I. Neonatal Seizures II. Conditions That Mimic Seizures

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Text of I. Neonatal Seizures II. Conditions That Mimic Seizures

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  • I. Neonatal Seizures II. Conditions That Mimic Seizures
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  • Seizure transient and reversible alteration of behavior caused by a paroxysmal, abnormal and excessive neuronal discharge transient and reversible alteration of behavior caused by a paroxysmal, abnormal and excessive neuronal discharge attack of cerebral origin attack of cerebral origin sudden and transitory abnormal phenomena motor, sensory, autonomic, or psychic sudden and transitory abnormal phenomena motor, sensory, autonomic, or psychic transient dysfunction of part or all of the brain
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  • Epilepsy A paroxysmal brain disorder of various etiologies characterized by recurrent seizures due to excessive electrical discharge of cerebral neurons associated with a variety of clinical and laboratory manifestations A paroxysmal brain disorder of various etiologies characterized by recurrent seizures due to excessive electrical discharge of cerebral neurons associated with a variety of clinical and laboratory manifestations two or more seizures not directly provoked by intracranial infection, drug withdrawal, acute metabolic changes or fever two or more seizures not directly provoked by intracranial infection, drug withdrawal, acute metabolic changes or fever
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  • Neonatal Seizures Tonic Seizuresfocal or generalized, may mimic decorticate or decerebrate posturing, primarily seen in preterms with intracranial hemorrhage & generally have poor prognosis Subtle seizures Consist of chewing motion, excessive salivation and alteration in respiratory rate including apnea, blinking, nystagmus, bicycling and pedaling movements, changes in color
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  • Clonic- focal (repetitive movements localized to a single limb) or multifocal (random migration of movements from limb to limb), consciousness may be preserved, primarily seen in term infants Myoclonic- sudden flexor movements (lightning-like jerks), may be focal, multifocal or generalized, may occuring singly or in clusters, if due to early myoclonic encephalopathy it carries a poor prognosis. Brief focal or generalized jerks of the extremities or body that tend to involve distal muscle groups
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  • Why are seizure patterns in neonates more fragmentary than in older children? The cellular organization of the mature and immature brain is different. The neonatal brain has incomplete glial proliferation, w/ continuing migration of neurons, establishing complex axonal & dendritic contacts and myelin deposition. The electrical discharges therefore spread incompletely and may remain localized to one hemisphere. The electrical discharges are slow to diffuse and bilateral synchronous discharges are rare.
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  • Neonatal Seizures EEG Classification Clinical seizure with consistent EEG event Clinical seizure occurs in relationship to seizure activity Includes focal clonic, focal tonic and myoclonic Responds to antiepileptic drugs Clinical seizure with inconsistent EEG event Clinical seizures with no EEG abnormality Seen in all generalized tonic and subtle seizures Seen in patients who are comatose, HIE
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  • Neonatal Seizures EEG Classification Electrical seizures with absent clinical seizures Electrical seizures associated with markedly abnormal background EEG Seen in comatose patients
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  • Epileptic vs Non-epileptic Neonatal Phenomena Clinical Characteristics EpilepticNon-epileptic Increases with Sensory stimulation RareCommon Suppresses with restraint -+ Autonomic Accompaniments +-
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  • Major Causes of Neonatal Seizures In Relation to Time of Seizure Onset and Relative Frequency TIME OF ONSET* RELATIVE FREQUENCY TIME OF ONSET* RELATIVE FREQUENCY Cause 0-3 Days >3 Days Premature Full Term Hypoxic-Ischemic encephalopathy + +++ +++ Intracranial hemorrhage + + ++ + Intracranial infection + + ++ ++ Developmental defects + + ++ ++ Hypoglycemia + + + Hypocalcemia + + + Other metabolic + + Epileptic syndromes + + +
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  • Neonatal Seizures Etiologic diagnosis Hypoxic ischemic encephalopathy Metabolic Infections Trauma Structural abnormalities Hemorrhagic and embolic strokes Maternal disturbances
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  • Causes of neonatal seizures Ages 1 4 days HIE Drug withdrawal Dug toxicity Lidocaine, penicillin Intraventricular hemorrhage Acute metabolic disorder Hypocalcemia Hypoglycemia Inborn errors of metabolism
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  • Causes of neonatal seizures Ages 4 14 days Infection Metabolic disorders Hypocalcemia Diet Hypoglycemia Inherited disorder of metabolism such as galactosemia,fructosemi a Hyperinsulinemic hypoglycemia Becwith syndrome Anterior pituitary hypoplasia Drug withdrawal Benign neonatal convulsion Kernicterus, hyperbilirubenemia
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  • Causes of neonatal seizures Ages 2 8 weeks Infection Head injury Subdural henatoma Inherited disorder of metabolism Aminoacidurias Urea cycle defects Organic acidurias Neonatal ALD Malformations of cortical development Lissencephaly Focal cortical dysplasia Tuberous sclerosis Sturge weber syndrome
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  • Neonatal Seizures Etiologic diagnosis Blood Glucose, calcium, magnesium, electrolytes, BUN In hypomagnesemia MgSO4 0.2 ml/kg Lumbar puncture Indicated in all neonates with seizures unless related to a metabolic disorder Inborn errors of metabolism Inherited as autosomal recessive or X-linked recessive
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  • Neonatal Seizures Etiologic diagnosis Inborn errors of metabolism Serum ammonia urea cycle abnormalities Acidosis + anion gap + hyperammonemia urine organic acids should be determined Unintentional injection of local anesthetic Supportive measures Promotion of urine output with IV fluids
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  • Idiopathic Syndromes of Clinical Seizures in the Newborn Epileptic Syndromes Benign familial Neonatal Seizures Benign idiopathic neonatal seizures (fifth-day fits) Early myoclonic encephalopathy Early infantile epileptic encephalopathy (Ohtahara syndrome) Malignant migrating partial seizures Nonepileptic Syndromes Benign neonatal sleep myoclonus Hyperekplexia
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  • Neonatal Seizures (Epileptic Syndromes) Benign familial neonatal seizures Begins on the 2 nd 3 rd day of life Seizure frequency : 10 20 /day Patients are normal between seizures Seizure stops in 1 6 months
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  • Neonatal Seizures Fifth-day fits 5 th day of life normal appearing neonates with mulifocal seizures Present for less than 24 hours Good prognosis
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  • Neonatal Seizures Etiologic diagnosis Pyridoxine dependency resistant to conventional AEDs Inherited as autosomal recessive Tx: Pyridoxine 100 200 mg IV May not have a dramatic effect with IV pyridoxine thus maintain on oral pyridoxine 10 -20 mg/day x 6 weeks Lifelong supplementation : 10 mg/day
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  • Neonatal Seizures Etiologic diagnosis Drug withdrawal seizures Barbiturates, benzodiazepenes, heroin and methadone Jittery, irritable, lethargic, may show myoclonus or frank seizures Serum or urine analysis may identify the responsible agent
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  • Prognosis of Neonatal Seizures: Relation to Neurological Diseases Neurological Disease* Normal Development Hypoxic-ischemic encephalopathy 50% Intraventricular hemorrhage 10% Primary subarachnoid hemorrhage 90% Hypocalcemia Early-onset 50% Early-onset 50% Later-onset 100% Later-onset 100% Hypoglycemia 50% Bacterial meningitis 50% Developmental defect 0%
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  • Why should the infant with epileptic seizures be treated with AED Potential adverse effects of seizure on: Ventilatory function Circulation Cerebral Metabolism Brain Development disturbance in cerebral blood flow energy metabolism homeostasis of excitotoxic amino acids neurogenesis and synaptic reorganization
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  • Acute Therapy of Neonatal Seizures With Hypoglycemia -- Glucose, 10% solution: 2 mL/kg, IV No Hypoglycemia Phenobarbital: 20 mg/kg, IV (1-2 mg/kg/min) If necessary: Additional phenobarbital: 5 mg/kg IV to a max. of 40 mg/kg (consider omission of this additional phenobarbital (consider omission of this additional phenobarbital if infant is severely asphyxiated) Phenytoin*: 20 mg/kg, IV (0.5-1.0 mg/kg/min) if infant is severely asphyxiated) Phenytoin*: 20 mg/kg, IV (0.5-1.0 mg/kg/min) (Lorazepam: 0.05-0.10 mg/kg, IV) if available (Lorazepam: 0.05-0.10 mg/kg, IV) if available Midazolam: 0.2 mg/kg, IV;then,0.1-0.4 mg/kg/hr, IV Midazolam: 0.2 mg/kg, IV;then,0.1-0.4 mg/kg/hr, IV
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  • Acute Therapy of Neonatal Seizures Other (as Indicated) Calcium gluconate, 5% solution: 4 mL/kg, IV Magnesium sulfate, 50% solution: 0.2 mL/kg, IM Pyridoxine: 50-100 mg, IV; repeat to maximum of 500 mg if needed Pyridoxal-5-phosphate,30 mg/kg/day, PO Folinic Acid, 4 mg/kg/day, PO
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  • Volpe, Neurology of the Newborn, 5 th ed. 2008 Maintenance Therapy of Neonatal Seizures Glucose: < 8 mg/kg/, IV Phenobarbital: 3-4 mg/kg/24 hr, IV, IM, or PO Phenytoin (as fosphenytoin): 3-4 mg/kg/24 hr, IV Calcium gluconate: 500 mg/kg/24 hr, PO Magnesium sulfate (50%): 0.2 mL/kg/24 hr, IM
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  • Clinical Scenario 1 F.M. a 36-37 month old baby boy is noted to have blinking of the eyelids with sucking movements of the mouth at 30 hours of life. The extremities are jittery when tactile stimuli is applied. Mat