Neonatal seizures Recent advance

Dr MANDAR HAVAL

DCH. DNB. Fellow In Neonatology(NNF)

INTRODUCTION

• Seizures is defined clinically as a paroxysmal alteration in clinical function

• i.e motor , behavior and autonomic function

Types

• Clonic movement (focal, multifocal, genralised)

• Myoclonus (multifocal, genralised)

• Tonic movement (focal, genralised)

• Motor (automatism and subtle seizure)

Interesting Evidence

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

• 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 interictalexamination is often abnormal.

Common cause of neonatal seizure

• HIE

• Intracranial Infection

• Metabolic disorder (Hypoglycemia, Hyponatrimia, Hypocaemia)

• Intracranial Hemorrhages (ICH)

• Inborn Error Of Metabolism

• Epileptic syndrome

Interesting evidence

• Study in PGI chandigarh found HIE is the commonest cause of seizure followed by meningitis

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

Recommendation for investigation

• 1st line ( BSL, iCa, Na, ABG)

• 2nd line - Add on Situational

A) Sick Neonate With Seizure

B) Intracranial Infection

C) Intracranial Hemorrhage

D) IEM workup

(EEG)

• Newborn frequently demonstrate electrographic seizure without clinical movement and vice versa

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 Myoclonic seizure where eighter not associated with EEG changes or had inconsistent relationship.

• Only 21% of seizure are seen on EEG

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

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

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

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)

Treatment of neonatal seizure

• Followed in four step

1) Stabilization

2) Identification

3) Specific Treatment

4) Prevention of recurrence

Flow Chart

Neonate with seizure

Ensure TABC, IV access, check dextrose

BSL<40 mg/dl

10 % dextrose

2ml/kg bolus

Continuous infusion at

6mg/kg/min

If Seizure Persist

Do ionized calcium by ABG

Consider giving 10% calcium gluconate

@ 2ml/kg IV over 5 to 10 min

If seizure persist then repeat calcium

If no response then consider 50%

MgSO4 @ 0.2ml/kg IM

Calcium step is consider in case of IDM , IUGR , preterm and sick neonate

Seizure persist Dextrose and Ca normal

Inj. Phenobarbitone 20mg/kg IV over 15 min . If seizure persist consider 2nd

bolus of 10mg/kg (Total 30mg) assess seizure control after 15min of bolus

Phenatoin or fosphenytoin20mg/kg , infuse over 10 min . Rate should be 1mg/kg/min. assess seizure control after 30 min

In neonate with hepatic dysfunction the max dose should be restricted to 20mg/kg

IF Seizure Persist *

Consider intubation ond mech. Ventilation

IV lidocacain loading dose 2mg/kg followed by intravenous infusion of 6mg/kg/hour, then 4mg/kg/hr for 12 hr, followed by 2mg/kg/hr for 12 hr

Midazolam infusion 0.15mg/kg IV bolus , followed by continuous infusion 1ug/kg/min increase by 0.5 to 1ug/kg/min every 2 min till response (max 18ug/kg/min

OR

* Consider using pyridoxine at these step

If Seizure persist

• Consider alternate drug

1) Levateracetam

2) Topiramate

Suggested guidelines for weaning AED

New born with seizure

Transient metabolic problem

Difficult to control seizure

Treat the cause and stop the AED immediately if

started initially

Stop AED observe for atleast48 hr for seizure recurrence

Yes

No

No

Yes

Cont..

Continue phenobarbitone and stop other AED . Assess neurological status after stoppage of AED and at discharge

Stop phenobarbitone

immediately

Discharge on phenobarbitone; repeteneurological exam at 1

month

NORMAL ABNORMAL

Normal • Taper and stop

phenobarbitoneover 2 week

Abnormal •Do EEG

After 1 month of repeat neurological exam

Normal • Taper and stop

phenobarbitoneover 2 week

Abnormal • Reasses at 3

month

EEG

Follow up sequelae

• Early infancy (12 to 18 mt follow up recognisemost babies with major disability)

cerebral palsy, mental retardation or hearing problem.

• School age and older age

learning and behavioral problem

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

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

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

ALL THE BEST