Neonatal Seizures

Amy Kao, M.D.

Division of Neurology
Doernbecher Childrens Hospital

Objectives
Review the clinical presentation and
differential diagnosis
Discuss pathophysiologic implications on
clinical presentation
Review etiology
Apply this information to evaluation and
treatment
Discuss prognosis

Clinical Classification
Focal/Multifocal Clonic
Not generalized
Migratory
Not necessarily focal etiology
Focal Tonic
Not usually generalized

Generalized Myoclonic

Clinical Classification
Subtle (Hypomotor)
Motor activity arrest
Apnea
Eye deviation
Autonomic changes
Motor automatisms
Oral-buccal-lingual movements
Swimming
Bicycling

The Definition of a Seizure

paroxysmal discharge of cerebral
neurons sufficient to cause clinically
detectable events that are apparent either
to the subject or to an observer

Definition of a Seizure in a Neonate?

Excitatory activity predominates
No paroxysmal discharge on EEG?
True seizure
The cortex is undeveloped
Deeper origin
Brainstem release phenomena

Definition of a Seizure in a Neonate

Clinically detectable events?
Subtle
Truly only electrographic
Iatrogenic paralysis
High doses AEDs
Encephalopathy or subcortical/spinal
cord damage

If It Isnt a Seizure, Then What Is It??

Possible clues
Stimulus-induced
Suppressable
No associated autonomic changes
(usually not bradycardia)

Weird Baby Movements

Jitteriness
Stimulus-sensitive
Tremor
Suppressable

Benign neonatal sleep myoclonus

Spinal myoclonus
Apnea of non-neurologic etiology
bradycardia

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

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

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

Other Syndromes
Benign idiopathic neonatal convulsions
(BINC or Fifth-day fits)
Benign familial neonatal convulsions
(BFNC)
Early myoclonic encephalopathy (EME)
Early infantile epileptic encephalopathy
(EIEE)
Glucose transporter type I

Evaluation of Neonatal Seizures

Serum lytes (gluc, Ca, Mg, Na)

CSF
Head ultrasound
EEG (B6?)

Tox screen
CT or MRI of brain
?metabolic w/u, congenital infection w/u

Treatment of Electroclinical Seizures

Phenobarbital 20 mg/kg
10 mg/kg boluses until 40-50 microgm/ml

Phenytoin 20 mg/kg
Lorazepam 0.1 mg/kg
Pyridoxine 50-100 mg IV with EEG

Outcome
45 % controlled after either phenobarb or
phosphenytoin
60 % controlled with both
30% of survivors develop epilepsy
WORSE: HIE, meningitis, dysplasia
WORSE: electrographic seizures
BETTER: hypoCa, BINC, BIFC, stroke