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Nangle AM, He Z, Bhalla S, Bullock J, Carlson A, Dutt M, Hamrick S, Jones P, Piazza A, Vale A, Sewell EK. Reducing the percentage of surviving infants with acute symptomatic seizures discharged on anti-seizure medication. J Perinatol 2024:10.1038/s41372-024-02044-9. [PMID: 39043995 DOI: 10.1038/s41372-024-02044-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/20/2024] [Accepted: 07/01/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To evaluate the impact of inclusion of an anti-seizure medication (ASM) weaning protocol in a neonatal seizure pathway on the percent of infants discharged on ASMs. STUDY DESIGN This cohort study included surviving infants with acute symptomatic seizures treated with ASMs across three institutions. We evaluated infants in 2 epochs, pre- and post-implementation of the ASM weaning protocol. The primary outcome was discharge on ASM. RESULTS Of 116 included infants, the percent of infants discharged on ASMs was 69% in epoch 1 versus 34% in epoch 2 (p < 0.001). There was no significant difference between epochs in recurrence of seizures after discharge by 1 year of age (p = 0.125). There was an annual decrease in the percent of infants discharged on ASM across all institutions. CONCLUSION Inclusion of a formal ASM weaning protocol as part of an institutional seizure pathway reduced percent of infants with acute symptomatic seizures discharged on ASM.
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Affiliation(s)
- Anne Marie Nangle
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Zhulin He
- Pediatric Biostatistics Core, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Sonam Bhalla
- Division of Pediatric Neurology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Alyssa Carlson
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
- Emory University School of Nursing, Atlanta, GA, USA
| | - Monideep Dutt
- Division of Pediatric Neurology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Shannon Hamrick
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Anthony Piazza
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Allison Vale
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Elizabeth K Sewell
- Division of Neonatology, Department of Pediatrics - Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
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Jagadish S, Czech TM, Zimmerman MB, Glykys J. Epilepsy Incidence and Developmental Outcomes After Early Discontinuation of Antiseizure Medication in Neonatal Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2024; 153:48-55. [PMID: 38320458 DOI: 10.1016/j.pediatrneurol.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Neonatal seizures caused by hypoxic-ischemic encephalopathy (HIE) have significant morbidity and mortality. There is variability in clinical practice regarding treatment duration with antiseizure medication (ASM) after resolution of provoked neonatal seizures. We examined epilepsy incidence and developmental outcomes in post-HIE neonates discharged or not on ASM. METHODS We conducted a retrospective chart review of all HIE-admitted neonates to the University of Iowa Hospitals & Clinics neonatal intensive care unit between January 2008 and February 2021 who presented with encephalopathy, underwent therapeutic hypothermia, and developed seizures. Neonates were divided into two groups depending on whether ASM was continued or discontinued on discharge. We evaluated the incidence of epilepsy and developmental outcomes on follow-up in these two cohorts up to 12 months. RESULTS Sixty-nine neonates met the study criteria. ASM was continued on discharge in 41 neonates (59%) and discontinued before discharge in 28 (41%). At the 12-month follow-up, nine neonates (13%) had a diagnosis of epilepsy, out of which seven neonates had ASM continued on discharge (odds ratio [OR]: 2.84; 95% confidence interval [CI]: 0.48, 29.9)]. There was no statistical difference between the development of postneonatal epilepsy between the two groups (P value 0.29). There was no significant difference in developmental outcome between the two groups after adjusting for covariates like magnetic resonance imaging (MRI) brain abnormality and number of seizure days (OR: 0.68; 95% CI: 0.21, 2.22; P = 0.52). CONCLUSION We found no significant risk of seizure recurrence by age 12 months in infants who had discontinued ASM before discharge compared with those who had continued ASM. There was no difference in developmental outcomes at the 12-month follow-up between groups after adjusting for brain MRI abnormality and the number of seizure days during admission. Our results support early discontinuation of ASM after resolution of acute provoked seizures in neonates with HIE.
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Affiliation(s)
- Spoorthi Jagadish
- Child Neurology Residency Program, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa
| | - Theresa Marie Czech
- Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Department of Neurology, The University of Iowa, Iowa City, Iowa
| | | | - Joseph Glykys
- Division of Child Neurology, Stead Family Department of Pediatrics, The University of Iowa, Iowa City, Iowa; Department of Neurology, The University of Iowa, Iowa City, Iowa; Iowa Neuroscience Institute, The University of Iowa, Iowa City, Iowa.
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Lugli L, Bariola MC, Guidotti I, Pugliese M, Roversi MF, Bedetti L, Della Casa Muttini E, Miselli F, Ori L, Lucaccioni L, Bertoncelli N, Rossi K, Crestani S, Bergonzini P, Iughetti L, Ferrari F, Berardi A. Neurodevelopmental outcome of neonatal seizures: A longitudinal study. Eur J Paediatr Neurol 2024; 49:17-26. [PMID: 38324990 DOI: 10.1016/j.ejpn.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Neonatal seizures (NS) are the most common neurological emergency in the neonatal period. The International League Against Epilepsy (ILAE) proposed a new classification of NS based on semiology and highlighted the correlation between semiology and aetiology. However, neurodevelopmental outcomes have not been comprehensively evaluated based on this new classification. AIMS To evaluate neurodevelopmental outcomes and potential risk factors for severe outcomes in NS. METHODS Patients with video electroencephalogram confirmed NS were evaluated. Seizure aetiology, cerebral magnetic resonance imaging (MRI) data, background electroencephalograms data, general movements, and neurodevelopmental outcomes were analysed. Severe outcomes were one of the following: death, cerebral palsy, Griffiths developmental quotient <70, epilepsy, deafness, or blindness. RESULTS A total of 74 neonates were evaluated: 62 (83.8 %) with acute provoked NS (primarily hypoxic-ischaemic encephalopathy), and 12 (16.2 %) with neonatal-onset epilepsies (self-limited neonatal epilepsy, developmental and epileptic encephalopathy, cerebral malformations). Of these, 32 (43.2 %) had electrographic seizures, while 42 (56.7 %) had electroclinical seizures - 38 (90.5 %) were motor (42.1 % clonic) and 4 (9.5 %) were non-motor phenomena. Severe outcomes occurred in 33 of the 74 (44.6 %) participants. In multivariate analysis, neonatal-onset epilepsies (odds ratio [OR]: 1.3; 95 % confidence interval [CI]: 1.1-1.6), status epilepticus (OR: 5.4; 95 % CI: 1.5-19.9), and abnormal general movements (OR: 3.4; 95 % CI: 1.9-7.6) were associated with severe outcomes. CONCLUSIONS At present, hypoxic-ischaemic encephalopathy remains the most frequent aetiology of NS. The prognosis of neonatal-onset epilepsies was worse than that of acute provoked NS, and status epilepticus was the most predictive factor for adverse outcomes.
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Affiliation(s)
- Licia Lugli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy.
| | | | - Isotta Guidotti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | | | - Luca Bedetti
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Francesca Miselli
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Italy
| | - Luca Ori
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Laura Lucaccioni
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | | | - Katia Rossi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Sara Crestani
- Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Patrizia Bergonzini
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Lorenzo Iughetti
- Pediatric Unit, Mother-Child Department, University Hospital of Modena, Italy; Postgraduate School of Pediatrics, Department of Medical and Surgical Sciences for Mother, Children and Adults, University of Modena and Reggio Emilia, Italy
| | - Fabrizio Ferrari
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
| | - Alberto Berardi
- Neonatology Unit, Mother-Child Department, University Hospital of Modena, Italy
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Schmidt R, Welzel B, Löscher W. Effects of season, daytime, sex, and stress on the incidence, latency, frequency, severity, and duration of neonatal seizures in a rat model of birth asphyxia. Epilepsy Behav 2023; 147:109415. [PMID: 37729684 DOI: 10.1016/j.yebeh.2023.109415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/14/2023] [Accepted: 08/19/2023] [Indexed: 09/22/2023]
Abstract
Neonatal seizures are common in newborn infants after birth asphyxia. They occur more frequently in male than female neonates, but it is not known whether sex also affects seizure severity or duration. Furthermore, although stress and diurnal, ultradian, circadian, or multidien cycles are known to affect epileptic seizures in adults, their potential impact on neonatal seizures is not understood. This prompted us to examine the effects of season, daytime, sex, and stress on neonatal seizures in a rat model of birth asphyxia. Seizures monitored in 176 rat pups exposed to asphyxia on 40 experimental days performed over 3 years were evaluated. All rat pups exhibited seizures when exposed to asphyxia at postnatal day 11 (P11), which in terms of cortical development corresponds to term human babies. A first examination of these data indicated a seasonal variation, with the highest seizure severity in the spring. Sex and daytime did not affect seizure characteristics. However, when rat pups were subdivided into animals that were exposed to acute (short-term) stress after asphyxia (restraint and i.p. injection of vehicle) and animals that were not exposed to this stress, the seizures in stress-exposed rats were more severe but less frequent. Acute stress induced an increase in hippocampal microglia density in sham-exposed rat pups, which may have an additive effect on microglia activation induced by asphyxia. When seasonal data were separately analyzed for stress-exposed vs. non-stress-exposed rat pups, no significant seasonal variation was observed. This study illustrates that without a detailed analysis of all factors, the data would have erroneously indicated significant seasonal variability in the severity of neonatal seizures. Instead, the study demonstrates that even mild, short-lasting postnatal stress has a profound effect on asphyxia-induced seizures, most likely by increasing the activity of the hypothalamic-pituitary-adrenal axis. It will be interesting to examine how postnatal stress affects the treatment and adverse outcomes of birth asphyxia and neonatal seizures in the rat model used here.
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Affiliation(s)
- Ricardo Schmidt
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Björn Welzel
- Center for Systems Neuroscience Hannover, Germany
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany; Translational Neuropharmacology Lab, NIFE, Department of Experimental Otology of the ENT Clinics, Hannover Medical School, Hannover, Germany.
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Sewell EK, Shankaran S, McDonald SA, Hamrick S, Wusthoff CJ, Adams-Chapman I, Chalak LF, Davis AS, Van Meurs K, Das A, Maitre N, Laptook A, Patel RM. Antiseizure medication at discharge in infants with hypoxic-ischaemic encephalopathy: an observational study. Arch Dis Child Fetal Neonatal Ed 2023; 108:421-428. [PMID: 36732048 PMCID: PMC10293046 DOI: 10.1136/archdischild-2022-324612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 01/06/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To assess variability in continuation of antiseizure medication (ASM) at discharge and to evaluate if continuation of ASM at discharge is associated with death or disability among infants with hypoxic-ischaemic encephalopathy (HIE) and seizures. DESIGN Retrospective study of infants enrolled in three National Institute of Child Health and Human Development Neonatal Research Network Trials of therapeutic hypothermia. SETTING 22 US centres. PATIENTS Infants with HIE who survived to discharge and had clinical or electrographic seizures treated with ASM. EXPOSURES ASM continued or discontinued at discharge. OUTCOMES Death or moderate-to-severe disability at 18-22 months, using trial definitions. Multivariable logistic regression evaluated the association between continuation of ASM at discharge and the primary outcome, adjusting for severity of HIE, hypothermia trial treatment arm, use of electroencephalogram, discharge on gavage feeds, Apgar Score at 5 min, birth year and centre. RESULTS Of 302 infants included, 61% were continued on ASMs at discharge (range 13%-100% among 22 centres). Electroencephalogram use occurred in 92% of the cohort. Infants with severe HIE comprised 24% and 22% of those discharged with and without ASM, respectively. The risk of death or moderate-to-severe disability was greater for infants continued on ASM at discharge, compared with those infants discharged without ASM (44% vs 28%, adjusted OR 2.14; 95% CI 1.13 to 4.05). CONCLUSIONS In infants with HIE and seizures, continuation of ASM at discharge varies substantially among centres and may be associated with a higher risk of death or disability at 18-22 months of age.
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Affiliation(s)
- Elizabeth K Sewell
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Seetha Shankaran
- Pediatrics Neonatology, Wayne State University Childrens Hospital of MI, Detroit, Michigan, USA
| | | | - Shannon Hamrick
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | | | - Ira Adams-Chapman
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Lina F Chalak
- Pediatrics, UT Southwestern Dallas, dallas, Texas, USA
| | - Alexis S Davis
- Pediatrics, Stanford University, Palo Alto, California, USA
| | - Krisa Van Meurs
- Division of Neonatology, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Abhik Das
- RTI International, Rockville, Maryland, USA
| | - Nathalie Maitre
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Abbott Laptook
- Pediatrics, Women and Infants Hospital of Rhode Island, Providence, Rhode Island, USA
| | - Ravi Mangal Patel
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Pediatrics, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
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Doandes FM, Manea AM, Lungu N, Brandibur T, Cioboata D, Costescu OC, Zaharie M, Boia M. The Role of Amplitude-Integrated Electroencephalography (aEEG) in Monitoring Infants with Neonatal Seizures and Predicting Their Neurodevelopmental Outcome. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050833. [PMID: 37238381 DOI: 10.3390/children10050833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023]
Abstract
Newborn monitoring in neonatal intensive care units (NICU) is mandatory, but neurological and especially electroencephalographic (EEG) monitoring can be overlooked or delayed until the newborn is clinically stable. However, the neonatal period is associated with the highest risk of seizures in humans, and the clinical symptoms may often be discrete, but the evolution and long-term neurodevelopmental disorders in these patients may be important. In response to this issue, we conducted a study to evaluate newborns who experienced neonatal seizures (NS) in the NICU and monitored their long-term neurological development. We enrolled 73 term and preterm newborns who underwent EEG monitoring using amplitude-integrated electroencephalography (aEEG). We then followed their neurological development until around 18 months of age, with 59 patients remaining in the long-term study. A total of 22% of patients with NS developed epilepsy, 12% cerebral palsy, 19% severe neurodevelopmental disabilities, and 8.5% died within the first 18 months of life. Our findings indicate that aEEG background pattern is a strong predictor of unfavorable neurological outcomes, with an odds ratio of 20.4174 (p < 0.05). Additionally, higher Apgar scores were associated with better outcomes (p < 0.05), with the odds of unfavorable neurological outcomes decreasing by 0.7-fold for every point increase in Apgar score. Furthermore, we found a statistically significant association between preterm birth and unfavorable neurological outcomes (p = 0.0104). Our study highlights the importance of early EEG monitoring in the NICU and provides valuable insights into predictors of unfavorable neurological outcomes in newborns who experienced NS.
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Affiliation(s)
- Florina Marinela Doandes
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Aniko Maria Manea
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Nicoleta Lungu
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Timea Brandibur
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Daniela Cioboata
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Oana Cristina Costescu
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Mihaela Zaharie
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Marioara Boia
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Welzel B, Schmidt R, Kirchhoff L, Gramer M, Löscher W. The loop diuretic torasemide but not azosemide potentiates the anti-seizure and disease-modifying effects of midazolam in a rat model of birth asphyxia. Epilepsy Behav 2023; 139:109057. [PMID: 36586153 DOI: 10.1016/j.yebeh.2022.109057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
Loop diuretics such as furosemide and bumetanide, which act by inhibiting the Na-K-2Cl cotransporter NKCC2 at the thick ascending limb of the loop of Henle, have been shown to exert anti-seizure effects. However, the exact mechanism of this effect is not known. For bumetanide, it has been suggested that inhibition of the NKCC isoform NKCC1 in the membrane of brain neurons may be involved; however, NKCC1 is expressed by virtually all cell types in the brain, which makes any specific targeting of neuronal NKCC1 by bumetanide impossible. In addition, bumetanide only poorly penetrates the brain. We have previously shown that loop diuretics azosemide and torasemide also potently inhibit NKCC1. In contrast to bumetanide and furosemide, azosemide and torasemide lack a carboxylic group, which should allow them to better penetrate through biomembranes by passive diffusion. Because of the urgent medical need to develop new treatments for neonatal seizures and their adverse outcome, we evaluated the effects of azosemide and torasemide, administered alone or in combination with phenobarbital or midazolam, in a rat model of birth asphyxia and neonatal seizures. Neither diuretic suppressed the seizures when administered alone but torasemide potentiated the anti-seizure effect of midazolam. Brain levels of torasemide were below those needed to inhibit NKCC1. In addition to suppressing seizures, the combination of torasemide and midazolam, but not midazolam alone, prevented the cognitive impairment of the post-asphyxial rats at 3 months after asphyxia. Furthermore, aberrant mossy fiber sprouting in the hippocampus was more effectively prevented by the combination. We assume that either an effect on NKCC1 at the blood-brain barrier and/or cells in the periphery or the NKCC2-mediated diuretic effect of torasemide are involved in the present findings. Our data suggest that torasemide may be a useful option for improving the treatment of neonatal seizures and their adverse outcome.
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Affiliation(s)
- Björn Welzel
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Ricardo Schmidt
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany
| | - Larsen Kirchhoff
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | - Martina Gramer
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany
| | - Wolfgang Löscher
- Dept. of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, Germany; Center for Systems Neuroscience Hannover, Germany.
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Kuhnke N, Wusthoff CJ, Swarnalingam E, Yanoussi M, Jacobs J. Epileptic high-frequency oscillations occur in neonates with a high risk for seizures. Front Neurol 2023; 13:1048629. [PMID: 36686542 PMCID: PMC9848430 DOI: 10.3389/fneur.2022.1048629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/30/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction Scalp high-frequency oscillations (HFOs, 80-250 Hz) are increasingly recognized as EEG markers of epileptic brain activity. It is, however, unclear what level of brain maturity is necessary to generate these oscillations. Many studies have reported the occurrence of scalp HFOs in children with a correlation between treatment success of epileptic seizures and the reduction of HFOs. More recent studies describe the reliable detection of HFOs on scalp EEG during the neonatal period. Methods In the present study, continuous EEGs of 38 neonates at risk for seizures were analyzed visually for the scalp HFOs using 30 min of quiet sleep EEG. EEGs of 14 patients were of acceptable quality to analyze HFOs. Results The average rate of HFOs was 0.34 ± 0.46/min. About 3.2% of HFOs occurred associated with epileptic spikes. HFOs were significantly more frequent in EEGs with abnormal vs. normal background activities (p = 0.005). Discussion Neonatal brains are capable of generating HFOs. HFO could be a viable biomarker for neonates at risk of developing seizures. Our preliminary data suggest that HFOs mainly occur in those neonates who have altered background activity. Larger data sets are needed to conclude whether HFO occurrence is linked to seizure generation and whether this might predict the development of epilepsy.
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Affiliation(s)
- Nicola Kuhnke
- Department of Pediatric Neurology and Muscular Disease, University Medical Center, Freiburg, Germany
| | | | - Eroshini Swarnalingam
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Mina Yanoussi
- Department of Pediatric Neurology and Muscular Disease, University Medical Center, Freiburg, Germany
| | - Julia Jacobs
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada,*Correspondence: Julia Jacobs ✉
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Pittet MP, Marini D, Ly L, Au-Young SH, Chau V, Seed M, Miller SP, Hahn CD. Prevalence, Risk Factors, and Impact of Preoperative Seizures in Neonates With Congenital Heart Disease. J Clin Neurophysiol 2022; 39:616-624. [PMID: 33560701 DOI: 10.1097/wnp.0000000000000825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of this study was to assess the prevalence, risk factors, and impact of electrographic seizures in neonates with complex congenital heart disease before cardiac surgery. METHODS A cohort of 31 neonates with congenital heart disease monitored preoperatively with continuous video-EEG (cEEG) was first reviewed for electrographic seizure burden and EEG background abnormalities. Second, cEEG findings were correlated with brain MRI and 18-month outcomes. RESULTS Continuous video-EEG was recorded preoperatively for a median duration of 20.5 hours (range, 2.5-93.5 hours). The five neonates (16%; 95% confidence interval, 5.5% to 34%) with seizures detected on cEEG in the preoperative period had a diagnosis of transposition of the great arteries or similar physiology, detected in four of five postnatally. None of the 157 recorded electrographic seizures had a clinical correlate. The median time to first seizure was 65 minutes (range, 6-300 minutes) after cEEG hookup. The median maximum hourly seizure burden was 12.4 minutes (range, 7-23 minutes). Before the first electrographic seizure, a prolonged interburst interval (>10 seconds) was not associated with seizures (coefficient 1.2; 95% confidence interval, -1.1 to 3.6). MRI brain lesions were three times more common in neonates with seizures. Sharp wave transients on cEEG were associated with delayed opercular development. CONCLUSIONS In this cohort, preoperative electrographic seizures were common, were all subclinical, and were associated with MRI brain injury and postnatal diagnosis of transposition of the great arteries. The findings motivate further study of the mechanisms of preoperative brain injury, particularly among neonates with a postnatal diagnosis of transposition of the great arteries.
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Affiliation(s)
- Marie P Pittet
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Division of Paediatric Neurology, Department of Paediatrics, Geneva University Hospital, Geneva, Switzerland
| | - Davide Marini
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; and
| | - Linh Ly
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Stephanie H Au-Young
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Vann Chau
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; and
| | - Steven P Miller
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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10
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Hashish M, Bassiouny MR. Neonatal seizures: stepping outside the comfort zone. Clin Exp Pediatr 2022; 65:521-528. [PMID: 35381172 PMCID: PMC9650361 DOI: 10.3345/cep.2022.00115] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/22/2022] [Indexed: 11/27/2022] Open
Abstract
Seizures are the most common neurological disorders in newborns. Managing neonatal seizures is challenging, especially for neurologists who are not neonatal specialists. Acute brain injury during ischemic insult is a key component of seizure occurrence, while genetic and metabolic disorders play less prevalent but more severe roles. The diagnosis of neonatal seizure is ambiguous, as the subjective differentiation between seizure and nonepileptic events is difficult; therefore, electrographic recording is the gold standard for diagnosis. The detection of electrographic seizures by neonatologists is currently facilitated by amplitude-integrated electroencephalography availability in many neonatal intensive care units. Although it is less sensitive than conventional electroencephalography, it is better to record all risky neonates to filter the abnormal events as early as possible to enable the initiation of dedicated therapy at proper dose and time and facilitate the initial response to antiepileptic drugs. This, in turn, helps maintain the balance between unnecessary drug use and their neurotoxic effects. Moreover, the early treatment of electrographic seizures plays a vital role in the suppression of subsequent abnormal brain electricity (status epilepticus) and shortening the hospital stay. An explicit understanding of seizure etiology and pathophysiology should direct attention to the proper prescription of short- and long-term antiepileptic medications to solve the challenging issue of whether neonatal seizures progress to postneonatal epilepsy and long-term cognitive deficits. This review addresses recent updates in different aspects of neonatal seizures, particularly electrographic discharge, including their definition, etiology, classification, diagnosis, management, and neurodevelopmental outcomes.
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Affiliation(s)
- Menna Hashish
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt
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11
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Jethwa S, Pressler RM, Kaya D, Datta AN. Sleep architecture in neonatal and infantile onset epilepsies in the first six months of life: A scoping review. Eur J Paediatr Neurol 2022; 41:99-108. [PMID: 36410286 DOI: 10.1016/j.ejpn.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/26/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
Abstract
AIM Epilepsy occurs in approximately 80 per 100,000 infants in the first year of life, ranging in severity from self-limited and likely to spontaneously resolve, to severe developmental and epileptic encephalopathies. Sleep plays a key role in early brain development and the reciprocal relationship between sleep and seizures is not yet fully understood, particularly in young children. We conducted a Scoping Review to synthesise current knowledge of sleep architecture in neonates and infants with epilepsy. METHOD Peer-reviewed publications from 2005 to 2022 describing sleep architecture in infants up to six months of age with unprovoked seizures were included. The analysis set was derived from EMBASE, Web of Science and PubMED using key terms "sleep, epilepsy and infant" and related descriptors. Inclusion criteria were prospectively described in a Scoping Review protocol. Sleep architecture was assessed as macro- and micro-structural elements. RESULTS 21 publications were included in the qualitative analysis. In self-limited familial and genetic epilepsy, sleep macrostructure was generally preserved. In DEEs and in epileptic encephalopathies of genetic or structural aetiology, sleep architecture was significantly disrupted. INTERPRETATION Early identification of infants with epilepsy is important to ensure early and effective treatment. In the DEE spectrum, sleep architecture is significantly impacted, and abnormal sleep architecture may be associated with compromised developmental outcome. Further research is needed to identify the sequence of events in abnormal brain development, epilepsy and sleep disruption and potentially help to predict the course of epilepsy towards a self-limited epilepsy versus a DEE.
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Affiliation(s)
- Sangeeta Jethwa
- Paediatric Neurology and Developmental Medicine, University Children's Hospital, UKBB, Basel, Switzerland.
| | - Ronit M Pressler
- Clinical Neuroscience, UCL; GOS Institute of Child Health and Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Didem Kaya
- Acibadem University School of Medicine, İstanbul, Turkey
| | - Alexandre N Datta
- Paediatric Neurology and Developmental Medicine, University Children's Hospital, UKBB, Basel, Switzerland
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12
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Westergren H, Marell Hesla H, Altman M, Wickström R. Validation of central nervous system-induced seizures and other neurological variables in the Swedish Neonatal Quality Register. Acta Paediatr 2022; 111:1331-1337. [PMID: 35298855 PMCID: PMC9314797 DOI: 10.1111/apa.16336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/06/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022]
Abstract
Aim We sought to validate neurological variables and relevant International Classification of Diseases, Tenth Revision (ICD‐10) codes in the Swedish Neonatal Quality (SNQ) Register. Methods Register data were collected for 351 neonates, born between January 2009 and December 2016, who were treated at a neonatal unit in the Stockholm region on 385 occasions. They were eligible if the check‐box for central nervous system (CNS)‐induced seizures was ticked. The Register data, including relevant ICD‐10 codes, were validated by checking the patients' electronic medical charts. Results Most of the neonates were born at term (76%) and weighed >2500 g (80%). The variable CNS‐induced seizures had a positive predictive value of 46%. The ICD‐10 diagnosis P90.9A had a positive predictive value of 90%. This comprises seizures validated with electroencephalography, amplitude‐integrated electroencephalography or continuous function monitoring. The majority of the associated neurological variables in the Register had positive predictive values above 85%. Conclusion When the check‐box was ticked for central nervous system‐induced seizures, most of the neurological variables in the Register had high validity. However, the CNS‐induced seizures variable per se had a lower positive predictive value. Future SNQ Register‐based studies of such neonatal seizures should also include ICD‐10 P90.9A.
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Affiliation(s)
- Hanna Westergren
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
| | - Helena Marell Hesla
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
| | - Maria Altman
- Paediatric Rheumatology Unit Department of Clinical Epidemiology Unit Department of Medicine Karolinska Institute Solna Sweden
| | - Ronny Wickström
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
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13
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Falsaperla R, Scalia B, Giaccone F, Suppiej A, Pulvirenti A, Mailo J, Ruggieri M. aEEG vs cEEG's sensivity for seizure detection in the setting of neonatal intensive care units: A systematic review and meta-analysis. Acta Paediatr 2022; 111:916-926. [PMID: 35006632 DOI: 10.1111/apa.16251] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/14/2021] [Accepted: 01/05/2022] [Indexed: 11/27/2022]
Abstract
AIM Amplitude-integrated electroencephalography (aEEG)'s accuracy compared to conventional electroencephalography (cEEG) has not been fully established. The aim of our study was to conduct a systematic review on the sensitivity of the aEEG for neonatal seizure detection. METHODS Studies from PubMed and Google Scholar databases comparing recordings of cEEG and aEEG in newborns were included according to the PRISMA method. A quality assessment using the QUADAS-2 tool was provided. A random-effect model was used to account for different sources of variations among studies. Publication biases were represented by a funnel plot, and funnel plot symmetry was assessed. RESULTS Fourteen studies were reported; sensitivity of each diagnostic tool used (single-channel aEEG, two-channel aEEG, two-channel aEEG plus raw trace EEG) was compared to that of the gold-standard cEEG and to those of the other methods used. Overall sensitivity of the aEEG ranged from 31.25% to 90%. CONCLUSION Our study provides evidence that sensitivity of aEEG varies significantly and that seizure detection rate is lower than that of cEEG. The two-channel aEEG with raw trace EEG shows a high sensitivity and might represent a valid alternative to the cEEG in the setting of neonatal intensive care units (NICUs).
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Affiliation(s)
- Raffaele Falsaperla
- Unit of Neonatology University Hospital "Policlinico – San Marco" Catania Italy
| | - Bruna Scalia
- Unit of Neonatology University Hospital "Policlinico – San Marco" Catania Italy
| | - Fabiola Giaccone
- Pediatrics Postgraduate Program Section of Pediatrics and Child Neuropsychiatry Department of Clinical and Experimental Medicine University of Catania Catania Italy
| | - Agnese Suppiej
- Department of Medical Sciences Pediatric Section University of Ferrara Ferrara Italy
| | - Alfredo Pulvirenti
- Bioinformatics Unit Department of Clinical and Experimental Medicine University of Catania Catania Italy
| | - Janette Mailo
- Division of Pediatric Neurology University of Alberta Edmonton Canada
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System Section of Pediatrics and Child Neuropsychiatry A.U.O. Policlinico‐Vittorio Emanuele Catania Catania Italy
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14
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Stephens CM, Pavel AM, Mathieson SR, McSweeney N, McNamara B, Moore M, Boylan GB. Case Report: Early Neonatal EEG in Two Infants with Pallister Killian Syndrome (PKS). HRB Open Res 2022; 5:14. [PMID: 36249954 PMCID: PMC9530620 DOI: 10.12688/hrbopenres.13493.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/28/2022] Open
Abstract
Pallister Killian Syndrome (PKS) is a rare genetic disorder caused by a mosaic tetrasomy of the short arm of chromosome 12. The syndrome is characterised by typical craniofacial dysmorphism, congenital anomalies and intellectual disability. Epilepsy is a known complication, with onset usually occurring in early childhood and characterised most commonly by spasms and myoclonic seizures. To the best of our knowledge, there have been no cases describing the early neonatal EEG in PKS and electrographic seizures, to date. Here, we report two cases of PKS presenting in the neonatal period with distinctive EEG features and seizures.
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Affiliation(s)
- Carol M Stephens
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Andreea M Pavel
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Sean R Mathieson
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Niamh McSweeney
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
- Department of Paediatric Neurology, Cork University Hospital, Cork, Ireland
| | - Brian McNamara
- Department of Neurophysiology, Cork University Hospital, Cork, Ireland
| | - Michael Moore
- Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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15
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Expert consensus on grading management of electroencephalogram monitoring in neonates. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2022; 24:115-123. [PMID: 35209975 PMCID: PMC8884055 DOI: 10.7499/j.issn.1008-8830.2112129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
Neonatal electroencephalogram (EEG) monitoring guidelines have been published by American Clinical Neurophysiology Society, and the expert consensus on neonatal amplitude-integrated EEG (aEEG) has also been published in China. It is difficult to strictly follow the guidelines or consensus for EEG monitoring in different levels of neonatal units due to a lack of EEG monitoring equipment and professional interpreters. The Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association, established an expert group composed of professionals in neonatology, pediatric neurology, and brain electrophysiology to review published guidelines and consensuses and the articles in related fields and propose grading management recommendations for EEG monitoring in different levels of neonatal units. Based on the characteristics of video EEG and aEEG, local medical resources, and disease features, the expert group recommends that video EEG and aEEG can complement each other and can be used in different levels of neonatal units. The consensus also gives recommendations for promoting collaboration between professionals in neonatology, pediatric neurology, and brain electrophysiology and implementing remote EEG monitoring.
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16
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Russell NK, Hariharan G. EBNEO Commentary: Safety of early discontinuation of anti-seizure medication in neonates. Acta Paediatr 2022; 111:449-450. [PMID: 34907580 DOI: 10.1111/apa.16200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/27/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | - Gopakumar Hariharan
- Mackay Base Hospital Queensland Health Mackay Qld Australia
- James Cook University North Queensland Qld Australia
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17
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Gailus B, Naundorf H, Welzel L, Johne M, Römermann K, Kaila K, Löscher W. Long-term outcome in a noninvasive rat model of birth asphyxia with neonatal seizures: Cognitive impairment, anxiety, epilepsy, and structural brain alterations. Epilepsia 2021; 62:2826-2844. [PMID: 34458992 DOI: 10.1111/epi.17050] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/30/2021] [Accepted: 08/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Birth asphyxia is a major cause of hypoxic-ischemic encephalopathy (HIE) in neonates and often associated with mortality, neonatal seizures, brain damage, and later life motor, cognitive, and behavioral impairments and epilepsy. Preclinical studies on rodent models are needed to develop more effective therapies for preventing HIE and its consequences. Thus far, the most popular rodent models have used either exposure of intact animals to hypoxia-only, or a combination of hypoxia and carotid occlusion, for the induction of neonatal seizures and adverse outcomes. However, such models lack systemic hypercapnia, which is a fundamental constituent of birth asphyxia with major effects on neuronal excitability. Here, we use a recently developed noninvasive rat model of birth asphyxia with subsequent neonatal seizures to study later life adverse outcome. METHODS Intermittent asphyxia was induced for 30 min by exposing male and female postnatal day 11 rat pups to three 7 + 3-min cycles of 9% and 5% O2 at constant 20% CO2 . All pups exhibited convulsive seizures after asphyxia. A set of behavioral tests were performed systematically over 14 months following asphyxia, that is, a large part of the rat's life span. Video-electroencephalographic (EEG) monitoring was used to determine whether asphyxia led to the development of epilepsy. Finally, structural brain alterations were examined. RESULTS The animals showed impaired spatial learning and memory and increased anxiety when tested at an age of 3-14 months. Video-EEG at ~10 months showed an abundance of spontaneous seizures, which was paralleled by neurodegeneration in the hippocampus and thalamus, and by aberrant mossy fiber sprouting. SIGNIFICANCE The present model of birth asphyxia recapitulates several of the later life consequences associated with human HIE. This model thus allows evaluation of the efficacy of novel therapies designed to prevent HIE and seizures following asphyxia, and of how such therapies might alleviate long-term adverse consequences.
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Affiliation(s)
- Björn Gailus
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Hannah Naundorf
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Lisa Welzel
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Marie Johne
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
| | - Kerstin Römermann
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany
| | - Kai Kaila
- Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, Hannover, Germany.,Center for Systems Neuroscience, Hannover, Germany
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18
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Glass HC, Soul JS, Chang T, Wusthoff CJ, Chu CJ, Massey SL, Abend NS, Lemmon M, Thomas C, Numis AL, Guillet R, Sturza J, McNamara NA, Rogers EE, Franck LS, McCulloch CE, Shellhaas RA. Safety of Early Discontinuation of Antiseizure Medication After Acute Symptomatic Neonatal Seizures. JAMA Neurol 2021; 78:817-825. [PMID: 34028496 PMCID: PMC8145161 DOI: 10.1001/jamaneurol.2021.1437] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is discontinuation of antiseizure medication (ASM) after resolution of acute symptomatic neonatal seizures and prior to discharge from the hospital associated with functional neurodevelopment or epilepsy at 24 months? Findings In this comparative effectiveness study of 303 children with neonatal seizures from 9 centers, 64% had ASM maintained at hospital discharge. No difference was found between ASM maintenance and discontinuation groups in functional neurodevelopment or epilepsy; 13% of children developed epilepsy, including more than one-third with infantile spasms. Meaning These results support discontinuing ASMs for most neonates with acute symptomatic seizures prior to discharge from the hospital, an approach that may represent an evidence-based change in practice for many clinicians. Importance Antiseizure medication (ASM) treatment duration for acute symptomatic neonatal seizures is variable. A randomized clinical trial of phenobarbital compared with placebo after resolution of acute symptomatic seizures closed early owing to low enrollment. Objective To assess whether ASM discontinuation after resolution of acute symptomatic neonatal seizures and before hospital discharge is associated with functional neurodevelopment or risk of epilepsy at age 24 months. Design, Setting, and Participants This comparative effectiveness study included 303 neonates with acute symptomatic seizures (282 with follow-up data and 270 with the primary outcome measure) from 9 US Neonatal Seizure Registry centers, born from July 2015 to March 2018. The centers all had level IV neonatal intensive care units and comprehensive pediatric epilepsy programs. Data were analyzed from June 2020 to February 2021. Exposures The primary exposure was duration of ASM treatment dichotomized as ASM discontinued vs ASM maintained at the time of discharge from the neonatal seizure admission. To enhance causal association, each outcome risk was adjusted for propensity to receive ASM at discharge. Propensity for ASM maintenance was defined by a logistic regression model including seizure cause, gestational age, therapeutic hypothermia, worst electroencephalogram background, days of electroencephalogram seizures, and discharge examination (all P ≤ .10 in a joint model except cause, which was included for face validity). Main Outcomes and Measures Functional neurodevelopment was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS) at 24 months powered for propensity-adjusted noninferiority of early ASM discontinuation. Postneonatal epilepsy, a prespecified secondary outcome, was defined per International League Against Epilepsy criteria, determined by parent interview, and corroborated by medical records. Results Most neonates (194 of 303 [64%]) had ASM maintained at the time of hospital discharge. Among 270 children evaluated at 24 months (mean [SD], 23.8 [0.7] months; 147 [54%] were male), the WIDEA-FS score was similar for the infants whose ASMs were discontinued (101 of 270 [37%]) compared with the infants with ASMs maintained (169 of 270 [63%]) at discharge (median score, 165 [interquartile range, 150-175] vs 161 [interquartile range, 129-174]; P = .09). The propensity-adjusted average difference was 4 points (90% CI, −3 to 11 points), which met the a priori noninferiority limit of −12 points. The epilepsy risk was similar (11% vs 14%; P = .49), with a propensity-adjusted odds ratio of 1.5 (95% CI, 0.7-3.4; P = .32). Conclusions and Relevance In this comparative effectiveness study, no difference was found in functional neurodevelopment or epilepsy at age 24 months among children whose ASM was discontinued vs maintained at hospital discharge after resolution of acute symptomatic neonatal seizures. These results support discontinuation of ASM prior to hospital discharge for most infants with acute symptomatic neonatal seizures.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Epidemiology & Biostatistics; University of California, San Francisco
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Courtney J Wusthoff
- Department of Neurology, Stanford University, Palo Alto, California.,Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shavonne L Massey
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Monica Lemmon
- Departments of Pediatrics, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Linda S Franck
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Family Health Care Nursing, University of California, San Francisco
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics; University of California, San Francisco
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19
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Garg A, Suthar R, Sundaram V, Kumar P, Angurana SK. Clinical profile, aetiology, short-term outcome and predictors of poor outcome of neonatal seizures among out-born neonates admitted to a neonatal unit in Paediatric emergency of a tertiary care hospital in North India: A prospective observational study. Trop Doct 2021; 51:365-371. [PMID: 34018889 DOI: 10.1177/00494755211016226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neonatal seizures are common manifestations of several neurological or systemic disorders and associated with high morbidity, mortality and poor short- and long-term developmental outcomes. It is important to determine the aetiology and factors that determine the poor outcome, more so in a newly developed setting. The early detection of predictors of poor outcome will help in planning acute management, counselling, follow-up and rehabilitation services. In this prospective observational study, we looked at the clinical profile, aetiology, short-term outcomes and predictors of poor outcome of neonatal seizures among out-born neonates. The common causes were hypoxic ischaemic encephalopathy, sepsis and metabolic disturbances. One-third of neonates had poor outcome. Abnormal neurological and cardiorespiratory examination at admission; low oxygen saturation, glucose and pH; and hypoxic ischemic encephalopathy-III were predictors of poor outcome.
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Affiliation(s)
- Ashish Garg
- Junior Resident, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Renu Suthar
- Associate Professor, Pediatric Neurology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Additional Professor, Neonatology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Praveen Kumar
- Professor and Unit Head, Neonatology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Suresh K Angurana
- Assistant Professor, Division of Paediatric Critical Care, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
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20
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Falsaperla R, Scalia B, Giugno A, Pavone P, Motta M, Caccamo M, Ruggieri M. Treating the symptom or treating the disease in neonatal seizures: a systematic review of the literature. Ital J Pediatr 2021; 47:85. [PMID: 33827647 PMCID: PMC8028713 DOI: 10.1186/s13052-021-01027-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/15/2021] [Indexed: 01/08/2023] Open
Abstract
Aim The existing treatment options for neonatal seizures have expanded over the last few decades, but no consensus has been reached regarding the optimal therapeutic protocols. We systematically reviewed the available literature examining neonatal seizure treatments to clarify which drugs are the most effective for the treatment of specific neurologic disorders in newborns. Method We reviewed all available, published, literature, identified using PubMed (published between August 1949 and November 2020), that focused on the pharmacological treatment of electroencephalogram (EEG)-confirmed neonatal seizures. Results Our search identified 427 articles, of which 67 were included in this review. Current knowledge allowed us to highlight the good clinical and electrographic responses of genetic early-onset epilepsies to sodium channel blockers and the overall good response to levetiracetam, whose administration has also been demonstrated to be safe in both full-term and preterm newborns. Interpretation Our work contributes by confirming the limited availability of evidence that can be used to guide the use of anticonvulsants to treat newborns in clinical practice and examining the efficacy and potentially harmful side effects of currently available drugs when used to treat the developing newborn brain; therefore, our work might also serve as a clinical reference for future studies.
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Affiliation(s)
- Raffaele Falsaperla
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Bruna Scalia
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy.
| | - Andrea Giugno
- Post graduate programme in Pediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Piero Pavone
- Unit of Clinical Pediatrics, A.O.U. "Policlinico", P.O. "G. Rodolico", University of Catania, Catania, Italy
| | - Milena Motta
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Martina Caccamo
- Neonatal Intensive Care Unit, A.O.U. San Marco-Policlinico, University of Catania, Via Carlo Azeglio Ciampi, 95121, Catania, Italy
| | - Martino Ruggieri
- Department of Clinical and Experimental Medicine Section of Pediatrics and Child Neuropsychiatry, A.O.U. San Marco- Policlinico, University of Catania, Catania, Italy
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21
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Hirfanoglu T, Ozturk Z, Gokdogan GS, Hirfanoglu IM, Onal EE, Turkyilmaz C, Ergenekon E, Koc E. Neonatal Seizures and Future Epilepsy: Predictive Value of Perinatal Risk Factors, Electroencephalography, and Imaging. J Pediatr Neurosci 2021; 15:190-198. [PMID: 33531931 PMCID: PMC7847114 DOI: 10.4103/jpn.jpn_159_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/18/2019] [Accepted: 05/25/2020] [Indexed: 11/04/2022] Open
Abstract
Context There are limited data in the literature about the relationship between neonatal seizures and subsequent epilepsy. Aims This study aimed to identify the predictive value of perinatal factors, etiologies, electroencephalography (EEG), and cranial ultrasonography (USG) for future epilepsy after neonatal seizures. Materials and Methods A total of 92 children with epilepsy who had seizures during their neonatal period were retrospectively evaluated whether the contribution of perinatal, natal, and postnatal risk factors confining clinical, laboratory, EEG, and imaging to subsequent epilepsy. Chi-square, uni, and multivariate logistic regression were applied to find out predictive factors for subsequent epilepsy. Results The rate of epilepsy was 57.6 % during 1-6 years follow-up. Birth weight, Apgar scores at first and fifth minutes, resuscitation history, abnormal neurological examination, etiology, response to the treatment, abnormal EEG, or USG findings were the most important risk factors for future epilepsy in univariate analysis (P < 0.05). Furthermore, asphyxia, fifth minute Apgar scores, response to the treatment, USG, and EEG were independent predictors (P < 0.05) for subsequent epilepsy in multivariate logistic regression. No relationship was found between subsequent epilepsy and mode of delivery, seizure onset time, and seizure types (P > 0.05). Conclusion Although there are recent promising and advanced techniques in neonatal intensive care units, asphyxia is still one of the most important risk factors for not only poor neurological conditions but also for future epilepsy after neonatal seizures. Apgar scores, treatment with multiple antiepileptic drugs, poor background EEG activity, and abnormal neuroimaging seem to have strong predictive values for developing subsequent epilepsy. Therefore, patients with a history of neonatal seizures should be closely followed up to decrease the risk of long-term outcomes and early detection of epilepsy.
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Affiliation(s)
- Tugba Hirfanoglu
- Department of Pediatric Neurology, Gazi University School of Medicine, Ankara, Turkey
| | - Zeynep Ozturk
- Department of Pediatric Neurology, Gazi University School of Medicine, Ankara, Turkey
| | | | | | - Eray Esra Onal
- Department of Pediatrics & Neonatology, Gazi University School of Medicine, Ankara, Turkey
| | - Canan Turkyilmaz
- Department of Pediatrics & Neonatology, Gazi University School of Medicine, Ankara, Turkey
| | - Ebru Ergenekon
- Department of Pediatrics & Neonatology, Gazi University School of Medicine, Ankara, Turkey
| | - Esin Koc
- Department of Pediatrics & Neonatology, Gazi University School of Medicine, Ankara, Turkey
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Consensus protocol for EEG and amplitude-integrated EEG assessment and monitoring in neonates. Clin Neurophysiol 2021; 132:886-903. [PMID: 33684728 DOI: 10.1016/j.clinph.2021.01.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/19/2020] [Accepted: 01/06/2021] [Indexed: 12/23/2022]
Abstract
The aim of this work is to establish inclusive guidelines on electroencephalography (EEG) applicable to all neonatal intensive care units (NICUs). Guidelines on ideal EEG monitoring for neonates are available, but there are significant barriers to their implementation in many centres around the world. These include barriers due to limited resources regarding the availability of equipment and technical and interpretive round-the-clock personnel. On the other hand, despite its limitations, amplitude-integrated EEG (aEEG) (previously called Cerebral Function Monitor [CFM]) is a common alternative used in NICUs. The Italian Neonatal Seizure Collaborative Network (INNESCO), working with all national scientific societies interested in the field of neonatal clinical neurophysiology, performed a systematic literature review and promoted interdisciplinary discussions among experts (neonatologists, paediatric neurologists, neurophysiologists, technicians) between 2017 and 2020 with the aim of elaborating shared recommendations. A consensus statement on videoEEG (vEEG) and aEEG for the principal neonatal indications was established. The authors propose a flexible frame of recommendations based on the complementary use of vEEG and aEEG applicable to the various neonatal units with different levels of complexity according to local resources and specific patient features. Suggestions for promoting cooperation between neonatologists, paediatric neurologists, and neurophysiologists, organisational restructuring, and teleneurophysiology implementation are provided.
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Yang S, Wang B, Han X. Models for predicting treatment efficacy of antiepileptic drugs and prognosis of treatment withdrawal in epilepsy patients. ACTA EPILEPTOLOGICA 2021. [DOI: 10.1186/s42494-020-00035-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AbstractAlthough antiepileptic drugs (AEDs) are the most effective treatment for epilepsy, 30–40% of patients with epilepsy would develop drug-refractory epilepsy. An accurate, preliminary prediction of the efficacy of AEDs has great clinical significance for patient treatment and prognosis. Some studies have developed statistical models and machine-learning algorithms (MLAs) to predict the efficacy of AEDs treatment and the progression of disease after treatment withdrawal, in order to provide assistance for making clinical decisions in the aim of precise, personalized treatment. The field of prediction models with statistical models and MLAs is attracting growing interest and is developing rapidly. What’s more, more and more studies focus on the external validation of the existing model. In this review, we will give a brief overview of recent developments in this discipline.
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Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
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25
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Mishra P, Jaseja H, Goyal M. A critical analysis of the purported role of hypoxaemia in the comorbidity of obstructive sleep apnoea and epilepsy. Clin Physiol Funct Imaging 2021; 41:4-9. [PMID: 33068455 DOI: 10.1111/cpf.12672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/30/2020] [Accepted: 10/13/2020] [Indexed: 02/05/2023]
Abstract
Obstructive sleep apnoea (OSA) is a globally prevalent sleep disorder of significant health concern and confounded with several comorbidities resulting in adverse effect(s) on quality of life in patients afflicted with it. Of particular interest is the enigmatic high comorbidity of OSA with epilepsy, the exact underlying pathophysiology of which remains elusive despite a multitude of research performed in the last four decades. Hypoxaemia, which is an important characteristic feature found in OSA during apnoeic spells, has been implicated in the high comorbidity of OSA with epilepsy, the basis of which rests upon hypoxaemia-mediated brain damage, subcortical release phenomenon, oxidative stress and neuroinflammatory reactions. However, several studies present contradictory evidences that potentially refute the hypoxaemia-based mechanism. Additionally, the role of hypercapnia thatgenerally accompanies hypoxaemia during apnoeic spells, cannot be overlooked and is known to be potentially protective against neuronal hyperexcitability. Thus, hypoxaemia theory implicated in the high comorbidity of OSA and epilepsy appears weak and refutable. This brief paper studies and critically analyses the role of hypoxaemia in conjunction with hypercapnia in the underlying pathophysiology of the comorbidity.
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Affiliation(s)
- Priyadarshini Mishra
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, India
| | | | - Manish Goyal
- Department of Physiology, All India Institute of Medical Sciences, Bhubaneswar, India
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Pisani F, Fusco C, Nagarajan L, Spagnoli C. Acute symptomatic neonatal seizures, brain injury, and long-term outcome: The role of neuroprotective strategies. Expert Rev Neurother 2020; 21:189-203. [PMID: 33176104 DOI: 10.1080/14737175.2021.1848547] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Neonatal seizures are frequent but underdiagnosed manifestations of acute brain dysfunction and an important contributor to unfavorable outcomes. Etiology and severity of brain injury are the single strongest outcome determinants. AREAS COVERED The authors will discuss the prognostic role of acute symptomatic seizures versus brain injury and the main neuroprotective and neurorestorative strategies for full-term and preterm infants. EXPERT OPINION Prolonged acute symptomatic seizures likely contribute to long-term outcomes by independently adding further brain injury to initial insults. Correct timing and dosing of therapeutic interventions, depending on etiology and gestational ages, need careful evaluation. Although promising strategies are under study, the only standard of care is whole-body therapeutic hypothermia in full-term newborns with hypoxic-ischemic encephalopathy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine and Surgery Department, University of Parma , Parma, Italy
| | - Carlo Fusco
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, University of Western Australia , Perth, Australia
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Paediatrics, Azienda USL-IRCCS Di Reggio Emilia , Reggio Emilia, Italy
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Sharma D, Hussain AM, Sharma SS. Efficacy of Levetiracetam in neonatal seizures: a systematic review. J Matern Fetal Neonatal Med 2020; 35:3923-3930. [PMID: 33172319 DOI: 10.1080/14767058.2020.1844651] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Neonatal seizures represent the most frequent presenting sign of any neurological abnormality secondary to various etiologies in the neonatal period. Phenobarbitone (PB) has been used as first-line anti-epileptic drug in the treatment of seizures but concerns have been raised regarding its neuro-apoptotic effects over the developing brain. Levetiracetam (LEV) is a newer anti-epileptic drug with neuroprotective property and has been used in adults and pediatric patient but its use in neonates have very limited experience. Recently many neonatal studies have sought the role of LEV in the management of neonatal seizures. AIMS AND OBJECTIVE To evaluate the efficacy of Levetiracetam in the management of neonatal seizures. SEARCH METHODS The literature search was done for this systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), and other various electronic databases including PubMed and various sites for ongoing trials and abstracts of conferences. RESULTS Two eligible studies were analyzed that fulfilled the inclusion criteria of the systematic review. Fifteen studies were excluded due to the non-fulfillment of inclusion criteria. The primary outcome of both studies was to see the efficiency of LEV in controlling neonatal seizures when compared to PB. Better seizure control after a single loading dose of LEV was seen. Rates of seizure cessation at 24 h was also better in the LEV arm. Neonatal seizures secondary to hypoxic-ischemic encephalopathy (HIE) and receiving therapeutic hypothermia were better controlled with LEV. The side effect of LEV was significantly less when compared to PB. CONCLUSION Levetiracetam has shown to have promising anti-epileptic properties for the management of neonatal seizure with better efficacy and less or no side effects. There is a need to conduct more randomized controlled trials seeking the role of LEV in the acute management of neonatal seizures and also for assessing its neuroprotective role and neurodevelopmental outcome in these neonates.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical and Sciences Medical College, Jaipur, India
| | - Ansar Murtuza Hussain
- Department of Pediatrics, Vijay Marie Hospital and Education society, Khairtabad, Hyderabad, India
| | - Sweta Shastri Sharma
- Department of Pathology, National Institute of Medical and Sciences Medical College, Jaipur, India
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Menéndez Méndez A, Smith J, Engel T. Neonatal Seizures and Purinergic Signalling. Int J Mol Sci 2020; 21:ijms21217832. [PMID: 33105750 PMCID: PMC7660091 DOI: 10.3390/ijms21217832] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/18/2020] [Accepted: 10/20/2020] [Indexed: 02/07/2023] Open
Abstract
Neonatal seizures are one of the most common comorbidities of neonatal encephalopathy, with seizures aggravating acute injury and clinical outcomes. Current treatment can control early life seizures; however, a high level of pharmacoresistance remains among infants, with increasing evidence suggesting current anti-seizure medication potentiating brain damage. This emphasises the need to develop safer therapeutic strategies with a different mechanism of action. The purinergic system, characterised by the use of adenosine triphosphate and its metabolites as signalling molecules, consists of the membrane-bound P1 and P2 purinoreceptors and proteins to modulate extracellular purine nucleotides and nucleoside levels. Targeting this system is proving successful at treating many disorders and diseases of the central nervous system, including epilepsy. Mounting evidence demonstrates that drugs targeting the purinergic system provide both convulsive and anticonvulsive effects. With components of the purinergic signalling system being widely expressed during brain development, emerging evidence suggests that purinergic signalling contributes to neonatal seizures. In this review, we first provide an overview on neonatal seizure pathology and purinergic signalling during brain development. We then describe in detail recent evidence demonstrating a role for purinergic signalling during neonatal seizures and discuss possible purine-based avenues for seizure suppression in neonates.
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Affiliation(s)
- Aida Menéndez Méndez
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
| | - Jonathon Smith
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
- FutureNeuro, Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland
| | - Tobias Engel
- Department of Physiology and Medical Physics, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland; (A.M.M.); (J.S.)
- FutureNeuro, Science Foundation Ireland Research Centre for Chronic and Rare Neurological Diseases, RCSI University of Medicine and Health Sciences, Dublin D02 YN77, Ireland
- Correspondence: ; Tel.: +35-314-025-199
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Santarone ME, Pietrafusa N, Fusco L. Neonatal seizures: When semiology points to etiology. Seizure 2020; 80:161-165. [DOI: 10.1016/j.seizure.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/20/2022] Open
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Pisani F, Facini C, Bianchi E, Giussani G, Piccolo B, Beghi E. Risk factors for neonatal seizures: A case-control study in the province of Parma, Italy. Epilepsy Behav 2020; 107:107075. [PMID: 32304988 DOI: 10.1016/j.yebeh.2020.107075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/25/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE The present study evaluated the risk factors for electroencephalographic (EEG)-confirmed seizures during the whole neonatal period in preterm and term neonates born in the province of Parma between January 2009 and December 2014. METHODS We selected as cases the infants that presented EEG-confirmed neonatal seizures (NS). Two population controls for each case were matched by gestational age (GA), sex, hospital, and period of birth. Information on the mother, the pregnancy, the labor and delivery, and the neonates were taken from the Emilia-Romagna Certificate of Delivery Assistance database and from hospital charts and ICD-9-CM codes. RESULTS AND INTERPRETATION In the 6-year period of this study, 22 patients were recorded with NS. The association between at least one pregnancy complication and at least one neonatal complication, a low Apgar score, the need for resuscitation at birth, intraventricular hemorrhages (IVH) grades II-IV for preterm, and acute perinatal asphyxia/hypoxic-ischemic encephalopathy (HIE) for term infants were all statistically significant among cases. Neonates presenting these risk factors are more prone to develop NS and have to be strictly monitored.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Italy
| | - Carlotta Facini
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Italy
| | - Elisa Bianchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Giorgia Giussani
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Benedetta Piccolo
- Child Neuropsychiatric Unit, Mother and Child Department, University-Hospital of Parma, Parma, Italy
| | - Ettore Beghi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy.
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Pembegul Yıldız E, Tatlı B, Ulak Ozkan M, Erarslan E, Aydınlı N, Çalışkan M, Özmen M. Evaluation of the prognostic factors in school age children who experienced neonatal seizures. Epilepsy Behav 2020; 102:106673. [PMID: 31770716 DOI: 10.1016/j.yebeh.2019.106673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/17/2019] [Accepted: 10/17/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND This prospective study aimed to evaluate long-term neurodevelopmental outcomes and risk factors of the previously reported cohort, at their school age. METHOD We included neonates whose seizures were directly observed by the child neurologist or neonatologist based on clinical observations. They were assessed for cognitive and neurological outcomes at the age of 9-11 years. The test battery included a neurological examination, the Wechsler Intelligence Scale for Children-Revised (WISC-R) test, and patients with the diagnosis of cerebral palsy (CP) were graded according to the Gross Motor Function Classification System (GMFCS). The primary outcome of this study was to determine risk factors for the long-term prognosis of neonatal seizures. RESULTS For the long-term follow-up, 97 out of 112 patients of the initial cohort were available (86.6%). We found that 40 patients (41%) have the normal prognosis, 22 patients (22.7%) have the diagnosis of CP, and 30 patients (30.9%) were diagnosed as having epilepsy. Twelve out of 22 patients with CP had the diagnosis of epilepsy. The WISC-R full-scale IQ scores were <55 points in 27 patients (27.8%) and were >85 points in 40 patients (41.2%). According to GMFCS, 10 patients were classified as levels 1-2, and 12 patients were classified as levels 3-5. In multivariate regression analyses, 5-min APGAR score <6 was found to be an independent risk factor for CP, and 5-min APGAR score <6 and neonatal status epilepticus were independent risk factors for epilepsy. CONCLUSIONS This prospective cohort study reveals that abnormal school age outcome after neonatal seizures are significantly related to 5-min APGAR score <6 and neonatal status epilepticus.
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Affiliation(s)
| | - Burak Tatlı
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
| | - Melis Ulak Ozkan
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
| | - Emine Erarslan
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
| | - Nur Aydınlı
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
| | - Mine Çalışkan
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
| | - Meral Özmen
- Department of Pediatric Neurology, Istanbul Medical Faculty, Turkey
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Pisani F, Prezioso G, Spagnoli C. Neonatal seizures in preterm infants: A systematic review of mortality risk and neurological outcomes from studies in the 2000's. Seizure 2019; 75:7-17. [PMID: 31864147 DOI: 10.1016/j.seizure.2019.12.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 11/28/2019] [Accepted: 12/06/2019] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Neonatal seizures (NS) are associated with increased mortality and risk of cerebral palsy, epilepsy and intellectual disability. We performed a systematic review with the primary objective to delineate the rate of these outcomes following NS in preterm infants from studies published in the 2000's and the secondary objective to identify risk factors. METHODS Inclusion criteria: original articles published between 1/1/2000 and 12/31/2018, written in English, evaluating newborns ≤37 weeks of gestational age and suffering from NS, in which at least one of these was evaluated: epilepsy, cerebral palsy, intellectual disability/developmental delay, normal outcome, death. RESULTS Twenty-two papers were selected and all were observational, with a retrospective design in 15. Three were population-based and twenty-one have a comparison. It has been found a 22-80 % of mortality, 11.3-38.9 % of epilepsy, 12-84.6 % of cerebral palsy, and 20-42.7 % of intellectual disability/developmental delay rate. An increased risk for all outcomes considered was reported. Risk factors for specific outcomes were provided by a minority of studies. However, inclusion criteria, definition of NS and measured outcomes, follow-up lengths differed considerably between studies. DISCUSSION Results of the selected studies are only partially comparable or generalizable because of differences in study design. They have a risk for potential biases, although they provide (if analyzed) readily available prognostic factors, easy to apply in clinical practice. Prospective, population-based studies with EEG-defined NS are warranted in order to produce evidence-based guidance for management of preterm newborns with seizures.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine & Surgery Department, Neuroscience Division, University of Parma, Parma, Italy
| | - Giovanni Prezioso
- Pediatrics & Neonatology Unit, Ospedale San Timoteo, ASREM Molise, Termoli, CB, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCSS di Reggio Emilia, Reggio Emilia, Italy.
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Pressler RM, Lagae L. Why we urgently need improved seizure and epilepsy therapies for children and neonates. Neuropharmacology 2019; 170:107854. [PMID: 31751548 DOI: 10.1016/j.neuropharm.2019.107854] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/22/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022]
Abstract
In contrast to epilepsy in adolescents and adults, neonatal seizures and early onset epilepsy poses unique challenges with significant repercussion for treatment choices. Most importantly, high seizure burden and epileptic encephalopathy are associated with developmental, behavioural and cognitive problems. The causes are multifactorial and include etiology, seizure burden, epileptic encephalopathy, but also antiseizure medication. In contrast to adults and older children only very few drugs have been licenced for infants and neonates, and after a long delay. Very recently, extrapolation of adult data has become possible as a path to speed up drug development for younger children but this is not necessarily possible for infants and neonates. With the advances in understanding the molecular basis of many epilepsies, targeted therapies become available, for example for KCNQ2 mutation related epilepsies, Dravet syndrome or tuberous sclerosis complex. Drug trials in neonates are particularly challenging because of their inconspicuous clinical presentation, the need for continuous EEG monitoring, high co-morbidity, and poor response to antiepileptic drugs. There is an urgent need for development of new drugs, evaluation of safety and efficacy of current antiseizure drugs, as well as for national policies and guidelines for the management of seizures and epilepsy in neonates and infants. This article is part of the special issue entitled 'New Epilepsy Therapies for the 21st Century - From Antiseizure Drugs to Prevention, Modification and Cure of Epilepsy'.
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Affiliation(s)
- Ronit M Pressler
- Neuroscience Unit, UCL Great Ormond Street Institute of Child Health, London, UK; Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Lieven Lagae
- Department Paediatric Neurology, University Hospitals, Leuven, Belgium
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Early changes in pro-inflammatory cytokine levels in neonates with encephalopathy are associated with remote epilepsy. Pediatr Res 2019; 86:616-621. [PMID: 31234194 PMCID: PMC6851466 DOI: 10.1038/s41390-019-0473-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/05/2019] [Accepted: 06/14/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Neonatal seizures are associated with adverse neurologic sequelae including epilepsy in childhood. Here we aim to determine whether levels of cytokines in neonates with brain injury are associated with acute symptomatic seizures or remote epilepsy. METHODS This is a cohort study of term newborns with encephalopathy at UCSF between 10/1993 and 1/2000 who had dried blood spots. Maternal, perinatal/postnatal, neuroimaging, and epilepsy variables were abstracted by chart review. Logistic regression was used to compare levels of cytokines with acute seizures and the development of epilepsy. RESULTS In a cohort of 26 newborns with neonatal encephalopathy at risk for hypoxic ischemic encephalopathy with blood spots for analysis, diffuse alterations in both pro- and anti-inflammatory cytokine levels were observed between those with (11/28, 39%) and without acute symptomatic seizures. Seventeen of the 26 (63%) patients had >2 years of follow-up and 4/17 (24%) developed epilepsy. Higher levels of pro-inflammatory cytokines IL-6 and TNF-α within the IL-1β pathway were significantly associated with epilepsy. CONCLUSIONS Elevations in pro-inflammatory cytokines in the IL-1β pathway were associated with later onset of epilepsy. Larger cohort studies are needed to confirm the predictive value of these circulating biomarkers.
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Gan J, Ma D, Xiong T. Efficacy and safety of levetiracetam in children with epilepsy: protocol for an umbrella review of systematic reviews and meta-analyses of randomised controlled trials. BMJ Open 2019; 9:e029811. [PMID: 31296513 PMCID: PMC6624056 DOI: 10.1136/bmjopen-2019-029811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Epilepsy causes serious suffering in children and is associated with high morbidity and increased mortality. It impairs children's quality of life and places a heavy burden on healthcare resources. Levetiracetam has been used to prevent and treat paediatric epilepsy for years. To date, a number of systematic reviews have been performed to assess the efficacy and safety of levetiracetam in a variety of clinical settings. Conflicting outcomes have been reported for the same clinical issues. Our objective is to provide a comprehensive overview of the literature for clinicians and policymakers via an umbrella review that assesses the efficacy and safety of levetiracetam in children with epilepsy. METHODS AND ANALYSIS We will follow the Joanna Briggs Institute's guidelines for umbrella reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The following seven databases will be searched from 1990 to February 2019: PubMed, Embase, Cochrane Database of Systematic Reviews, JBISRIR, EPPI, Epistemonikos and PROSPERO. We will provide evidence from existing systematic reviews and meta-analyses of randomised controlled trials regarding the use of levetiracetam in children with epilepsy. The intervention of interest is levetiracetam monotherapy and add-on therapies for prevention or treatment purposes. Studies will be individually selected and assessed by two reviewers. The primary outcomes of interest are epilepsy control, the efficacy of prophylaxis for provoked seizures and the mortality rate of children with epilepsy who received levetiracetam treatment. The secondary outcomes are adverse events and withdrawal rates due to adverse effects. The methodological quality of all reviews will be individually assessed by two reviewers using the 'A Measurement Tool to Assess Systematic Reviews' instrument. The Grading of Recommendations Assessment, Development and Evaluation assessment will be applied to evaluate the quality of evidence for each outcome of interest. A narrative description of an analysis of the systematic reviews will be tabulated to address objective and specific questions. Information from each review will be detailed in a table including the population, number of studies, total number of participants, year range of the trials, study designs of the primary trials, countries and settings of the trials, heterogeneity of results and assessment tools. Recommendations regarding each outcome of levetiracetam will be categorised based on a protocol. ETHICS AND DISSEMINATION This umbrella review will inform clinical and policy decisions regarding the efficacy and safety of levetiracetam for preventing and treating paediatric epilepsy. The results will be disseminated through a peer-reviewed publication and conference presentations. Ethical approval is not required for this study.
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Affiliation(s)
- Jing Gan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Dan Ma
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
- Deep Underground Space Medical Center, West China Hospital, Sichuan University, Chengdu, China
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Spagnoli C, Pisani F. The independent role of neonatal seizures in epilepsy and other long-term neurological outcomes. Dev Med Child Neurol 2019; 61:624. [PMID: 30762238 DOI: 10.1111/dmcn.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Carlotta Spagnoli
- Child Neuropsychiatry Unit, Department of Pediatrics, Azienda USL-IRCSS di Reggio Emilia, Reggio Emilia, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Neuroscience Division, Medicine and Surgery Department, University of Parma, Parma, Italy
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Correlation of Neonatal Birth-Associated Greenstick Skull Fractures with Perinatal Factors and Long-Term Outcome: Children with a Greater Number of Greenstick Skull Fractures Showed Poor Results in Terms of Long-Term Neurodevelopment. World Neurosurg 2019; 126:e1197-e1205. [DOI: 10.1016/j.wneu.2019.03.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/23/2022]
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38
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Baudou E, Cances C, Dimeglio C, Hachon Lecamus C. Etiology of neonatal seizures and maintenance therapy use: a 10-year retrospective study at Toulouse Children's hospital. BMC Pediatr 2019; 19:136. [PMID: 31035972 PMCID: PMC6487521 DOI: 10.1186/s12887-019-1508-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/11/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND No guidelines exist concerning the maintenance antiepileptic drug to use after neonatal seizures. Practices vary from one hospital to another. The aim of this study was to investigate etiologies and to report on the use of maintenance antiepileptic therapy in our population of full-term neonates presenting neonatal seizures. METHODS From January 2004 to October 2014, we retrospectively collected data from all full-term neonates with neonatal seizures admitted to the Children's Hospital of Toulouse, France. RESULTS Two hundred and forty-three neonates were included (59% males, 48% electroencephalographic confirmation). The frequencies of etiologies of neonatal seizures were: hypoxic-ischemic encephalopathy (HIE) (n = 91; 37%), ischemic infarction (n = 36; 15%), intracranial hemorrhage (n = 29; 12%), intracranial infection (n = 19; 8%), metabolic or electrolyte disorders (n = 9; 3%), inborn errors of metabolism (n = 5; 2%), congenital malformations of the central nervous system (n = 11; 5%), epileptic syndromes (n = 27; 12%) and unknown (n = 16; 7%). A maintenance therapy was prescribed in 180 (72%) newborns: valproic acid (n = 123), carbamazepine (n = 28), levetiracetam (n = 17), vigabatrin (n = 2), and phenobarbital (n = 4). In our cohort, the choice of antiepileptic drug depended mainly on etiology. The average duration of treatment was six months. CONCLUSIONS In our cohort, valproic acid was the most frequently prescribed maintenance antiepileptic therapy. However, the arrival on the market of new antiepileptic drugs and a better understanding of the physiopathology of genetic encephalopathies is changing our practice. TRIAL REGISTRATION Retrospectively registered. Patient data were reported to the "Commission Nationale Informatique et Libertés" under the number 2106953 .
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Affiliation(s)
- E Baudou
- Unit of Pediatric Neurology, Hôpital des Enfants, CHU Toulouse, 330 av de Grande Bretagne-TSA, 31059, Toulouse Cedex, France. .,Service de Neurologie Pédiatrique, Hôpital des Enfants, CHU Toulouse, 330 avenue de Grande Bretagne-TSA, 31059, Toulouse Cedex, France.
| | - C Cances
- Unit of Pediatric Neurology, Hôpital des Enfants, CHU Toulouse, 330 av de Grande Bretagne-TSA, 31059, Toulouse Cedex, France
| | - C Dimeglio
- Biostatistiques, Informatique Médicale, UMR 1027 Inserm, Université Paul Sabatier, Toulouse, France
| | - C Hachon Lecamus
- Unit of Pediatric Neurology, Hôpital des Enfants, CHU Toulouse, 330 av de Grande Bretagne-TSA, 31059, Toulouse Cedex, France
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McNally MA, Chavez-Valdez R, Felling RJ, Flock DL, Northington FJ, Stafstrom CE. Seizure Susceptibility Correlates with Brain Injury in Male Mice Treated with Hypothermia after Neonatal Hypoxia-Ischemia. Dev Neurosci 2019; 40:1-10. [PMID: 30820019 PMCID: PMC9109068 DOI: 10.1159/000496468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022] Open
Abstract
Hypoxic-ischemic encephalopathy is a common neonatal brain injury associated with significant morbidity and mortality despite the administration of therapeutic hypothermia (TH). Neonatal seizures and subsequent chronic epilepsy are frequent in this patient population and current treatments are partially effective. We used a neonatal murine hypoxia-ischemia (HI) model to test whether the severity of hippocampal and cortical injury predicts seizure susceptibility 8 days after HI and whether TH mitigates this susceptibility. HI at postnatal day 10 (P10) caused hippocampal injury not mitigated by TH in male or female pups. TH did not confer protection against flurothyl seizure susceptibility at P18 in this model. Hippocampal (R2 = 0.33, p = 0.001) and cortical (R2 = 0.33, p = 0.003) injury directly correlated with seizure susceptibility in male but not female pups. Thus, there are sex-specific consequences of neonatal HI on flurothyl seizure susceptibility in a murine neonatal HI model. Further studies are necessary to elucidate the underlying mechanisms of sex dimorphism in seizure susceptibility after neonatal HI.
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Affiliation(s)
- Melanie A McNally
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Raul Chavez-Valdez
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debra L Flock
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J Northington
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carl E Stafstrom
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Abstract
Most neonatal seizures in preterm newborns are of acute symptomatic origin with a prevalence higher than in full-term infants. To date, recommendations for management of seizures in preterm newborns are scarce and do not differ from those in full-term newborns. Mortality in preterm newborns with seizures has significantly declined over the last decades, from figures of 84%-94% in the 1970s and 1980s to 22%-45% in the last years. However, mortality is significantly higher in those with a birth weight<1000g and a gestational age<28 weeks. Seizures are a strong predictor of unfavorable outcomes, including not only cerebral palsy, epilepsy, and intellectual disability, but also vision, hearing impairment, and microcephaly. The majority of patients with developmental delay are severely affected and this is usually associated with cerebral palsy. Furthermore, the incidence of epilepsy after neonatal seizures seems to be lower in preterm than in full-term infants but the risk is approximately 40 times greater than in the general population. Clinical studies cannot disentangle the specific and independent contributions of seizure-induced functional changes and the role of etiology and brain damage severity in determining the long-term outcomes in these newborns.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Department of Medicine & Surgery, University of Parma, Parma, Italy.
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Santa Maria Nuova Hospital, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Statello R, Carnevali L, Alinovi D, Pisani F, Sgoifo A. Heart rate variability in neonatal patients with seizures. Clin Neurophysiol 2018; 129:2534-2540. [PMID: 30384023 DOI: 10.1016/j.clinph.2018.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Seizures are frequently observed in neurological conditions affecting newborns. Since autonomic alterations are commonly associated with neonatal seizures (NS), we investigated the utility of heart rate variability (HRV) indexes of cardiac autonomic regulation for NS detection. METHODS HRV analysis was conducted on ECG tracings recorded during video-EEG monitoring in newborns with NS and matched-controls. The effects of gestational age on HRV were also evaluated. RESULTS Newborns with NS showed lower resting state HRV compared to controls. Moreover, seizure episodes were characterized by a short-lasting increase in vagal indexes of HRV. Pre-term newborns with NS had a lower HRV than full-term at rest. In pre-term newborns, no changes in HRV were observed before and during NS. On the contrary, full-term newborns showed significantly higher HRV before and during NS compared to the respective baseline values. CONCLUSION Our data point to resting autonomic impairment in newborns with NS. In addition, an increment in HRV has been observed during NS only in full term newborns. SIGNIFICANCE Although these findings do not allow validation of HRV measures for NS prediction and detection, they suggest that a putative protective vagal mechanism might be adopted when an advanced maturation of autonomic nervous system is achieved.
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Affiliation(s)
- Rosario Statello
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Luca Carnevali
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Davide Alinovi
- Department of Engineering and Architecture, Information Engineering Unit, University of Parma, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Neuroscience Unit, Department of Medicine and Surgery, University of Parma, Italy
| | - Andrea Sgoifo
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy.
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42
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Pisani F, Facini C, Bianchi E, Giussani G, Piccolo B, Beghi E. Incidence of neonatal seizures, perinatal risk factors for epilepsy and mortality after neonatal seizures in the province of Parma, Italy. Epilepsia 2018; 59:1764-1773. [PMID: 30132843 DOI: 10.1111/epi.14537] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 06/07/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Information about the incidence of neonatal seizures (NS) is scarce. Previous studies relied primarily on a clinical diagnosis of seizures. This population-based, retrospective study evaluated the incidence of electroencephalography (EEG)-confirmed seizures in neonates born in the province of Parma and the perinatal risk factors for mortality and epilepsy. METHODS All neonates with suspected seizures or with medical conditions at high risk for seizures from the study area were recorded in the neonatal intensive care unit (NICU) of the Parma University Hospital. NS were EEG confirmed. Perinatal risk factors for mortality and epilepsy after NS were evaluated with Cox's proportional hazards models. RESULTS In a 13-year period, 112 patients presented with NS: 102 newborns had electroclinical seizures (46 full-term and 56 preterm), whereas 10 presented only electrical seizures. The incidence was 2.29/1000 live births (95% confidence interval [CI] 1.87-2.72), with higher rates in preterm neonates (14.28/1000 in preterm vs 1.10/1000 in full-term infants). The incidence increased with decreasing gestational age (31-36 weeks of gestation: 5.01/1000, 28-30: 54.9/1000, and <28: 85.6/1000) and with decreasing birth weight (≥2500 g: 1.19/1000, <1000 g: 127.57/1000). Twenty-eight patients (25%) died, 16 (14.3%) had a diagnosis of epilepsy, 33 (29.5%) had cerebral palsy, and 39 (34.8%) had a developmental delay. Among the perinatal risk factors considered, the multivariate analysis showed an association between a 5-minute Apgar score of 0-7 and etiology with increased mortality and between female gender and status epilepticus with epilepsy. SIGNIFICANCE The incidence of NS is inversely associated with gestational age and birth weight. The etiology and a low Apgar score are strongly related to mortality; female gender and status epilepticus are risk factors for the development of epilepsy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Carlotta Facini
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Elisa Bianchi
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
| | - Giorgia Giussani
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
| | - Benedetta Piccolo
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Ettore Beghi
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
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Lugli L, Balestri E, Berardi A, Guidotti I, Cavalleri F, Todeschini A, Pugliese M, Muttini Della Casa E, Lucaccioni L, Ferrari F. Brain cooling reduces the risk of postneonatal epilepsy in newborns affected by moderate to severe hypoxic-ischemic encephalopathy. Minerva Pediatr (Torino) 2018; 73:150-158. [PMID: 29968450 DOI: 10.23736/s2724-5276.18.05224-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Neonatal hypoxic-ischemic encephalopathy is still a significant cause of neonatal death and neurodevelopmental disabilities, such as cerebral palsy, mental delay, and epilepsy. After the introduction of therapeutic hypothermia, the prognosis of hypoxic-ischemic encephalopathy has improved, with reduction of death and disabilities. However, few studies evaluated whether hypothermia affects rate and severity of postneonatal epilepsy. We evaluated rates, characteristics and prognostic markers of postneonatal epilepsy in infants with moderate to severe hypoxic-ischemic encephalopathy treated or not with therapeutic hypothermia. METHODS We analyzed clinical data, EEG recordings, cerebral Magnetic Resonance Imaging (MRI) and outcome in 23 cooled and 26 non-cooled asphyxiated neonates (≥36 weeks' gestation), admitted from 2004 to 2012. RESULTS Among 49 neonates 11 (22%) had postneonatal epilepsy, of which 9 (18%) were non-cooled and 2 (4%) were cooled (P=0.05). Six of 11 infants (55%) had West syndrome, 4 (36%) had focal epilepsy and 1 (9%) had Lennox-Gastaut Syndrome. At multiple logistic regression analysis MRI pattern significantly correlated with postneonatal epilepsy (OR 0.19, 95% CI 0.04-0.88, P=0.03). Extensive lesions in basal ganglia and thalami plus cortical and white matter were associated with postneonatal epilepsy. CONCLUSIONS Only perinatal asphyxia with extensive lesions in basal ganglia and thalami plus cortical and white matter lesion conveys a high risk for early and severe postneonatal epilepsy. Moreover, therapeutic hypothermia is associated with a decrease of the risk of developing postneonatal epilepsy.
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Affiliation(s)
- Licia Lugli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy -
| | - Eleonora Balestri
- Division of Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Reggio Emilia, Italy
| | - Alberto Berardi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Isotta Guidotti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Francesca Cavalleri
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino Estense, Modena, Italy
| | - Alessandra Todeschini
- Division of Neuroradiology, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino Estense, Modena, Italy
| | - Marisa Pugliese
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Elisa Muttini Della Casa
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Laura Lucaccioni
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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Quinlan SMM, Rodriguez-Alvarez N, Molloy EJ, Madden SF, Boylan GB, Henshall DC, Jimenez-Mateos EM. Complex spectrum of phenobarbital effects in a mouse model of neonatal hypoxia-induced seizures. Sci Rep 2018; 8:9986. [PMID: 29968748 PMCID: PMC6030182 DOI: 10.1038/s41598-018-28044-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 06/11/2018] [Indexed: 11/09/2022] Open
Abstract
Seizures in neonates, mainly caused by hypoxic-ischemic encephalopathy, are thought to be harmful to the brain. Phenobarbital remains the first line drug therapy for the treatment of suspected neonatal seizures but concerns remain with efficacy and safety. Here we explored the short- and long-term outcomes of phenobarbital treatment in a mouse model of hypoxia-induced neonatal seizures. Seizures were induced in P7 mice by exposure to 5% O2 for 15 minutes. Immediately after hypoxia, pups received a single dose of phenobarbital (25 mg.kg-1) or saline. We observed that after administration of phenobarbital seizure burden and number of seizures were reduced compared to the hypoxic period; however, PhB did not suppress acute histopathology. Behavioural analysis of mice at 5 weeks of age previously subjected to hypoxia-seizures revealed an increase in anxiety-like behaviour and impaired memory function compared to control littermates, and these effects were not normalized by phenobarbital. In a seizure susceptibility test, pups previously exposed to hypoxia, with or without phenobarbital, developed longer and more severe seizures in response to kainic acid injection compared to control mice. Unexpectedly, mice treated with phenobarbital developed less hippocampal damage after kainic acid than untreated counterparts. The present study suggests phenobarbital treatment in immature mice does not improve the long lasting functional deficits induces by hypoxia-induced seizures but, unexpectedly, may reduce neuronal death caused by exposure to a second seizure event in later life.
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Affiliation(s)
- Sean M M Quinlan
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, 123, St Stephen Green, Dublin, 2, Dublin, Ireland
| | - Natalia Rodriguez-Alvarez
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, 123, St Stephen Green, Dublin, 2, Dublin, Ireland
| | - Eleanor J Molloy
- Paediatrics, Academic Centre, Tallaght Hospital, Trinity College, The University of Dublin, Dublin, Ireland.,Neonatology, Coombe Women and Infants' University Hospital, Dublin, Ireland.,Neonatology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Stephen F Madden
- Data Science Centre, Beaux Lane House, Royal College of Surgeons in Ireland, Dublin, 2, Ireland
| | - Geraldine B Boylan
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland.,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - David C Henshall
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, 123, St Stephen Green, Dublin, 2, Dublin, Ireland.,Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
| | - Eva M Jimenez-Mateos
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, 123, St Stephen Green, Dublin, 2, Dublin, Ireland.
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45
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Glass HC, Numis AL, Gano D, Bali V, Rogers EE. Outcomes After Acute Symptomatic Seizures in Children Admitted to a Neonatal Neurocritical Care Service. Pediatr Neurol 2018; 84:39-45. [PMID: 29886041 DOI: 10.1016/j.pediatrneurol.2018.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Neonatal seizures due to acute brain injury are associated with high rates of death, disability, and epilepsy. Our objective was to examine incidence of and risk factors for epilepsy among survivors of acute symptomatic neonatal seizures who were cared for by a neonatal neurocritical care service. METHODS Neonates with acute symptomatic seizures who were admitted to UCSF Benioff Children's Hospital Neuro-Intensive Care Nursery from July 2008 to June 2014 were considered for inclusion. RESULTS A total of 144 children with acute symptomatic seizures met study criteria and 37 (26%) died before age one. Eighty-seven children (85% of eligible survivors) were followed up to one year or longer. Epilepsy was diagnosed in eight children at median age 4.9 (interquartile range 1.7, 6.1) years. The cumulative incidence risk of epilepsy at one year was 2% (95% confidence interval 0.6% to 9%) and at five years was 7% (95% confidence interval 3% to 20%). Cerebral palsy was diagnosed in 21%. Bayley-III cognitive subscale less than 85 was present in 13%. Children with epilepsy were more likely to be preterm, have brain injury, and be discharged home on antiseizure medication, although the results were not significant after adjusted analysis. CONCLUSIONS The risk of epilepsy was lower and age at onset was older than in previous reports, which may be related to multiple factors including a neurocritical care approach, treatment of hypoxic-ischemic encephalopathy with hypothermia, high rate of neonatal transition to palliative care, and the exclusion of neonatal onset epilepsies. Continuation of antiseizure medications in infancy did not decrease the risk of epilepsy. Long-term, multicenter studies are needed to understand whether neonatal seizure management can alter the risk of epilepsy.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Adam L Numis
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Dawn Gano
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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46
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Massey SL, Jensen FE, Abend NS. Electroencephalographic monitoring for seizure identification and prognosis in term neonates. Semin Fetal Neonatal Med 2018; 23:168-174. [PMID: 29352657 DOI: 10.1016/j.siny.2018.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Seizures represent a manifestation of neurological disease in the neonatal period. Historically, neonatal seizures were identified by direct clinical observation. However, since most seizures are electroencephalographic (EEG)-only (subclinical, non-convulsive) and clinical manifestations may be subtle, many clinicians place increasing importance on EEG data including conventional EEG or amplitude-integrated EEG to identify seizures in neonates. Beyond seizure identification, the EEG is a robust source of information about brain function that can be useful for neurobehavioral prognostication in some neonates. This review summarizes the available data regarding EEG for neonatal seizure diagnosis and brain function assessment.
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Affiliation(s)
- Shavonne L Massey
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA.
| | - Frances E Jensen
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
| | - Nicholas S Abend
- Department of Neurology and Pediatrics, Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
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47
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De Haan TR, Langeslag J, van der Lee JH, van Kaam AH. A systematic review comparing neurodevelopmental outcome in term infants with hypoxic and vascular brain injury with and without seizures. BMC Pediatr 2018; 18:147. [PMID: 29720158 PMCID: PMC5930747 DOI: 10.1186/s12887-018-1116-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/16/2018] [Indexed: 12/03/2022] Open
Abstract
Background There is increasing evidence that neonatal seizures in term neonates with stroke, asphyxia or brain haemorrhage might be associated with adverse neurodevelopment and development of epilepsy. The extent of this association is not known. The objective of this study was to assess the possible impact of neonatal seizures on these outcomes and if possible calculate a relative risk. Methods A systematic review and meta-analysis was performed (study period January 2000–June 2015). PubMed, Medline and Embase were searched for cohort studies evaluating neurodevelopmental outcome at the age of at least 18 months or development of epilepsy in surviving term neonates with or without neonatal seizures. The methodological quality of included studies was assessed and data extractions were performed in a standardized manner by independent reviewers. Pooled Relative Risks (RR) with 95% confidence intervals for adverse outcome were calculated if possible. Results Out of 1443 eligible studies 48 were selected for full text reading leaving 9 cohort studies for the final analyses (4 studies on stroke, 4 on perinatal asphyxia and one on cerebral hemorrhage). For all cases with stroke or asphyxia combined the pooled risk ratio (RR) for adverse outcome when suffering neonatal seizures was 7.42 (3.84–14.34); for neonates with perinatal asphyxia: 8.41 (4.07–17.39) and for neonates with stroke: 4.95 (1.07–23.0). The pooled RR for development of late onset epilepsy could only be determined for infants suffering from stroke: 1.48 (0.82–2.68). Results were biased and evidence sparse. Conclusions The presence of neonatal seizures in term newborns with vascular or hypoxic brain injury may have an impact on or be a predictor of neurodevelopmental outcome. The biased available data yield insufficient evidence about the true size of this association. Electronic supplementary material The online version of this article (10.1186/s12887-018-1116-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T R De Haan
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - J Langeslag
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands
| | - J H van der Lee
- Pediatric clinical Research Office, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - A H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands
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48
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McNally MA, Hartman AL. Variability in Preferred Management of Electrographic Seizures in Neonatal Hypoxic Ischemic Encephalopathy. Pediatr Neurol 2017; 77:37-41. [PMID: 28982530 DOI: 10.1016/j.pediatrneurol.2017.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/05/2017] [Accepted: 06/13/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Seizures may cause added harm in neonates with hypoxic-ischemic encephalopathy (HIE). Specific recommendations about seizure treatment in this context are lacking. We sought to determine the scope of practice regarding management of non-status epilepticus electrographic-only seizures in this setting. METHODS A case-based survey was distributed to members of the Child Neurology Society. Providers were asked about their preferred management strategy for sequential clinical scenarios. RESULTS A total of 177 child neurologists responded to the survey. Seventy-seven percent of providers would treat 20 seconds or less of electrographic seizure activity. In a neonate with mild HIE and an electrographic-only seizure, there was no agreement among providers regarding whether to start maintenance therapy in addition to a one-time anti-seizure drug load. In a neonate with moderate HIE on phenobarbital for early electro-clinical seizures, most providers would escalate treatment for ongoing electrographic-only seizures by increasing phenobarbital dosing. In a neonate with severe HIE complicated by status epilepticus on phenobarbital who subsequently develops recurrent electrographic-only seizures, providers varied substantially in their management preferences. For all three cases, 75% to 85% of providers would not change their management preferences based on the absence of a clinical correlate with the electrographic seizure. CONCLUSIONS We found marked variability among providers regarding preferred management of non-status epilepticus electrographic-only seizures after HIE. Our results identified specific aspects of electrographic-only seizure management in neonatal HIE where there is limited consensus. These discrepancies may serve as opportunities for future investigation.
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Affiliation(s)
- Melanie A McNally
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Adam L Hartman
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland; Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland.
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49
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Kirischuk S, Sinning A, Blanquie O, Yang JW, Luhmann HJ, Kilb W. Modulation of Neocortical Development by Early Neuronal Activity: Physiology and Pathophysiology. Front Cell Neurosci 2017; 11:379. [PMID: 29238291 PMCID: PMC5712676 DOI: 10.3389/fncel.2017.00379] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/13/2017] [Indexed: 12/23/2022] Open
Abstract
Animal and human studies revealed that patterned neuronal activity is an inherent feature of developing nervous systems. This review summarizes our current knowledge about the mechanisms generating early electrical activity patterns and their impact on structural and functional development of the cerebral cortex. All neocortical areas display distinct spontaneous and sensory-driven neuronal activity patterns already at early phases of development. At embryonic stages, intermittent spontaneous activity is synchronized within small neuronal networks, becoming more complex with further development. This transition is accompanied by a gradual shift from electrical to chemical synaptic transmission, with a particular role of non-synaptic tonic currents before the onset of phasic synaptic activity. In this review article we first describe functional impacts of classical neurotransmitters (GABA, glutamate) and modulatory systems (e.g., acetylcholine, ACh) on early neuronal activities in the neocortex with special emphasis on electrical synapses, nonsynaptic and synaptic currents. Early neuronal activity influences probably all developmental processes and is crucial for the proper formation of neuronal circuits. In the second part of our review, we illustrate how specific activity patterns might interfere with distinct neurodevelopmental processes like proliferation, migration, axonal and dendritic sprouting, synapse formation and neurotransmitter specification. Finally, we present evidence that transient alterations in neuronal activity during restricted perinatal periods can lead to persistent changes in functional connectivity and therefore might underlie the manifestation of neurological and neuropsychiatric diseases.
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Affiliation(s)
- Sergei Kirischuk
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anne Sinning
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Oriane Blanquie
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jenq-Wei Yang
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Heiko J Luhmann
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Werner Kilb
- Institute of Physiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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50
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Dereymaeker A, Ansari AH, Jansen K, Cherian PJ, Vervisch J, Govaert P, De Wispelaere L, Dielman C, Matic V, Dorado AC, De Vos M, Van Huffel S, Naulaers G. Interrater agreement in visual scoring of neonatal seizures based on majority voting on a web-based system: The Neoguard EEG database. Clin Neurophysiol 2017; 128:1737-1745. [DOI: 10.1016/j.clinph.2017.06.250] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 01/15/2023]
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