neonatal seizures-1

Neonatal Seizure: 

Neonatal Seizure DR.V.R.V.K.KISHORE

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DEFINITION : Seizures are paroxysmal involuntary disturbance of brain function that may be manifested as: Impairment of Consciousness, abnormal motor activity, behavioral abnormality, sensory disturbance or autonomic dysfunction.

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Neonates are at particular risk for seizures because of: -Metabolic Disturbances. -Toxic. - Structural abnormality. - Infectious Diseases.

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Neonatal seizures are dissimilar from those in children or adults because of: -Incomplete arborization of axons, and dendritic processes as well as myelination is also immature or incomplete.

Factors causing seizures:: 

Factors causing seizures : Perinatal Anatomical and Physiological Features of Importance in Determining Neonatal Seizure Phenomena ANATOMICAL: Neuritic outgrowth—dendritic and axonal ramifications—in process Synaptogenesis -not complete Deficient myelination in cortical efferent systems

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PHYSIOLOGICAL: *In limbic and neocortical regions—excitatory synapses develop before inhibitory synapses (  N-methyl-D-aspartate receptor activity, gamma-aminobutyric acid excitatory) * Immature hippocampal and cortical neurons more susceptible to seizure activity than mature neurons *Deficient development of substantia nigra system for inhibition of seizures

Biochemical:: 

Biochemical: Na + -K + ATPase theory: In epileptic cortices- Levels of Na + -K + ATPase are low Sod. Ions leaks into neuronal cell and pot. Ions outside the cell RMP altered and there is depolarization with excitation of the cell Electrical discharges (as long as depolarization continues) SEIZURES

Classification of Neonatal Seizures: 

Classification of Neonatal Seizures Clinical Electroencephalographic

Classification :: 

Classification : I. Clinical Seizure Subtle Tonic Clonic Myoclonic

Classification:: 

Classification: II. Electroencephalographic seizure Epileptic Non-epileptic

Clinical Classification:: 

Clinical Classification: 1. Subtle : More in preterm than in term Eye deviation (term) Blinking, fixed stare (preterm) Repetitive mouth and tongue movements;excessive salivation. Nystagmus . Alteration of resp.rate .

Contd:types: 

Contd:types -Bicycling or pedalic movements -Change in skin color. -apnea due to seizures: most often has either an accelerated or normal heart rate; while apnea due to other cause usually associated with bradycardia.

Clinical Classification:: 

Clinical Classification: 2. Tonic: Primarily in Preterm May be focal or generalized Sustained extension of the upper and lower limbs (mimics decerebrate posturing) Sustained flexion of upper with extension of lower limbs (mimics decorticate posturing). Usually assoc. with eye deviation or apnea. Signals severe ICH in preterm infants

Clinical Classification:: 

Clinical Classification: 3. Clonic : Primarily in term Focal or multifocal Clonic limb movements(synchronous or asynchronous, localized or often with no anatomic order of progression) Consciousness may be preserved Signals focal cerebral injury Prognosis is good.

Clinical Classification:: 

Clinical Classification: 4. Myoclonic: Rare Focal, multifocal or generalized Lightning-like jerks of extremities (upper > lower)-single/multiple. Assoc. with diffuse CNS pathology. prognosis is poor.

Electroencephalographic seizure:: 

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

Electroencephalographic seizures:: 

Electroencephalographic seizures: II. Non-epileptic: No electro-cortical signature Provoked by stimulation Suppressed by restraint or repositioning Brainstem release phenomena (reflex)

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Classification of Neonatal Seizures 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.4 th ed.

EEG Classifications of Neonatal Seizures: 

EEG Classifications of Neonatal Seizures 1- Clinical seizures with a consistent EEG events. Which includes: *focal clonic. *focal tonic. *some myoclonic seizures. These seizures are clearly epileptic and are likely to respond to an anticonvulsants

Classification contd:: 

Classification contd: 2- Clinical seizures with inconsistent EEG events: This is observed with all generalized tonic seizures, subtle seizures and with some myoclonic seizures. Seizures in this category are likely to be of Non- epileptic origin and may not require or respond to anti epileptics.

Classification contd:: 

Classification contd: 3- Electrically silent clinical seizures : According to this,seizure discharges originating in the inferomedial cortex are transmitted to the deep brainstem centres where they elicit paroxysmal behavioural phenomenon. However, these deep discharges are not transmitted through the injured and dysfunctional hemispheric pathways to higher cortical centres and therefore remain undetected.

Classification contd:: 

Classification contd: 4- Electrical seizures with absent clinical seizures: may develop in comatose infant who are not on anti convulsants, conversely electrical seizures may persist in patients with focal tonic or clonic seizures without clinical signs after the introduction of an anticonvulsant.

Etiology : 

Etiology 1- Hypoxic Ischemic Encephalopathy: represent 60% - 65% of cases of neonatal seizures, occurs in babies with severe fetal distress who are apneic at birth. -Seizures usually occur in the first day of life most often beginning in the first 12 hours(The seizure onset is influenced by severity,duration and onset of intrauterine asphyxial insult(more severeinsult,more earlier onset). -

Etiology contd:: 

Etiology contd: Focal ischemic injury : Neonatal arterial strokes: -second most common cause of neonatal seizures,and seizures are the most common presentation of stroke in the newborn period. -typically unifocal with minimal spread. -MC involves left MCA,hence “right-sided clonic seizures are the most common clinical presentation. -good outcome.

Etiology-ischaemic contd:: 

Etiology-ischaemic contd: Cerebral venous thrombosis : -usually occur in large dural sinuses –in the posterior aspects of superior sagittal sinus. -Lethargy, is the usual feature but in some cases present with clonic seizures. -there will be depressed mental status before and between seizures unlike in arterial stroke.

ETIOLOGY:: 

ETIOLOGY: 2- Intracranial hemorrhage:( 10%) Location of haemorrhage and clinical features varies with gestational age. TERM: Subarachnoid hemorrhage. Subdural hemorrhage. PRETERM : Intraventricular hemorrhage. Periventricular haemorrhage.

Contd:: 

Contd: Primary subarachnoid haemorrhage occur frequently after difficult prolonged and traumatic labor. Cause Focal or Multifocal seizures usually starting on the second day of life,in infants who appear relatively well between seizures. Good prognosis and long-term outcome.

Haemorrhage contd:: 

Haemorrhage contd: Subdural haemorrhage: usually presenting in the first days of life. -Neonatal SDH usually occrs in large babies,breech delivery,difficult instrumental delivery.

Preterm haemorrhage:: 

Preterm haemorrhage: Poor outcome. Usually associated with severe IVH,or its parenchymal complication PVHI. Seizure following IVH usually present within the first 3 days of life. Seizures are usually Generalised Tonic seizures with poor prognosis,often evolves to coma and death in acute phase. Seizures associated with PVHI tend to occur after third day of life.

Etiology:METABOLIC:: 

Etiology:METABOLIC: Two types: Transient and rapidly correctable. Inherited and persistent cause-IBM. TRANSIENT CAUSES: - Hypoglycaemia. -Hypocalcaemia. -Hyponatraemia.

Inherited and permanent causes:: 

Inherited and permanent causes: Inborn Errors of Metabolism Associated With Neonatal Seizures Conditions That Have a Specific Treatment Pyridoxine (B6) dependency Folinic acid-responsive seizures Glucose transporter defect Creatine deficiency

IBM:Contd:: 

IBM:Contd: other Conditions: Nonketotic hyperglycinemia Sulfite oxidase deficiency Molybdenum cofactor deficiency (combined deficiency) Carbohydrate-deficient glycoprotein disorder Lactic acid disorders Mitochondrial disorders Maple syrup urine disease Isovaleric acidemia (sweaty feet, cheesy odor)

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4- Infections: -bacterial meningitis. -viral infection. -toxoplasmosis. -syphilis. 5- Developmental disorders: -cerebral dysgenesis. -Others which include: neurofibromatosis, sturge weber disease and tuberous sclerosis.

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6- Drug associated seizures: -narcotic and sedative withdrawal. -local anesthesia. -Theophyllin. 7- Polycythemia and hyperviscosity.

Etiology:: 

Etiology: 8.NEONATAL EPILEPTIC SYNDROMES : B enign:2 types- Benign familial neonatal seizures. Benign idiopathic neonatal seizures. M alignant:3 types- Neonatal myoclonic encephalopathy. Ohtahara syndrome Migrating partial seizures of infancy(Coppola syndrome)

Causes of Neonatal Seizures:: 

Causes of Neonatal Seizures: Within first 24 hours of life Hypoxic ischemic encephalopathy Meningitis/sepsis Subdural/Subarachnoid/Interventricular hemorrhage Intrauterine infection Trauma Pyridoxine dependency Drug effect/withdrawal

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24-72 hours Meningitis/sepsis In premature infants: IVH In full-term infants: infarction, venous thrombosis Cerebral dysgenesis

Causes:: 

Causes: 72 hours to 1 week Above causes Inborn errors of metabolism Hypocalcemia Familial neonatal seizures 1 week to 4 weeks Above causes HSV

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Major Etiologies of Neonatal Seizures in Relation to Time of Seizure Onset and Relative Frequency TIME OF ONSET * RELATIVE FREQUENCY† 0-3 DAYS >3DAYS PREMATURE FULL TERM Hypoxic-ischemic + +++ +++ encephalopathy Intracranial + + ++ + hemorrhage ‡ Intracranial infection + + ++ ++ Developmental + + ++ ++ defects Hypoglycemia + + + Hypocalcaemia + + + + Other metabolic + + Epileptic syndromes + + +

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Comparison of prominent etiologic diagnoses of seizures in the newborn period. (Data modified from Mizrahi and Kellaway, 1987; Rose and Lombroso, 1970) Fanaroff A, Martin R.Neonatal seizures. In:Neonatal and Perinatal Medicine, Diseases of the Fetus and Infant,6 th ed.

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Jitterness and Clonus Charaterictics of jitterness and clonus that help to differentiate them from seizures are as follows: 1- absence of abnormal gaze or eye movement. 2- provocation by stimulation of the infant or by stretching a joint in contrast to the usual spontaneous occurrence of seizures. 3- cessation of movements with passive fexion or gentle resistant . 4- absence of the fast and slow components that are characteristics of a clonic fit.

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5- Tremor and Clonus with no associated EEG abnormality. 6- Repetitive jerks in seizures are at a rate of 2 to 3 per second, whereas clonus tend to be faster as 5-6 per second. 7- Jitterness and non-seizure clonus not accompanied by increased blood pressure, bradycardia, or tachycardia.

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Normal Neonatal Motor Activity Commonly Mistaken for Seizure Activity AWAKE OR DROWSY Roving, sometimes dysconjugate eye movements, with occasional nonsustained nystagmoid jerks at the extremes of horizontal movement (contrast with fixed, tonic horizontal deviation of eyes with or without jerking —characteristic of subtle seizure Sucking, puckering movements not accompanied by ocular fixation or deviation SLEEP Fragmentary myoclonic jerks —may be multiple Isolated, generalized myoclonic jerk as infant wakes from sleep Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4 th ed.

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Treatment Treatment of the underlying cause. Anticonvulsant therapy: -phenobarbital. -phenytoin. -diazepam. -lorazepam. -medazolam.

Prognosis: 

Prognosis The overall prognosis in neonatal seizures is death in 15%. Neurologic squally such as mental retardation, motor deficit in 30%. Normal outcome in 50%. Chronic seizure disorder will develop in 15%-20% of survivors.

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Prognosis is affected by the following factors: Gestational age. Etiology. Seizure pattern. EEG. Abgar score. Duration of seizures. Association of hypotonia. The presence of tonic or myoclonic seizures. Early onset of seizures. The need +ve pressure ventilation.

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3- Metabolic problems: -hypoglycemia. -hypocalcemia. -hypomagnesemia. -hyponatremia. -hypernatremia. -pyridoxin deficiency. -disorders of metabolism as phenylketoneurea, hyperglycinemia, urea cycle disorders and β-alanine abnormalities. -organic acidemia. -biotin responsive disorders. -fructose intolerance disorders.

Good prognostic Factors: 

Good prognostic Factors Seizures free at discharge from hospital. Seizures subside within 24 hours. Neurological examination is normal with no abnormal eye movement. Return to normal routine feeding within 5 days. EEG is not persistently abnormal.

Bad prognostic Factors: 

Bad prognostic Factors Prolonged and repetitive seizures (more than 30 minutes). Abnormal eye movements. Abnormal interictal EEG. Apgar score less than 7 at 5 minutes. Prematures. Early onset of convulsions.

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Etiology Normal outcome(%) Subarachnoid hemorrhage 90 Uncertain 75 Early Hypocalcemia 50 Late hypocalcemia 100 Hypoglycemia 33-71 Neonatal Encephalopathy 31-50 IVH 10 Meningitis 11-65 Dysgenesis zero Prognosis of Seizures by Etiology

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Prognosis of seizures by seizure pattern: Normal outcome(%) by gestational age at birth Seizure pattern Full term(%) Premature(%) Focal clonic 100 33 Multifocal 33 33 Generalized 59 41 Tonic 50 36 Myoclonic 0 0 Subtle 57 44

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