seizures

Jitteriness

Sleep apnea

Isolated sucking movements

Benign neonatal sleep myoclonus


16/38

Jitteriness Versus Seizure

CLINICAL FEATURE JITTERINESS SEIZURE

Abnormality of gaze or eye - +

movement

Movements exquisitely stimulus + -sensitive

Predominant movement Tremor Clonic jerking

Movements cease with passive + -

flexionAutonomic changes - +

The flexion and extension phases + -

are equal in amplitude

EEG abnormalities - +/-------------------------------------------------------------------------------------------------------------------


17/38

often seen in neonates with hypoglycemia, drug

withdrawal, hypocalcemia, hypothermia and in

(SGA) neonates.

spontaneously resolve within few weeks.

......Jitteriness (cont)


18/38

Sleep Apnea

Not associated with abnormal movements and is

usually associated with bradycardia.

When seizures are present with apnea, abnormalmovements, tachycardia and increased blood

pressure are present as well.

Isolated Sucking Movements

Random, infrequent and not well sustained

sucking movements are not seizures.


19/38

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.


20/38

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


21/38

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


22/38

..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.


23/38

23

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


24/38

24

TORCH titers, ammonia level, head sonogramand 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

.Laboratory Investigations, cont


25/38

25

Management of Seizures

Management goals

To minimize brain damage

Achieve systemic homeostasis (airway,

breathing and circulation).

Correct the underlying cause if possible.


26/38

Medical Management :

10% dextrose solution (2cc/kg IV) empirically to any seizingneonate.

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


27/38

27

Stopping Seizures with Anticonvulsants

Drug Dose Comments Side Effects

Phenobarbital Loading dose:10-20 mg/kg.

Add 5 mg/kg toa maximum of40 mg/kg

Maintenance:3-5 mg/kg/dayin divideddoses every 12hours.

It is the drug ofchoice.

Administer IVover 5 minutes.

Therapeuticlevel: 20-40

g/ml.

Administer IM,IV, or PO every12 hours.

Begin therapy12 hours after

loading dose.

Hypotension

Apnea

Monitorrespiratorystatus duringadministrationand assess IV

site.


28/38

28

Drug Dose Comments Side Effects

When seizures are not controlled with phenobarbital alone.

Phenytoin Loading dose:15-20 mg/kg IVover 30 min.

Maintenance:3-5 mg/kg/day.

Administer IV ata maximum rateof 0.5 mg/kg/min

Maintenance: 4-8 mg/kg/day byIV push or PO.

Divide total doseand administerIV every 12hours.

Do not give IM.

Toxicity is aproblem with thisdrug.

Cardiacarrhythmias

Cerebellardamage



29/38

29

rug Dose Comments Side Effects

or treatment of status epilepticus.

enzodiazepines Lorazepam:0.050.1 mg/kg

Diazepam: 0.10.3 mg/kg/dose.

Administer IV. Repeat every 15

minutes for 2-3doses if needed.

Maximum dose is2-5 mg.

It can be givenonce as a POdose of 0.1-0.3

mg/kg.

Respiratorydepression,

Interferes withbilirubin binding toalbumin



30/38

30

When to Stop Anticonvulsant Drugs /

AEDS

No specific practice guidelines for the timing forstopping these medications, however:

Stopping AEDs two weeks after last seizureepisode is acceptable as prolonged medicationcan adversely affect the developing brain.


31/38

31

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.

When to Stop Anticonvulsant Drugs /

AEDS (cont)


32/38

Determinants of Duration of

anticonvulsant therapy for neonatal

seizures

Neonatal neurological examination

Cause of neonatal seizure

Electroencephalogram


33/38

Prognosis

Two most useful approaches in utilizing outcome

EEG

Recognition of the underlying neurological

disease


34/38

Complications

Cerebral palsy

Hydrocephalus

Epilepsy Spasticity

Feeding difficulties


35/38

Consultations

Neurology consult needed for

- evaluation of seizures

- evaluation of EEG and video EEGmonitoring

- management of anticonvulsant

medications


36/38

Further Outpatient Care

Neurology outpatient evaluation

Developmental evaluation for earlyidentification of physical or cognitive deficits

Orthopedic evaluations if with jointdeformities

Consider physical medicine/physical therapy

referral if indicated


37/38

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;5:327-3353.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-PerinatalMedicine-Diseases of the fetus and infant.6th

ed.St.Louis,MO:Mosby-Yearbook Inc.1997:899-911

6.Sheth R, Neonatal seizures;Emedicine.com


38/38

hank You

20.neonatal convulsion

Documents