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| content:neonatal_seizures [2020/02/23 12:51] – icna | content:neonatal_seizures [2022/04/30 11:32] (current) – changed pubmed syntax administrator@icnapedia.org | ||
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| * Neonatal epileptic seizures occur from birth to the end of the neonatal period. | * Neonatal epileptic seizures occur from birth to the end of the neonatal period. | ||
| * The neonatal period is defined as the first 28 days of life of a full-term infant. | * The neonatal period is defined as the first 28 days of life of a full-term infant. | ||
| - | * Most neonatal seizures are acute (pro-voked, occasional, reactive) | + | * Most neonatal seizures are acute symptomatic seizures caused by an acute illness such as hypoxic–ischaemic encephalopathy, |
| * seizures are the most common and important sign of acute neonatal encephalopathy | * seizures are the most common and important sign of acute neonatal encephalopathy | ||
| * neonatal seizures are a major risk for death or subsequent neurological disability and, by themselves, may contribute to an adverse neuro-developmental outcome. | * neonatal seizures are a major risk for death or subsequent neurological disability and, by themselves, may contribute to an adverse neuro-developmental outcome. | ||
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| ===== Classification ===== | ===== Classification ===== | ||
| - | * The ILAE Commission (1989)[(: | + | * The ILAE Commission (1989)[(: |
| - | * In the ILAE (2010)[(: | + | * In the ILAE (2010)[(: |
| ===== Clinical features ===== | ===== Clinical features ===== | ||
| - | Five main types of seizures are recognised[(: | + | Five main types of seizures are recognised[(: |
| * subtle seizures (50%) | * subtle seizures (50%) | ||
| * tonic seizures (5%) | * tonic seizures (5%) | ||
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| **Myoclonic seizures** | **Myoclonic seizures** | ||
| * rapid, single or arrhythmic repetitive jerks. They may affect a finger, a limb or the whole body. They may mimic Moro reflex and startling responses | * rapid, single or arrhythmic repetitive jerks. They may affect a finger, a limb or the whole body. They may mimic Moro reflex and startling responses | ||
| - | * more frequently in pre-term than in full-term infants indicating, if massive, major brain injury and poor prognosis[(: | + | * more frequently in pre-term than in full-term infants indicating, if massive, major brain injury and poor prognosis[(: |
| * healthy pre-term and, although rarely, full-term neonates may have abundant myoclonic movements during sleep | * healthy pre-term and, although rarely, full-term neonates may have abundant myoclonic movements during sleep | ||
| * Neonates have cortical, reticular and segmental types of myoclonus, similar to adult forms (Scher, 1985). | * Neonates have cortical, reticular and segmental types of myoclonus, similar to adult forms (Scher, 1985). | ||
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| * autonomic ictal manifestations commonly occur with motor manifestations in 37% of subtle seizures | * autonomic ictal manifestations commonly occur with motor manifestations in 37% of subtle seizures | ||
| * paroxysmal changes of heart rate, respiration and systemic blood pressure, salivation, pupillary changes | * paroxysmal changes of heart rate, respiration and systemic blood pressure, salivation, pupillary changes | ||
| - | * Apnoea, as an isolated seizure phenomenon unaccompanied by other clinical epileptic features, is rare[(: | + | * Apnoea, as an isolated seizure phenomenon unaccompanied by other clinical epileptic features, is rare[(: |
| - | ==== Duration ==== | + | The duration of neonatal seizures is usually brief (10 s to 1–2 min) and repetitive with a median of 8 min in between each seizure. Longer seizures and status epilepticus develop more readily at this age, but convulsive neonatal status epilepticus is not as severe as that of older infants and children. |
| - | + | ||
| - | * The duration of neonatal seizures is usually brief (10 s to 1–2 min) and repetitive with a median of 8 min in between each seizure | + | |
| - | * Longer seizures and status epilepticus develop more readily at this age, but convulsive neonatal status epilepticus is not as severe as that of older infants and children. | + | |
| ==== Non-epileptic neonatal seizures ==== | ==== Non-epileptic neonatal seizures ==== | ||
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| * suppression–burst pattern in neonatal epileptic encephalopathies[{{ : | * suppression–burst pattern in neonatal epileptic encephalopathies[{{ : | ||
| * relatively common in neonatal period | * relatively common in neonatal period | ||
| - | * can be induced by drugs[(: | + | * can be induced by drugs[(: |
| * usually transient in ischemic encephalopathy | * usually transient in ischemic encephalopathy | ||
| * stable lasting for more than 2 weeks in [[content: | * stable lasting for more than 2 weeks in [[content: | ||
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| **Stimulus-evoked electrographic patterns** | **Stimulus-evoked electrographic patterns** | ||
| * electrographic seizures are elicited by tactile or painful stimulation (with or without concomitant clinical ictal manifestations) | * electrographic seizures are elicited by tactile or painful stimulation (with or without concomitant clinical ictal manifestations) | ||
| - | * represent an abnormal form of cortical reactivity to sensory stimuli in the developing brain[(: | + | * represent an abnormal form of cortical reactivity to sensory stimuli in the developing brain[(: |
| * most neonates with these patterns have significant diffuse or multifocal damage to the neocortex | * most neonates with these patterns have significant diffuse or multifocal damage to the neocortex | ||
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| * clinical component of a seizure occurs at times with or without an electrical correlate | * clinical component of a seizure occurs at times with or without an electrical correlate | ||
| * ‘decoupling response’ - commonly seen after starting AEDs where AEDs may suppress the clinical manifestations of seizures but not the EEG ictal discharge | * ‘decoupling response’ - commonly seen after starting AEDs where AEDs may suppress the clinical manifestations of seizures but not the EEG ictal discharge | ||
| - | * may arise from foci not consistently echoed by surface electrodes[(: | + | * may arise from foci not consistently echoed by surface electrodes[(: |
| + | ==== Differential diagnosis ==== | ||
| + | * [[hyperekplexia]] | ||
| + | * [[benign neonatal sleep myoclonus]] | ||
| + | * [[Benign Non-Epileptic Myoclonus of Early Infancy]] ([[benign non-epileptic infantile spasms]]) | ||
| + | * paroxysmal, non-epileptic movement disorder of otherwise healthy infants who have normal EEG and development[(: | ||
| + | * ‘benign non-epileptic infantile spasms’ is descriptively more accurate than myoclonus[(: | ||
| + | * thought to be the same condition as ‘shuddering attacks’[(: | ||
| ==== Prognosis ==== | ==== Prognosis ==== | ||
| - | * depends on the underlying cause | + | * depends on the underlying cause[(: |
| * Indicators of bad prognosis | * Indicators of bad prognosis | ||
| * Severe hypoxia–ischaemia | * Severe hypoxia–ischaemia | ||
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| * EEG persistence of immature patterns | * EEG persistence of immature patterns | ||
| * Frequent or prolonged clonic seizures and clonic status epilepticus | * Frequent or prolonged clonic seizures and clonic status epilepticus | ||
| + | |||
| + | ==== Management ==== | ||
| + | === Investigations === | ||
| + | * Neuroimaging | ||
| + | * CT, MRI, Cranial USS | ||
| + | * EEG | ||
| + | * Blood tests | ||
| + | * CSF studies | ||
| + | |||
| + | === Treatment === | ||
| + | {{page> | ||
| + | There is limited evidence regarding the best pharmacologic treatment for neonatal seizures. World Health Organisation recommends electrographic seizures should be treated in the same way as clinical seizures[(: | ||
| + | |||
| + | * **phenobarbital** | ||
| + | * often recommended as first-line treatment[(: | ||
| + | * recommended as first line treatment in the UK[(: | ||
| + | * included in RCTs of first-line treatment of neonatal seizure | ||
| + | * most studied anti-epileptic medication in animals | ||
| + | * historical precedence as the first-line antiepileptic drug for neonates | ||
| + | * extremely limited evidence on the effect of phenobarbital on long-term neonatal neurodevelopment | ||
| + | * U.S. Food and Drug Administration (FDA) has never approved phenobarbital for use in any patient population[(: | ||
| + | * animal studies have raised concerns that neonatal phenobarbital exposure induces neuronal apoptosis, disruption of synaptic development in the striatum, and other behavioral deficits[(: | ||
| + | * **Levetiracetam** | ||
| + | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital | ||
| + | * FDA-approved for children as young as one-month of age[(: | ||
| + | * efficacy and safety profile has not been adequately studied in term or preterm neonates within the first month of life | ||
| + | * current literature suggests loading doses of 10 to 20 mg/kg are appropriate and effective in neonates, with a maintenance dose range of 10 to 80 mg/kg/day divided twice daily[(: | ||
| + | * dosing of 40–50mg/ | ||
| + | * a recent open labelled RCT (Level III neonatal unit; 100 neonates) used Levetiracetam (20 mg/kg) or Phenobarbitone (20 mg/kg) intravenously and concluded that Levetiracetam achieves better control than Phenobarbitone for neonatal clinical seizures when used as first-line antiepileptic drug, and is not associated with adverse drug reactions[(: | ||
| + | * phenytoin/ | ||
| + | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital | ||
| + | * requires frequent blood-level monitoring | ||
| + | * erratic oral absorption & needs 6-8hrly oral dosing | ||
| + | * **lidocaine** | ||
| + | * effective as second-line treatments for neonatal seizures that are unresponsive to phenobarbital. | ||
| + | * narrow therapeutic window and the potential to cause cardiac arrhythmias or hypotension | ||
| + | * can induce seizures at high doses | ||
| + | * may be considered in status epilepticus if phenytoin was no previously given | ||
| + | * Benzodiazepines (midazolam) | ||
| + | * sedation is a serious side effect | ||
| + | * may be considered as a second- or third-line therapy choice, especially in already intubated neonates | ||
| + | |||
| + | Other considerations | ||
| + | * consider pyridoxine challenge when other antiepileptics provide no response | ||
| + | * minimal data for many antiepileptics including topiramate, which is being increasingly used in neonates | ||
| + | * steroids and / or [[vigabatrin]] are considered in epileptic spasms | ||
| + | * Low-dose carbamazepine (CBZ) should be considered as first-line treatment for benign familial neonatal epilepsy (BNFE), even in cases of status epilepticus[(: | ||
| + | * there is equipoise on levetiracetam vs phenobarbitone as first line treatment[(: | ||
| + | * The 2011 World Health Organization (WHO) guidelines for neonatal seizures[(: | ||
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| ===== References ===== | ===== References ===== | ||
| ~~REFNOTES cite~~ | ~~REFNOTES cite~~ | ||