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Neonatal Seizures. Seizures are a common manifestation of serious CNS disease in the newborn, and Indicate serious underlying disease (90%-95% of cases). . - PowerPoint PPT Presentation
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Neonatal Seizures
Seizures are a common manifestation of serious CNS disease in the newborn, and Indicate serious underlying disease (90%-95% of cases).
85% of neonatal seizure occurs in the first two weeks of life 65% occurs between 2-5 days after birth 25% in NICU in preterm neonates. And 0.8% In term infant.
Neonatal seizures may have a deleterious effect on the developing brain by depleting cerebral glucose levels, which , in turn, may interfere with deoxyribonucleic acid (DNA) synthesis and myelination.
Seizures also causes to deficiency in cell brain numbers and repeated seizures causes brain Injery.
ETLOGY OF NEONATAL SEIZURES
Gestational AgeTime of onset (days of age)
Etiology Premature Term 0-3 4-10
Hypoxic-ischemic encephalopathy intracranial hemorrhage
+ + +
Intraventricular hemorrhage
+ - +
Subarachnoid hemorrhage
- + +
Hypoglycemia + + +
Gestational AgeTime of onset (days of age)
Etiology Premature Term 0-3 4-10
Infection + + +Developmental Anomalies
+ + +
Hypocalcemia
Early onset + + +Late onset - + +
cont
Seizure type Major clinical Manifestations
Subtle
Repetitive blinking, eye deviation, staring Repetitive mouth or tongue movements apnea
Tonic (i.e. generalized or focal)
Bicycing movements’ tonic extension of limb or limbs’ tonic flexion of upper limbs’ extension of lower limbs
Clonic (i.e. multifocal or focal)
Multifocal, synchronous or asynchronous limb movements Repetitive , jerky limb movements nonordered progression Localized repetitive clonic limb movements with preservation of consciousness
Myoclonic (i.e. generalized, focal, multifocal )
Single or several flexion jerks of upper limbs(common) and lower limbs (rare)
cont.
JITTERINESS VERSUS SEIZURE
CLINCAL FEATURE JITTERINESS SEIZURE
Abnormality of gaze or eye movement
0 +
Movements exquisitely stimulus sensitive
+ 0
Predominant movement Tremor Clonic jerking
movemnts cease with passive flexion
+ 0
Autonomic changes 0 +
Movement Description
Benign neonatal sleep myoclonus
Bilateral or unilateral jerking during sleep Occurs during active sleep
Not stimulus sensitive
Often involve upper> lower trunk
CAUSES OF NEONATAL JITTERINESS
Metabolic Disorders HypoglycemiaHypocalcemiaHypomagnesemiaCNS Disorders HemorrhageHypoxia
(cont).Congenital abnormalityHyperviscosity (high hematocrit)syndorme
Drug WithdrawalHeroinMethadoneBarbituratesIdiopathicPrefeeding Others
Clinical features Neonatal seizures differ
considerably from seizures observed in older children , because the immature brain is less capable of propagating generalized electrical discharges, so primary generalized seizures are very rare in the newborn.
Diagnosis :1. Maternalal History :
A. History of drug abuse B. History of intrauterine infection C. History of Genetic or metabolic
conditionsD. Use of local anesthetic drugs during
labour.E. History of previous child with seizures
2. Nconatal Ph ex: - General ex- Neurological ex- Retinal ex- Skin ex
3- Laboratory testes: Evaluation of metabolic
diseases (Bs- ca p-Mg) evaluation of Infectious
diseases (BC-LP-Torch)Evaluation of Electrolit
disorders (Na- K)
4- Neuroimaging studies Scalp sonography (I.V. H. …) Ct scan or MRI (focal seizures) EEG Monitoring (for prognosis
& duration of therapy.
ACUTE THERAPY OF NEONATAL SEIZUES
HYPOGLYCEMIA Glucose 10% solution: 2 ml/kg. I.V.
NO HYPOGLYCEMIA
Phenobarbital: 20 Mg/kg (10-15 min) If necessary additional Phenobarbital: 5mg /kg(10-15 min) I.V. to a maximum of 20 mg/kg (consider omission of this additional Phenobarbital if infant is severely “asphyxiated”)
* Phenytoin: 20 mg/kg. I.V. (1 mg/kg/min)
lorazepam: 0.05 -0.10 mg/kg. I.V.
* Fosphenytoin: my be a preferred form of phenytion
Cont.
OTHER (AS INDICATED) Caicium gluconate, 5% solution: 4
ml/kg, I.V. Magnesium sulfate, 50%solution:
0.2ml/kg, I.M. Pyridoxine: 50-100 mg, I.V.
EXPECTED RESPONSE OF NEONATAL SEIZURES TO SEQUENCE OF
THERAPYANTICONVULSANT DRUG (CUMULATVE DOSE)
CESSATION OF SEIZURES (CUMULATIVE%)
Phenobarbital, 20mg/kg 40%Phenobarbital ,40mg/kg 70%Phenytion, 20mg/kg 85%Lorazepam, 0.05-0.10 mg/kg 95-100%
Maintenance Therapy of Neonatal Seizures
Glucose: as high as 8mg/kg/min,IV
Phenobarbital: 3-4 mg/kg/24hr , IV, IM, or PO
Pheyntoin: 3-4mg/kg/24hr IV
Calcum gluconate: 500mg/kg/24hr, Po
Magnesium sulfate (50%):0.2 ml/kg/24hr, IM
Determinants of duration of Anticonvulsant Drug therapy for
Neonatal seizuresNeonatal neurological examination Cause of the neonatal seizure Electroencephalogram
Duration of Anticonvulsant therapy-Guidelines Neonatal period If neonatal neurological examination becomes normal, discontinue therapy
If neonatal neurological examination is persistently abnormal,
consider etiology and obtain electroencephalogram (EEG) Continue Phenobarbital
Discontinue phenytoin Reevaluate in 1 month
ONE MONTH AFTER DISCHARGE
If neurologic examination has become normal, discontinue phenobarbital
If neurologic examination is persistently abnorrmal, obtain EEG If no seizure activity on EEG, discontinue Phenobarbital
Porognosis Dependent to three major
predictors: 1. the underlying aetiology2. EEG features 3. Gestational age
Other useful predictors: a- neurologic examination b- neuroimaging finding
Normal EEG neurological sequelae 10%
Moderate abnormal EEG Neurological sequelae = 50%
Severe abnormal EEG Neurological sequelae ≥ 90%
cont
contThe inedience of neurological
sequelae (mental retardation – motor deficits – epilepsy)=25%-35%)
M.R , Motor deficits (C.P) are more common than Epilepsy=15%-20%
cnotNeanatal seizures in infants
<32 weeks high mortality (80%)& higher risk of adverse neurological outcome
Overall , presentation of seizures at the first hours of life & prolonged seizures that do not respond to therapy have worse prognosis
Prognosis of Neonatal seizures by etiology
Normal outcome(%) Etiology
50 Hypoxia-ischemia
50 Meningitis
50 Hypoglycemia
90 Subarachnoid hemorrhage
50 Early hypocalcemia
100 Late hypocalcemia
10 Intraventricular hemorrhage
0 Dysgenesis
75 Unknown
Other anticonvulsant drugs for treatment of refractory neonatal
seizures:
1. Diazepam drip (continuous infusion) 0.1-0.3 mg/kg/hour
2. Midazolam drip (continuous infusion) 0.06-0.4mg/kg/hour
3. Carbamazepine10mg/kg.NG No adverse effects , but more data are needed
cont4. Valproic Acid Hepatotoxic 5. LidocainIv infusion 4-6mg/kg/hour
cardiac toxicity-BP6. Thiopental BP (more data are needed)7. Paraldehyde 0.3ml/kg/dose / PR BP
respiratory disturbance8. Primidone( more data are needed)9. Lamotrigine & topiramate (more data
are needed)