N EONATAL S EIZURE Dr.Mirzarahimi Neonatologist

Seizures are paroxysmal involuntary disturbance of brain function that maybe manifested as Impairment of Consciousness, abnormal motor activity, behavioral abnormality, sensory disturbance or autonomic dysfunction. Neonates are at particular risk for seizures because of: -Metabolic Disturbances. -Toxic. - Structural abnormality. - Infectious Diseases.

Neonatal seizures are dissimilar from those in children or adults because of: -Incomplete arborization of axons, and dedritic processes as well as mylenation are also incomplete. At least five seizure types are recognized in a new born infant: 1. Focal seizure which usually involves specific group of muscles secondary to: -Structural lesions. -Infection. -Subarachnoid hemorrhage.

2- Multifocal seizure (clonic): These seizures are characterized by random clonic movements of limbs similar to those seen in normal infants under 34 weeks of gestation. The EEG is most often unifocally abnormal, the prognosis is generally good. 3- Tonic seizures: Divided into general and focal usually associated with eye deviation or apnea and most often seen in prematures and carry a poor prognosis.

4- Myoclonic Seizure: the manifestations include synchronous single or multiple slow jerks of upper or lower limbs or both and are associated with diffuse CNS pathology, the prognosis is poor. 5- Subtle seizure: 50% of seizures in both term and prematures. usually presented as: Excessive salivation. Alteration of respiratory rate. blinking. nystagmus.

-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.

EEG C LASSIFICATIONS OF N EONATAL S EIZURES 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 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. 3- 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.

E TIOLOGY 1-Hypoxic Ischemic Encephalopathy: represent 60% - 65% of cases of neonatal seizures, occurs in babies with severe fetal distress who are apnic at birth. Seizures usually occur in the first day of life most often beginning in the first 12 hours. 2-Intracranial hemorrhage: Subarachnoid hemorrhage. Perivetricular hemorrhage. Subdural hemorrhage. Intraventricular hemorrhage.

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.

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

6- Drug associated seizures: -narcotic and sedative withdrawal. -local anesthesia. -theophyllin. 7- Polycythemia and hyperviscosity. 8- Familial neonatal seizures. 9- Focal infarction. 10- Hypertensive encephalopathy. 11- Idiopathic.

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.

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.

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

P ROGNOSIS 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.

Prognosis is affected by the following factors: 1. Gestational age. 2. Etiology. 3. Seizure pattern. 4. EEG. 5. Abgar score. 6. Duration of seizures. 7. Association of hypotonia. 8. The presence of tonic or myoclonic seizures. 9. Early onset of seizures. 10. The need +ve pressure ventilation.

G OOD PROGNOSTIC F ACTORS 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.

B AD PROGNOSTIC F ACTORS Prolonged and repetitive seizures (more than 30 minutes). Abnormal eye movements. Abnormal interictal EEG. Abgar score less than 7 at 5 minutes. Prematures. Early onset of convulsions.

EtiologyNormal outcome(%) Subarachnoid hemorrhage90 Uncertain75 Early Hypocalcemia50 Late hypocalcemia100 Hypoglycemia33-71 Neonatal Encephalopathy31-50 IVH10 Meningitis11-65 Dysgenesiszero Prognosis of Seizures by Etiology

Prognosis of seizures by seizure pattern: Normal outcome(%) by gestational age at birth Seizure patternFull term(%)Premature(%) Focal clonic10033 Multifocal33 Generalized5941 Tonic5036 Myoclonic00 Subtle5744