NEONATAL SEIZURES

NEONATAL SEIZURES Dr. MITHUN H. K .

INTRODUCTION Paroxysmal alteration in neonatal behavior and (or) motor, autonomic function initiated by hypersynchronous activity of neurons in the brain.

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

INCIDENCE • 4-6 / 1000 Neonates - Nelson • 0.5% in Term Babies Joseph • 21% in Preterm Infants J. Volpe • ICH & HC, Egmore, - 10.5% of Total Chennai Admissions in MNB UNIT

CORRELATION OF TIME OF ONSET OF SEIZURES AND AETIOLOGY

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.

Classification. • Subtle seizures • Clonicseizures • Tonic seizures • Myoclonic seizures.

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

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.

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

CLINICAL SEIZURES - Contd.. • IV Myoclonic seizures Involve flexor muscles of an Upper extremity • 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

NORMAL NEONATAL MOTOR ACTIVITYCOMMONLY MISTAKEN FOR SEIZURES AWAKE or DROWSY • Roving eye movements • Nystagmoid jerks • Unsustained, Sucking, Puckering SLEEP • Fragmentary myoclonic jerks • Isolate, generalized myoclonic jerks on arousal

CLINICAL CHARACTERISTICS WHICH DISTINGUISH JITTERINESS FROM SEIZURES

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

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

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

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.

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. Lorazepam0.05 mg/kg IV bolus over 2-5 minutes; may be repeated (Contd..)

MANAGEMENT – Contd.. (or) • Inj. Clonzepam0.1–0.2 mg/kg IV bolus followed by infusion 10-30 mg/kg/hr. (or) • Inj. Midazolam0.05 mg/kg IV bolus over 2-5 minutes; may be repeated • DIAZEPAM : Not safe in neonates as it interferes with vital functions its sedative effect half life exceeds 24 hours

MANAGEMENT – Contd.. OTHER MEDICATIONS • Calcium : 10% Cal. Gluconate 2 ml/kg mixed with equal amount of 10% dextrose given by slow I.V. over 10 mts. • Magnesium : Hypomagnesimia is treated with 50% magnesium sulphate 0.2 ml/kg administered by IM route.

Lidocaine: • 4mg/kg/hr IV on first day, • reduce by 1mg/kg/hr on each subsequent • day or load with • 2mg/kg IV and maintain on 6 mg/kg/hr. • Adverse effects include • arrythmias, hypotension and seizures. • It should not be administered with phenytoin.

Paraldehyde: • A dose of 0.1-0.2 ml/kg/dose may be given IM or 0.3 ml/kg/dose mixed with coconut oil in 3:1 may be used by per rectal route. Additional doses may be used after 30 minutes and q 4-6 hourly. • Adverse effects include pulmonary hemorrhage, pulmonary edema, hypotension, and liver injury.

Sodium valproate: • IV preparation is now available. • Dose is 20-25 mg/kg/d • followed by 5-10 mg/kg every 12 hours.

Vigabatrin: • used in neonates for refractory seizures, • primarily for infantile spasms. • The dose is 50 mg/kg/day.

Topiramate: • Its potential neuroprotectiveeffect against injury caused by seizures. • Initial and maintenance doses of approximately 3 mg/kg.

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

PROGNOSIS OF NEONATAL SEIZURES IN RELATION TO ETIOLOGY

EEG BACKGROUND SCORES • Normal • Mildly abnormal • Moderately Abnormal • Low – Voltage Undifferentiated • Suppression – Burst Pattern • Electrocerebral Inactivity Better Worse

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

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

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.

Thank you

NEONATAL SEIZURES