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NEONATAL

SEIZURES

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INTRODUCTION
Paroxysmal alteration in neonatal behavior and (or)

motor,

autonomic

function

initiated

hypersynchronous activity of neurons in the brain.

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by

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

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CORRELATION OF TIME OF
ONSET OF SEIZURES AND
AETIOLOGY
Most Frequent Time Aetiology of Seizures
Hypoxic - ischaemic encephalopathy
< 48 Hrs.
Intra cranial haemorrhage
Hypoglycemia, Hypoelectrolytemia
Congenital Viral infections
Drug induced
Pyridoxine dependency
Non-ketotic Hyperglycemia
Urea cycle disorder

48-72 Hrs.

Cerebral dysgenesis, Early sepsis, Urea cycle


disorder

7 days

Organic acidemias, Amino acidopathies,


Bacterial meningitis, BFNC and BINS

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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
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ontogenesis.

CLINICAL FEATURES
SUBTLE SEIZURES
Eyes

: Sustained Opening, Ocular Movements,


Blinking,
Tonic Horizontal Deviation

Oral
Apnea

: Chewing, Drooling, Sucking, Laughing


: Full Term ? Premature

Motor

: Boxing, Hooking, Rotary Pedalling,


Stepping movements of the
Extremities

Autonomic
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: Elevated Blood Pressure & Heart Rate


In Premature Infants
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NORMAL NEONATAL MOTOR ACTIVITY


COMMONLY MISTAKEN FOR SEIZURES
AWAKE or DROWSY
Roving eye movements
Nystagmoid jerks
Unsustained, Sucking, Puckering
SLEEP
Fragmentary myoclonic jerks
Isolate, generalized myoclonic jerks on arousal

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CLINICAL CHARACTERISTICS WHICH


DISTINGUISH JITTERINESS FROM
SEIZURES
CLINICAL FEATURES
Stimulus Sensitive
Movements
Movements Cease with
Restraint
Associated Abnormal Eye
Movements
Quality of Movement
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JITTERINESS

SEIZURES

Tremor

Clonic
Jerking
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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 :

:
:

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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 /
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
IV Myoclonic seizures

Involve flexor muscles of an Upper extremity


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CLINICAL SEIZURES - Contd..


Multifocal
Generalized

:Asynchronous twitching of
several parts of body.
: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.
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:Presence suggests severe diffuse brain

INVESTIGATIONS
- Complete Hemogram

: Sugar, Calcium, Magnesium, Na+,


K+ & HCO3 Elevated
Ammonia,
Lactate Levels

- Blood

Culture & Sensitivity


- CSF

Analysis, Biochemical &

Plays an important role

C/s.
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- EEG

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MANAGEMENT OF NEONATAL SEIZURES


DURING ACUTE PHASE

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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
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EVENTS :
Associated with EEG Seizure

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
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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.
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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. Lorazepam


0.05 to 0.1 mg/kg/by I.V. is Administered.
(Contd..)
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MANAGEMENT Contd..
(or)
Inj. Clonzepam Loading dose of 0.25 mg/kg
followed by 0.01 to 0.03 mg/kg/orally given
(or)
Inj. Midazolam 0.02 to 0.1 mg/kg - I.V. can be
given
DIAZEPAM : Not safe in neonates as it interferes

with vital functions its sedative effect half life


exceeds 24 hours

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MANAGEMENT Contd..

I.V. DIAZEPAM

Ends you in trouble

answerable for three generations

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MANAGEMENT Contd..
OTHER MEDICATIONS
Calcium : 10% Cal. Gluconate 2 ml/kg mixed

with equal amount of 10% dextrose given by


slow I.V. over 3 mts.
Magnesium : Hypomagnesimia is treated with

50%
magnesium
sulphate
administered by IM route.
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0.2

ml/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

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PROGNOSIS OF NEONATAL SEIZURES


IN RELATION TO ETIOLOGY
Etiology
Hypoxic Ischemic
Encephalopathy
Hemorrhage
a) Intraventricular
b) Sub Arachnoid
Bacterial Meningitis
Development Defect
Hypocalcemia
Early Onset
Late Onset
Hypoglycemia
Unknown

Normal Development (%)


16-50
0-10
85-90
25-65
0-5
42-50
91-100
25-50
50-62
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EEG BACKGROUND SCORES


Normal

Mildly abnormal

Better

Moderately Abnormal

Low Voltage Undifferentiated


Suppression Burst Pattern
Electrocerebral Inactivity

Worse
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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
discontinue Phenobarbital

has

become

normal,

If neurologic examination is persistently abnormal, obtain EEG.


If no seizure activity on EEG, discontinue Phenobarbital
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EPILEPSY AFTER NEONATAL


SEIZURES
Overall, 15 30% develop seizures later in life

Again, depends on the cause of neonatal

seizures
Hypoxic ischemic brain injury
Cortical dysgenesis
Hypocalcemia, late

30%
100%
0%

Other factors include neurologic examination and

neonatal EEG

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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

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contribute to seizure Occurrence in later


years. Hence the main aim should be to
control the seizure with Anti-convulsants at
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any cost apart from treating the underlying

Thank you
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