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Anwar T, Triplett RL, Ahmed A, Glass HC, Shellhaas RA. Treating Seizures and Improving Newborn Outcomes for Infants with Hypoxic-Ischemic Encephalopathy. Clin Perinatol 2024; 51:573-586. [PMID: 39095097 DOI: 10.1016/j.clp.2024.04.013] [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] [Indexed: 08/04/2024]
Abstract
Hypoxic-ischemic encephalopathy is the most common cause of neonatal seizures. Continuous electroencephalographic monitoring is recommended given high rates of subclinical seizures. Prompt diagnosis and treatment of seizures may improve neurodevelopmental outcomes. International League Against Epilepsy guidelines indicate that (1) phenobarbital remains the first-line treatment of neonatal seizures and (2) early discontinuation of antiseizure medications following resolution of acute provoked seizures, and prior to discharge home, is recommended. Long-term follow-up of these infants is necessary to screen for postneonatal epilepsy and support neurodevelopment.
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Affiliation(s)
- Tayyba Anwar
- Department of Neurology, Children's National Hospital, 111 Michigan Avenue Northwest, Washington, DC 20010, USA
| | - Regina L Triplett
- Department of Neurology, Washington University in St Louis, 1 Brookings Drive, Saint Louis, MO 63130, USA
| | - Afaf Ahmed
- Division of Pediatric and Developmental Neurology, Department of Neurology, Washington University in St Louis, 1 Brookings Drive, Saint Louis, MO 63130, USA
| | - Hannah C Glass
- Department of Neurology, University of California San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Renée A Shellhaas
- Department of Neurology, Washington University in St Louis, MSC 8091-29-12400, 660 South Euclid Avenue, Saint Louis, MO 63110, USA.
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Proietti J, O'Toole JM, Murray DM, Boylan GB. Advances in Electroencephalographic Biomarkers of Neonatal Hypoxic Ischemic Encephalopathy. Clin Perinatol 2024; 51:649-663. [PMID: 39095102 DOI: 10.1016/j.clp.2024.04.006] [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] [Indexed: 08/04/2024]
Abstract
Electroencephalography (EEG) is a key objective biomarker of newborn brain function, delivering critical, cotside insights to aid the management of encephalopathy. Access to continuous EEG is limited, forcing reliance on subjective clinical assessments. In hypoxia ischaemia, the primary cause of encephalopathy, alterations in EEG patterns correlate with. injury severity and evolution. As HIE evolves, causing secondary neuronal death, EEG can track injury progression, informing neuroprotective strategies, seizure management and prognosis. Despite its value, challenges with interpretation and lack of on site expertise has limited its broader adoption. Technological advances, particularly in digital EEG and machine learning, are enhancing real-time analysis. This will allow EEG to expand its role in HIE diagnosis, management and outcome prediction.
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Affiliation(s)
- Jacopo Proietti
- Department of Engineering for Innovation Medicine, University of Verona, Strada le Grazie, Verona 37134, Italy; INFANT Research Centre, University College Cork, Cork, Ireland
| | - John M O'Toole
- INFANT Research Centre, University College Cork, Cork, Ireland; Cergenx Ltd., Dublin, Ireland
| | - Deirdre M Murray
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics & Child Health, University College Cork, Paediatric Academic Unit, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland
| | - Geraldine B Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland; Department of Paediatrics & Child Health, University College Cork, Paediatric Academic Unit, Cork University Hospital, Wilton, Cork, T12 DC4A, Ireland.
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Lacan L, Betrouni N, Chaton L, Lamblin MD, Flamein F, Riadh Boukhris M, Derambure P, Nguyen The Tich S. Early automated classification of neonatal hypoxic-ischemic encephalopathy - An aid to the decision to use therapeutic hypothermia. Clin Neurophysiol 2024; 166:108-116. [PMID: 39153459 DOI: 10.1016/j.clinph.2024.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 07/18/2024] [Accepted: 07/27/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE The study aimed to address the challenge of early assessment of neonatal hypoxic-ischemic encephalopathy (HIE) severity to identify candidates for therapeutic hypothermia (TH). The objective was to develop an automated classification model for neonatal EEGs, enabling accurate HIE severity assessment 24/7. METHODS EEGs recorded within 6 h of life after perinatal anoxia were visually graded into 3 severity groups (HIE French Classification) and quantified using 6 qEEG markers measuring amplitude, continuity and frequency content. Machine learning models were developed on a dataset of 90 EEGs and validated on an independent dataset of 60 EEGs. RESULTS The selected model achieved an overall accuracy of 80.6% in the development phase and 80% in the validation phase. Notably, the model accurately identified 28 out of 30 children for whom TH was indicated after visual EEG analysis, with only 2 cases (moderate EEG abnormalities) not recommended for cooling. CONCLUSIONS The combination of clinically relevant qEEG markers led to the development of an effective automated EEG classification model, particularly suited for the post-anoxic latency phase. This model successfully discriminated neonates requiring TH. SIGNIFICANCE The proposed model has potential as a bedside clinical decision support tool for TH.
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Affiliation(s)
- Laure Lacan
- ULR 2694 - METRICS, University of Lille, Faculty of Medicine, Avenue Eugène Avinée, Lille F-59000, France; Department of Pediatric Neurology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Nacim Betrouni
- INSERM U 1172, F-59000, University of Lille, Faculty of Medicine, 2 Avenue Eugène Avinée, Lille F-59000, France; Department of Clinical Neurophysiology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Laurence Chaton
- INSERM U 1172, F-59000, University of Lille, Faculty of Medicine, 2 Avenue Eugène Avinée, Lille F-59000, France; Department of Clinical Neurophysiology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Marie-Dominique Lamblin
- Department of Clinical Neurophysiology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Florence Flamein
- Department of Neonatology, CHU Lille, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, Lille F-59000, France.
| | - Mohamed Riadh Boukhris
- Department of Neonatology, CHU Lille, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, Lille F-59000, France.
| | - Philippe Derambure
- INSERM U 1172, F-59000, University of Lille, Faculty of Medicine, 2 Avenue Eugène Avinée, Lille F-59000, France; Department of Clinical Neurophysiology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
| | - Sylvie Nguyen The Tich
- ULR 2694 - METRICS, University of Lille, Faculty of Medicine, Avenue Eugène Avinée, Lille F-59000, France; Department of Pediatric Neurology, CHU Lille, Hôpital Roger Salengro, Rue Emile Laine, Lille F-59000, France.
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Stieren ES, Rottkamp CA, Brooks-Kayal AR. Neonatal Seizures. Neoreviews 2024; 25:e338-e349. [PMID: 38821905 DOI: 10.1542/neo.25-6-e338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 01/09/2024] [Accepted: 01/10/2024] [Indexed: 06/02/2024]
Abstract
Neonatal seizures are common among patients with acute brain injury or critical illness and can be difficult to diagnose and treat. The most common etiology of neonatal seizures is hypoxic-ischemic encephalopathy, with other common causes including ischemic stroke and intracranial hemorrhage. Neonatal clinicians can use a standardized approach to patients with suspected or confirmed neonatal seizures that entails laboratory testing, neuromonitoring, and brain imaging. The primary goals of management of neonatal seizures are to identify the underlying cause, correct it if possible, and prevent further brain injury. This article reviews recent evidence-based guidelines for the treatment of neonatal seizures and discusses the long-term outcomes of patients with neonatal seizures.
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Affiliation(s)
- Emily S Stieren
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, CA
| | - Catherine A Rottkamp
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, CA
| | - Amy R Brooks-Kayal
- Department of Neurology, University of California, Davis, Sacramento, CA
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Bersani I, Lapergola G, Patacchiola R, D'Adamo E, Stuppia L, de Laurenzi V, Damiani V, Cataldo I, Clemente K, Primavera A, Salomone R, Barbante E, Campi F, Savarese I, Ronci S, Dotta A, Braguglia A, Longo D, Gavilanes DAW, Gazzolo F, Serpero L, Strozzi MC, Maconi A, Cassinari M, Libener R, Gazzolo D. Elevated S100B urine levels predict seizures in infants complicated by perinatal asphyxia and undergoing therapeutic hypothermia. Clin Chem Lab Med 2024; 62:1109-1117. [PMID: 38290722 DOI: 10.1515/cclm-2023-1471] [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: 12/19/2023] [Accepted: 01/23/2024] [Indexed: 02/01/2024]
Abstract
OBJECTIVES Seizures (SZ) are one of the main complications occurring in infants undergoing therapeutic hypothermia (TH) due to perinatal asphyxia (PA) and hypoxic ischemic encephalopathy (HIE). Phenobarbital (PB) is the first-line therapeutic strategy, although data on its potential side-effects need elucidation. We investigated whether: i) PB administration in PA-HIE TH-treated infants affects S100B urine levels, and ii) S100B could be a reliable early predictor of SZ. METHODS We performed a prospective case-control study in 88 PA-HIE TH infants, complicated (n=44) or not (n=44) by SZ requiring PB treatment. S100B urine levels were measured at 11 predetermined monitoring time-points from first void up to 96-h from birth. Standard-of-care monitoring parameters were also recorded. RESULTS S100B significantly increased in the first 24-h independently from HIE severity in the cases who later developed SZ and requested PB treatment. ROC curve analysis showed that S100B, as SZ predictor, at a cut-off of 2.78 μg/L achieved a sensitivity/specificity of 63 and 84 %, positive/negative predictive values of 83 and 64 %. CONCLUSIONS The present results offer additional support to the usefulness of S100B as a trustable diagnostic tool in the clinical daily monitoring of therapeutic and pharmacological procedures in infants complicated by PA-HIE.
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Affiliation(s)
- Iliana Bersani
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giuseppe Lapergola
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Roberta Patacchiola
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Ebe D'Adamo
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Liborio Stuppia
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Vincenzo de Laurenzi
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Verena Damiani
- Center for Advances Studies and Technology (CAST), G. d'Annunzio University, Chieti, Italy
| | - Ivana Cataldo
- Laboratory of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy
| | - Katia Clemente
- Laboratory of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy
| | - Adele Primavera
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Rita Salomone
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Elisabetta Barbante
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
| | - Francesca Campi
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Immacolata Savarese
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sara Ronci
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Dotta
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Annabella Braguglia
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Longo
- Department of Neonatology, Neonatal Intensive Care Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Danilo A W Gavilanes
- Department of Pediatrics and Neonatology, Maastricht University, Maastricht, The Netherlands
| | | | - Laura Serpero
- Department of Maternal, Fetal and Neonatal Medicine, SS Antonio, Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Maria Chiara Strozzi
- Department of Pediatrics and Neonatology, Ospedale Cardinal Massaia, Asti, Italy
| | - Antonio Maconi
- Social Security Administration Development and Promotion of Scientific Research Unit, SS Antonio, Biagio and C. Arrigo Hospital, Alessandria, Italy
| | - Maurizio Cassinari
- Department of Clinical Biochemistry, Transfusion and Regeneration Medicine Alessandria Hospital, Alessandria, Italy
| | - Roberta Libener
- Department of Clinical Biochemistry, Transfusion and Regeneration Medicine Alessandria Hospital, Alessandria, Italy
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, G. d'Annunzio University of Chieti, Chieti, Italy
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Hensel D, Zahedi-Spung L, Carter EB, Cahill AG, Raghuraman N, Rosenbloom JI. The Risk of Neonatal Morbidity in Umbilical Artery Hypercarbia and Respiratory Acidosis. Am J Perinatol 2024; 41:e1001-e1007. [PMID: 36543241 DOI: 10.1055/s-0042-1759721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To test the hypothesis that elevated umbilical artery (UA) partial pressure of carbon dioxide (pCO2) is associated with neonatal morbidity and to compare the risk of neonatal morbidity with different patterns of UA acidosis. STUDY DESIGN This was a secondary analysis of a prospective cohort of term, singleton, nonanomalous deliveries with universal cord gas collection. The primary outcome was composite neonatal morbidity. Multivariable logistic regression was used to determine the relative risk (RR) for neonatal morbidity in patients with and without UA hypercarbia. A receiver operating characteristic curve determined the predictive value of pCO2 for neonatal morbidity. An additional multivariable logistic regression was used to evaluate the risk of neonatal morbidity in different patterns of UA acidosis. RESULTS UA hypercarbia was associated with an increased risk of neonatal morbidity (RR: 2.56, 95% confidence interval [CI]: [2.07, 3.17]). After adjusting for UA acidemia, this association remained significant (adjusted RR: 1.39, 95% CI: [1.05, 1.83]). UA pCO2 was less predictive of neonatal morbidity than UA pH (area under the curve [AUC]: 0.65, 95% CI: [0.62, 0.68] vs. AUC: 0.72, 95% CI: [0.69, 0.75], p < 0.01). The odds ratios for neonatal morbidity for respiratory, mixed, and metabolic acidosis compared with normal cord gases were 1.48 (95% CI: [0.88, 2.49]), 6.41 (95% CI: [3.68, 11.17]), and 7.49 (95% CI: [5.76, 9.72]), respectively, p-trend < 0.01. CONCLUSION UA hypercarbia is an independent predictor of neonatal morbidity, even in the setting of concomitant UA acidemia. UA mixed and metabolic acidosis carry significantly greater risk of neonatal morbidity compared with respiratory acidosis. KEY POINTS · UA pCO2 is associated with neonatal morbidity.. · UA respiratory acidosis is the UA cord gas pattern least associated with neonatal morbidity.. · UA pH is a superior predictor of neonatal morbidity compared with UA pCO2..
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Affiliation(s)
- Drew Hensel
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Leilah Zahedi-Spung
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Ebony B Carter
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Alison G Cahill
- Department of Women's Health, The University of Texas at Austin Dell Medical School, Austin, Texas
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
| | - Joshua I Rosenbloom
- Division of Maternal-Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
- Faculty of Medicine, Department of Obstetrics and Gynecology, Hadassah Medical Organization, The Hebrew University of Jerusalem, Jerusalem, Israel
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Arad N, Meledin I, Hazan I, Noyman I, Marks KA, Abramsky R, Shany E. The Association of Therapeutic Hypothermia With Seizure Burden in Neonates With Hypoxic-Ischemic Encephalopathy. Pediatr Neurol 2024; 151:143-148. [PMID: 38157720 DOI: 10.1016/j.pediatrneurol.2023.12.005] [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: 07/22/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To compare seizure burden between newborn infants treated with therapeutic hypothermia (TH) and those that were not and to compare the need for antiseizure medications (ASM) in a cohort of infants who were diagnosed with neonatal hypoxic-ischemic encephalopathy (HIE). METHODS This was a retrospective cohort study on infants born after 35 weeks' gestation, diagnosed with moderate to severe HIE, monitored with amplitude-integrated electroencephalography (aEEG) and eligible for TH. Infants born before the implementation of TH in 2008 were compared with infants born thereafter who received TH. Seizure burden was assessed from aEEG as total time in minutes of seizures activity per hour of recording. Other clinical and demographic data were retrieved from a prospective local database of infants with HIE. RESULTS Overall, 149 of 207 infants were included in the study: 112 exposed to TH and 37 not exposed. Cooled infants had a lower seizure burden overall (0.4 vs 2.3 min/h, P < 0.001) and were also less likely to be treated with ASM (74% vs 100%, P < 0.001). In multivariable regression models, not exposed to TH, having a depressed aEEG background, and having higher Apgar scores were associated with higher seizure burden (incidence rate ratio: 4.78 for noncooled infants, P < 0.001); also, not exposed to TH was associated with a higher likelihood of multidrug ASM (odds ratio: 4.83, P < 0.001). CONCLUSIONS TH in infants with moderate to severe HIE is associated with significant reduction of seizure burden and ASM therapy.
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Affiliation(s)
- Noa Arad
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Irina Meledin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Neonatology, Cheryl and Haim Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel
| | - Itai Hazan
- Clinical Research Center, Soroka Medical Center, Beer-Sheva, Israel
| | - Iris Noyman
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Pediatric Neurology Unit, Cheryl and Haim Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel
| | - Kyla A Marks
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Neonatology, Cheryl and Haim Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel
| | - Ramy Abramsky
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Neonatology, Cheryl and Haim Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel
| | - Eilon Shany
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Department of Neonatology, Cheryl and Haim Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel.
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Battin MR, Davis SL, Gardner M, Joe P, Rasmussen M, Haas R, Sharpe C. Seizures after initiation of rewarming in cooled infants with hypoxic ischaemic encephalopathy. Pediatr Res 2024; 95:752-757. [PMID: 37914821 DOI: 10.1038/s41390-023-02863-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Seizures after initiation of rewarming from therapeutic hypothermia for neonatal encephalopathy are well recognised but not easy to predict. METHODS A secondary analysis was performed of NEOLEV2 trial data, a multicentre randomised trial of levetiracetam versus phenobarbital for neonatal seizures. Enrolled infants underwent continuous video EEG (cEEG) monitoring. The trial data were reviewed for 42 infants with seizures during therapeutic hypothermia and 118 infants who received therapeutic hypothermia but had no seizures on cEEG. RESULTS Overall, 112 of 160 (70%) had cEEG monitoring continued until rewarming was completed. Of the 42 infants with prior seizures, there were 30 infants with valid cEEG available and seizures occurred following the initiation of rewarming in 8 (26.6%). For the 118 seizure-naive infants, 82 (69.5%) continued cEEG until either rewarming was completed or 90 h of age and none had documented seizures. CONCLUSION Overall, just over a quarter of infants with prior seizures had cEEG evidence of at least one seizure in the 24 h after initiation of rewarming but no seizure-naive infant had cEEG evidence of seizure(s) on rewarming. Critically, by reporting the two groups separately, the data can provide guidance on the duration of EEG monitoring. IMPACT Infants with hypoxic ischaemic encephalopathy who have cEEG evidence of seizures during therapeutic hypothermia have a significant risk of further seizures on rewarming. For infants with hypoxic ischaemic encephalopathy but no cEEG evidence of seizures during therapeutic hypothermia, there is very little risk of de novo seizures. Ongoing work utilising large cohorts may generate EEG criteria that refine estimates of risk for rewarming seizures. Based on current experience, if seizures have occurred during therapeutic hypothermia for hypoxic ischaemic encephalopathy, the EEG monitoring should be continued during rewarming and for 12 h thereafter to minimise the risk of missing an event.
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Affiliation(s)
| | - Suzanne L Davis
- Paediatric Neurology, Starship Hospital, Auckland, New Zealand
| | - Marisa Gardner
- Pediatric Neurology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Hospital, Oakland, CA, USA
| | - Maynard Rasmussen
- Neonatology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | - Richard Haas
- Department of Neurosciences and Pediatrics, University of California, San Diego, CA, USA
| | - Cynthia Sharpe
- Paediatric Neurology, Starship Hospital, Auckland, New Zealand
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Altınbezer P, Çolak R, Çalkavur Ş, Yılmaz Ü. Epilepsy Frequency and Risk Factors Three Years After Neonatal Seizures. Pediatr Neurol 2023; 149:120-126. [PMID: 37866139 DOI: 10.1016/j.pediatrneurol.2023.09.015] [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: 04/11/2023] [Revised: 07/18/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Neonatal seizures, one of the main risk factors for the development of epilepsy, remain a clinical concern. In children with neonatal seizures, early recognition of risk factors is important for the early diagnosis and appropriate treatment of epilepsy and for improving prognosis. In this study, we aimed to determine the frequency of and the risk factors for the development of epilepsy in patients with neonatal seizures. METHODS The hospital files of 228 children who experienced seizures in the neonatal period were reviewed. The frequency of epilepsy and risk factors for the development of epilepsy were determined at age 36 months. RESULTS Epilepsy was diagnosed in 40.8% of the cases. Univariate analysis revealed family history of epilepsy, parental consanguinity, abnormal neurological examination findings, microcephaly, unresponsiveness to antiepileptic drugs or antiseizure medication, use of more than one antiepileptic drugs to antiseizure medication at discharge, status epilepticus, electroencephalography abnormalities, abnormal neuroimaging findings, invasive ventilation requirement, myoclonic seizures, central nervous system malformation, and congenital metabolic disease as risk factors for the development of epilepsy. Of these, a family history of epilepsy, abnormal neurological examination findings at discharge, and use of at least two antiepileptic drugs to antiseizure medication at discharge were found as independent risk factors in multivariate analysis. CONCLUSIONS Neonatal seizures appear to be associated with epilepsy in more than one-third of the patients. Of the newborns with seizures, those with a family history of epilepsy, abnormal neurological examination findings at discharge, and those using at least two antiepileptic drugs to antiseizure medication at discharge should be monitored more carefully for the development of epilepsy.
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Affiliation(s)
- Pelin Altınbezer
- Department of Pediatrics, Dr. Behçet Uz Children's Education and Research Hospital, University of Health Sciences Turkey, Izmir, Turkey.
| | - Rüya Çolak
- Division of Neonatalogy, Department of Pediatrics, Dr. Behçet Uz Children's Education and Research Hospital, University of Health Sciences Turkey, Izmir, Turkey
| | - Şebnem Çalkavur
- Division of Neonatalogy, Department of Pediatrics, Dr. Behçet Uz Children's Education and Research Hospital, University of Health Sciences Turkey, Izmir, Turkey
| | - Ünsal Yılmaz
- İzmir Faculty of Medicine, Division of Pediatric Neurology, Department of Pediatrics, Dr. Behçet Uz Children's Education and Research Hospital, University of Health Sciences Turkey, Izmir, Turkey
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Pressler RM, Abend NS, Auvin S, Boylan G, Brigo F, Cilio MR, De Vries LS, Elia M, Espeche A, Hahn CD, Inder T, Jette N, Kakooza-Mwesige A, Mader S, Mizrahi EM, Moshé SL, Nagarajan L, Noyman I, Nunes ML, Samia P, Shany E, Shellhaas RA, Subota A, Triki CC, Tsuchida T, Vinayan KP, Wilmshurst JM, Yozawitz EG, Hartmann H. Treatment of seizures in the neonate: Guidelines and consensus-based recommendations-Special report from the ILAE Task Force on Neonatal Seizures. Epilepsia 2023; 64:2550-2570. [PMID: 37655702 DOI: 10.1111/epi.17745] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 09/02/2023]
Abstract
Seizures are common in neonates, but there is substantial management variability. The Neonatal Task Force of the International League Against Epilepsy (ILAE) developed evidence-based recommendations about antiseizure medication (ASM) management in neonates in accordance with ILAE standards. Six priority questions were formulated, a systematic literature review and meta-analysis were performed, and results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 standards. Bias was evaluated using the Cochrane tool and risk of Bias in non-randomised studies - of interventions (ROBINS-I), and quality of evidence was evaluated using grading of recommendations, assessment, development and evaluation (GRADE). If insufficient evidence was available, then expert opinion was sought using Delphi consensus methodology. The strength of recommendations was defined according to the ILAE Clinical Practice Guidelines development tool. There were six main recommendations. First, phenobarbital should be the first-line ASM (evidence-based recommendation) regardless of etiology (expert agreement), unless channelopathy is likely the cause for seizures (e.g., due to family history), in which case phenytoin or carbamazepine should be used. Second, among neonates with seizures not responding to first-line ASM, phenytoin, levetiracetam, midazolam, or lidocaine may be used as a second-line ASM (expert agreement). In neonates with cardiac disorders, levetiracetam may be the preferred second-line ASM (expert agreement). Third, following cessation of acute provoked seizures without evidence for neonatal-onset epilepsy, ASMs should be discontinued before discharge home, regardless of magnetic resonance imaging or electroencephalographic findings (expert agreement). Fourth, therapeutic hypothermia may reduce seizure burden in neonates with hypoxic-ischemic encephalopathy (evidence-based recommendation). Fifth, treating neonatal seizures (including electrographic-only seizures) to achieve a lower seizure burden may be associated with improved outcome (expert agreement). Sixth, a trial of pyridoxine may be attempted in neonates presenting with clinical features of vitamin B6-dependent epilepsy and seizures unresponsive to second-line ASM (expert agreement). Additional considerations include a standardized pathway for the management of neonatal seizures in each neonatal unit and informing parents/guardians about the diagnosis of seizures and initial treatment options.
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Affiliation(s)
- Ronit M Pressler
- Clinical Neuroscience, 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
| | - Nicholas S Abend
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stéphan Auvin
- Department Medico-Universitaire Innovation Robert-Debré, Robert Debré Hospital, Public Hospital Network of Paris, Pediatric Neurology, University of Paris, Paris, France
| | - Geraldine Boylan
- INFANT Research Centre, University College Cork, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of Paracelsus Medical Private University, Bolzano-Bozen, Italy
| | - Maria Roberta Cilio
- Division of Pediatric Neurology, Saint-Luc University Hospital, and Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Linda S De Vries
- Department of Neonatology, University Medical Center, Utrecht, the Netherlands
| | - Maurizio Elia
- Unit of Neurology and Clinical Neurophysiopathology, Oasi Research Institute-IRCCS, Troina, Italy
| | - Alberto Espeche
- Department of Neurology, Hospital Materno Infantil, Salta, Argentina
| | - Cecil D Hahn
- Department of Pediatrics, Division of Neurology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Terrie Inder
- Department of Pediatrics, Newborn Medicine, Children's Hospital of Orange County, University of California, Irvine, Irvine, California, USA
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angelina Kakooza-Mwesige
- Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Silke Mader
- Scientific Affairs, European Foundation for the Care of Newborn Infants, Munich, Germany
| | - Eli M Mizrahi
- Departments of Neurology and Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Solomon L Moshé
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
- Departments of Neuroscience and Pediatrics, Albert Einstein College of Medicine, and Montefiore Medical Center, Bronx, New York, USA
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital and University of Western Australia, Nedlands, Western Australia, Australia
| | - Iris Noyman
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Pediatric Neurology Unit, Pediatric Division, Soroka Medical Center, Beer-Sheva, Israel
| | - Magda L Nunes
- Pontifícia Universidade Católica do Rio Grande do Sul-PUCRS School of Medicine and the Brain Institute, Porto Alegre, Brazil
| | - Pauline Samia
- Departments of Pediatrics and Child Health, Aga Khan University, Nairobi, Kenya
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Eilon Shany
- Department of Neonatology, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Renée A Shellhaas
- Department of Neurology, Washington University, St. Louis, Missouri, USA
| | - Ann Subota
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chahnez Charfi Triki
- Child Neurology Department, Hedi Chaker Hospital, Sfax Medical School, University of Sfax, Sfax, Tunisia
| | - Tammy Tsuchida
- Departments of Neurology and Pediatrics, Children's National Health System, George Washington University School of Medicine, Washington, District of Columbia, USA
| | | | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Elissa G Yozawitz
- Isabelle Rapin Division of Child Neurology, Saul R. Korey Department of Neurology, Montefiore Medical Center, Bronx, New York, USA
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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11
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McKee JL, Kaufman MC, Gonzalez AK, Fitzgerald MP, Massey SL, Fung F, Kessler SK, Witzman S, Abend NS, Helbig I. Leveraging electronic medical record-embedded standardised electroencephalogram reporting to develop neonatal seizure prediction models: a retrospective cohort study. Lancet Digit Health 2023; 5:e217-e226. [PMID: 36963911 PMCID: PMC10065843 DOI: 10.1016/s2589-7500(23)00004-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 11/09/2022] [Accepted: 01/06/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Accurate prediction of seizures can help to direct resource-intense continuous electroencephalogram (CEEG) monitoring to neonates at high risk of seizures. We aimed to use data from standardised EEG reports to generate seizure prediction models for vulnerable neonates. METHODS In this retrospective cohort study, we included neonates who underwent CEEG during the first 30 days of life at the Children's Hospital of Philadelphia (Philadelphia, PA, USA). The hypoxic ischaemic encephalopathy subgroup included only patients with CEEG data during the first 5 days of life, International Classification of Diseases, revision 10, codes for hypoxic ischaemic encephalopathy, and documented therapeutic hypothermia. In January, 2018, we implemented a novel CEEG reporting system within the electronic medical record (EMR) using common data elements that incorporated standardised terminology. All neonatal CEEG data from Jan 10, 2018, to Feb 15, 2022, were extracted from the EMR using age at the time of CEEG. We developed logistic regression, decision tree, and random forest models of neonatal seizure prediction using EEG features on day 1 to predict seizures on future days. FINDINGS We evaluated 1117 neonates, including 150 neonates with hypoxic ischaemic encephalopathy, with CEEG data reported using standardised templates between Jan 10, 2018, and Feb 15, 2022. Implementation of a consistent EEG reporting system that documents discrete and standardised EEG variables resulted in more than 95% reporting of key EEG features. Several EEG features were highly correlated, and patients could be clustered on the basis of specific features. However, no simple combination of features adequately predicted seizure risk. We therefore applied computational models to complement clinical identification of neonates at high risk of seizures. Random forest models incorporating background features performed with classification accuracies of up to 90% (95% CI 83-94) for all neonates and 97% (88-99) for neonates with hypoxic ischaemic encephalopathy; recall (sensitivity) of up to 97% (91-100) for all neonates and 100% (100-100) for neonates with hypoxic ischaemic encephalopathy; and precision (positive predictive value) of up to 92% (84-96) in the overall cohort and 97% (80-99) in neonates with hypoxic ischaemic encephalopathy. INTERPRETATION Using data extracted from the standardised EEG report on the first day of CEEG, we predict the presence or absence of neonatal seizures on subsequent days with classification performances of more than 90%. This information, incorporated into routine care, could guide decisions about the necessity of continuing EEG monitoring beyond the first day, thereby improving the allocation of limited CEEG resources. Additionally, this analysis shows the benefits of standardised clinical data collection, which can drive learning health system approaches to personalised CEEG use. FUNDING Children's Hospital of Philadelphia, the Hartwell Foundation, the National Institute of Neurological Disorders and Stroke, and the Wolfson Foundation.
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Affiliation(s)
- Jillian L McKee
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael C Kaufman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander K Gonzalez
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P Fitzgerald
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shavonne L Massey
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - France Fung
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sudha K Kessler
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephanie Witzman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas S Abend
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Anesthesia and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ingo Helbig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA; The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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12
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Pavel AM, O'Toole JM, Proietti J, Livingstone V, Mitra S, Marnane WP, Finder M, Dempsey EM, Murray DM, Boylan GB. Machine learning for the early prediction of infants with electrographic seizures in neonatal hypoxic-ischemic encephalopathy. Epilepsia 2023; 64:456-468. [PMID: 36398397 PMCID: PMC10107538 DOI: 10.1111/epi.17468] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 10/26/2022] [Accepted: 11/15/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess if early clinical and electroencephalography (EEG) features predict later seizure development in infants with hypoxic-ischemic encephalopathy (HIE). METHODS Clinical and EEG parameters <12 h of birth from infants with HIE across eight European Neonatal Units were used to develop seizure-prediction models. Clinical parameters included intrapartum complications, fetal distress, gestational age, delivery mode, gender, birth weight, Apgar scores, assisted ventilation, cord pH, and blood gases. The earliest EEG hour provided a qualitative analysis (discontinuity, amplitude, asymmetry/asynchrony, sleep-wake cycle [SWC]) and a quantitative analysis (power, discontinuity, spectral distribution, inter-hemispheric connectivity) from full montage and two-channel amplitude-integrated EEG (aEEG). Subgroup analysis, only including infants without anti-seizure medication (ASM) prior to EEG was also performed. Machine-learning (ML) models (random forest and gradient boosting algorithms) were developed to predict infants who would later develop seizures and assessed using Matthews correlation coefficient (MCC) and area under the receiver-operating characteristic curve (AUC). RESULTS The study included 162 infants with HIE (53 had seizures). Low Apgar, need for ventilation, high lactate, low base excess, absent SWC, low EEG power, and increased EEG discontinuity were associated with seizures. The following predictive models were developed: clinical (MCC 0.368, AUC 0.681), qualitative EEG (MCC 0.467, AUC 0.729), quantitative EEG (MCC 0.473, AUC 0.730), clinical and qualitative EEG (MCC 0.470, AUC 0.721), and clinical and quantitative EEG (MCC 0.513, AUC 0.746). The clinical and qualitative-EEG model significantly outperformed the clinical model alone (MCC 0.470 vs 0.368, p-value .037). The clinical and quantitative-EEG model significantly outperformed the clinical model (MCC 0.513 vs 0.368, p-value .012). The clinical and quantitative-EEG model for infants without ASM (n = 131) had MCC 0.588, AUC 0.832. Performance for quantitative aEEG (n = 159) was MCC 0.381, AUC 0.696 and clinical and quantitative aEEG was MCC 0.384, AUC 0.720. SIGNIFICANCE Early EEG background analysis combined with readily available clinical data helped predict infants who were at highest risk of seizures, hours before they occur. Automated quantitative-EEG analysis was as good as expert analysis for predicting seizures, supporting the use of automated assessment tools for early evaluation of HIE.
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Affiliation(s)
- Andreea M. Pavel
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - John M. O'Toole
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | | | - Vicki Livingstone
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | | | - William P. Marnane
- INFANT Research CentreUniversity College CorkCorkIreland
- Electrical & Electronic EngineeringSchool of EngineeringUniversity College CorkCorkIreland
| | - Mikael Finder
- Department of Neonatal MedicineKarolinska University HospitalStockholmSweden
- Division of Paediatrics, Department CLINTECKarolinska InstitutetStockholmSweden
| | - Eugene M. Dempsey
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - Deirdre M. Murray
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
| | - Geraldine B. Boylan
- INFANT Research CentreUniversity College CorkCorkIreland
- Department of Paediatrics and Child HealthUniversity College CorkCorkIreland
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Guidotti I, Lugli L, Ori L, Roversi MF, Casa Muttini ED, Bedetti L, Pugliese M, Cavalleri F, Stefanelli F, Ferrari F, Berardi A. Neonatal seizures treatment based on conventional multichannel EEG monitoring: an overview of therapeutic options. Expert Rev Neurother 2022; 22:623-638. [PMID: 35876114 DOI: 10.1080/14737175.2022.2105698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Seizures are the main neurological emergency during the neonatal period and are mostly acute and focal. The prognosis mainly depends on the underlying etiology. Conventional multichannel video-electroencephalographic (cEEG) monitoring is the gold standard for diagnosis, but treatment remains a challenge. AREAS COVERED : This review, based on PubMed search over the last 4 decades, focuses on the current treatment options for neonatal seizures based on cEEG monitoring. There is still no consensus on seizure therapy, owing to poor scientific evidence. Traditionally, the first-line treatments are phenobarbital and phenytoin, followed by midazolam and lidocaine, but their efficacy is limited. Therefore, current evidence strongly suggests the use of alternative antiseizure medications. Randomized controlled trials of new drugs are ongoing. EXPERT OPINION : Therapy for neonatal seizures should be prompt and tailored, based on semeiology, mirror of the underlying cause, and cEEG features. Further research should focus on antiseizure medications that directly act on the etiopathogenetic mechanism responsible for seizures and are therefore more effective in seizure control.
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Affiliation(s)
- Isotta Guidotti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Licia Lugli
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Ori
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Maria Federica Roversi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Elisa Della Casa Muttini
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Luca Bedetti
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Marisa Pugliese
- 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
| | - Francesca Stefanelli
- Department of Medical and Surgical Sciences of the Mothers, Children and Adults, Post Graduate School of Pediatrics, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Ferrari
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
| | - Alberto Berardi
- Division of Neonatology and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital, Modena, Italy
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Hensel D, Zhang F, Carter EB, Frolova AI, Odibo AO, Kelly JC, Cahill AG, Raghuraman N. Severity of intrapartum fever and neonatal outcomes. Am J Obstet Gynecol 2022; 227:513.e1-513.e8. [PMID: 35598690 DOI: 10.1016/j.ajog.2022.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/06/2022] [Accepted: 05/12/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The few studies that have addressed the relationship between severity of intrapartum fever and neonatal and maternal morbidity have had mixed results. The impact of the duration between reaching maximum intrapartum temperature and delivery on neonatal outcomes remains unknown. OBJECTIVE To test the association of severity of intrapartum fever and duration from reaching maximum temperature to delivery with neonatal and maternal morbidity. STUDY DESIGN This was a secondary analysis of a prospective cohort of term, singleton patients admitted for induction of labor or spontaneous labor who had intrapartum fever (≥38°C). Patients were divided into 3 groups according to maximum temperature during labor: afebrile (<38°C), mild fever (38°C-39°C), and severe fever (>39°C). The primary outcome was composite neonatal morbidity (umbilical artery pH <7.1, mechanical ventilation, respiratory distress, meconium aspiration with pulmonary hypertension, hypoglycemia, neonatal intensive care unit admission, and Apgar <7 at 5 minutes). Secondary outcomes were composite neonatal neurologic morbidity (hypoxic-ischemic encephalopathy, hypothermia treatment, and seizures) and composite maternal morbidity (postpartum hemorrhage, endometritis, and maternal packed red blood cell transfusion). Outcomes were compared between the maximum temperature groups using multivariable logistic regression. Cox proportional-hazards regression modeling accounted for the duration between reaching maximum intrapartum temperature and delivery. RESULTS Of the 8132 patients included, 278 (3.4%) had a mild fever and 74 (0.9%) had a severe fever. The incidence of composite neonatal morbidity increased with intrapartum fever severity (afebrile 5.4% vs mild 18.0% vs severe 29.7%; P<.01). After adjusting for confounders, there were increased odds of composite neonatal morbidity with severe fever compared with mild fever (adjusted odds ratio, 1.93 [95% confidence interval, 1.07-3.48]). Severe fevers remained associated with composite neonatal morbidity compared with mild fevers after accounting for the duration between reaching maximum intrapartum temperature and delivery (adjusted hazard ratio, 2.05 [95% confidence interval, 1.23-3.43]). Composite neonatal neurologic morbidity and composite maternal morbidity were not different between patients with mild and patients with severe fevers. CONCLUSION Composite neonatal morbidity correlated with intrapartum fever severity in a potentially dose-dependent fashion. This correlation was independent of the duration from reaching maximum intrapartum temperature to delivery, suggesting that clinical management of intrapartum fever, in terms of timing or mode of delivery, should not be affected by this duration.
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15
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Deep nuclei injury distribution in isolated “basal ganglia–thalamus” (BGT) versus combined “BGT and watershed” patterns of hypoxic–ischaemic injury (HII) in children with cerebral palsy. Clin Radiol 2022; 77:825-832. [DOI: 10.1016/j.crad.2022.04.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/27/2022] [Indexed: 11/22/2022]
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16
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Bor M, Ilhan O, Karaca M, Calik M. Risk Factors for Clinical Seizures in Neonates with Hypoxic-ischemic Encephalopathy Treated with Therapeutic Hypothermia. KLINISCHE PADIATRIE 2022; 234:206-214. [PMID: 35231937 DOI: 10.1055/a-1731-7773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study aimed to assess the risk factors for clinical seizures in newborns treated with whole body cooling (WBC) for hypoxic ischemic encephalopathy (HIE). METHODS Infants with gestational age≥36 weeks and birth weight≥2.000 g who were treated with WBC due to HIE were retrospectively enrolled in this study. Patients were assigned to two groups: infants without clinical seizures (Group 1) and infants with clinical seizures (Group 2). The two groups were compared to determine the risk factors for the occurrence of clinical seizures. RESULTS A total of 25 patients (Group 1=10 and Group 2=15) were included in the study. Prothrombin time (PT) was determined as independent risk factor for clinical seizures (p=0.046) and the odds ratio for the effect of PT was found as 1.475 (%95 CI:1.006-2.299). PT (area under the curve [AUC]=0.764; p=0.041), and increased cardiac troponin-I (cTnI) (AUC=0.935; p=0.002) were found to be significant risk factors for predicting the occurrence of clinical seizures. The optimal PT cut-off value was 22.7 sec, with a sensitivity and specificity of 45.4% and 90%, respectively; as well as positive and negative predictive value of 83.3% and 60.0%, respectively. The chest compression in the delivery room, severely abnormal amplitude integrated electroencephalography and high encephalopathy score were also found risk factors for occurrence of clinical seizures. CONCLUSION Chest compression in the delivery room, high encephalopathy score, prolonged PT, and increased cTnI are significant factors for clinical seizures in newborns treated with WBC for HIE.
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Affiliation(s)
- Meltem Bor
- Department of Pediatrics, Division of Neonatology, Harran University School of Medicine, Sanliurfa, Turkey
| | - Ozkan Ilhan
- Department of Pediatrics, Division of Neonatology, Harran University School of Medicine, Sanliurfa, Turkey.,Department of Pediatrics, Division of Neonatology, Mugla Sitki Kocman University School of Medicine, Mugla, Turkey
| | - Meryem Karaca
- Department of Pediatrics, Division of Pediatric Metabolism and Nutrition, Harran University School of Medicine, Sanliurfa, Turkey
| | - Mustafa Calik
- Department of Pediatrics, Division of Pediatric Neurology, Harran University School of Medicine, Sanliurfa, Turkey
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17
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Chen MW, Lee JK, Vezina G, Tekes A, Perin J, Li R, O’Kane A, McGowan M, Chang T, Parkinson C, Krein C, Al-Shargabi T, Northington FJ, Brady KM, Massaro AN, Govindan RB. The Utility of Cerebral Autoregulation Indices in Detecting Severe Brain Injury Varies by Cooling Treatment Phase in Neonates with Hypoxic-Ischemic Encephalopathy. Dev Neurosci 2022; 44:363-372. [PMID: 35100588 PMCID: PMC9828944 DOI: 10.1159/000522314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/27/2022] [Indexed: 01/12/2023] Open
Abstract
Identifying the hemodynamic range that best supports cerebral perfusion using near infrared spectroscopy (NIRS) autoregulation monitoring is a potential physiologic marker for neonatal hypoxic-ischemic encephalopathy (HIE) during therapeutic hypothermia. However, an optimal autoregulation monitoring algorithm has not been identified for neonatal clinical medicine. We tested whether the hemoglobin volume phase (HVP), hemoglobin volume (HVx), and pressure passivity index (PPI) identify changes in autoregulation that are associated with brain injury on MRI or death. The HVP measures the phase difference between a NIRS metric of cerebral blood volume, the total hemoglobin (THb), and mean arterial blood pressure (MAP) at the frequency of maximum coherence. The HVx is the correlation coefficient between MAP and THb. The PPI is the percentage of coherent MAP-DHb (difference between oxygenated and deoxygenated hemoglobin, a marker of cerebral blood flow) epochs in a chosen time period. Neonates cooled for HIE were prospectively enrolled in an observational study in two neonatal intensive care units. In analyses adjusted for study site and encephalopathy level, all indices detected relationships between poor autoregulation in the first 6 h after rewarming with a higher injury score on MRI. Only HVx and PPI during hypothermia and the PPI during rewarming identified autoregulatory dysfunction associated with a poor outcome independent of study site and encephalopathy level. Our findings suggest that the accuracy of mathematical autoregulation algorithms in detecting the risk of brain injury or death may depend on temperature and postnatal age. Extending autoregulation monitoring beyond the standard 72 h of therapeutic hypothermia may serve as a method to provide personalized care by assessing the need for and efficacy of future therapies after the hypothermia treatment phase.
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Affiliation(s)
- May W. Chen
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gilbert Vezina
- Division of Diagnostic Imaging and Radiology, Children’s National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ruoying Li
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Alexandra O’Kane
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Meaghan McGowan
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Taeun Chang
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Neurology, Children’s National Hospital, Washington, DC, USA
| | - Charlamaine Parkinson
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Colleen Krein
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
| | - Tareq Al-Shargabi
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
| | - Frances J. Northington
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ken M. Brady
- Department of Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - An N. Massaro
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Neonatology, Children’s National Hospital, Washington, DC, USA
| | - Rathinaswamy B. Govindan
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Prenatal Pediatrics Institute, Children’s National Hospital, Washington, DC, USA
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18
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Schüssler SC, Schmidt M, Deiters L, Candova A, Fahlbusch FB, Trollmann R. Long-term outcomes of very-low-birth-weight and low-birth-weight preterm newborns with neonatal seizures: A single-center perspective. Eur J Paediatr Neurol 2022; 36:137-142. [PMID: 34973622 DOI: 10.1016/j.ejpn.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/17/2021] [Accepted: 12/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Newborn seizures are frequent in preterm newborns and indicate brain lesions in many cases. The objective of this observational study was to investigate the long-term outcome of very-low-birth-weight (VLBW) and low-birth-weight (LBW) preterm infants with neonatal seizures. METHODS We examined 54 preterm infants (40 VLBW and 14 LBW cases) born between 2008 and 2011 with clinical seizures during the neonatal period confirmed by interictal or ictal electroencephalography recordings in a retrospective single-center study. Neurodevelopmental follow-up included an expert neurological examination and cognitive testing (Kaufman Assessment Battery for Children) at a mean age of six years. RESULTS The (mean ± standard deviation) gestational ages of the VLBW and LBW infants were 27.2 ± 1.9 weeks and 33.4 ± 1.7 weeks, respectively, and the postnatal age at seizure onset was 13 ± 11 days in VLBW infants and 9 ± 8 days in LBW infants, with a wide range of one to 62 days. LBW infants more frequently developed non-motor seizures (50.0%) than VLBW infants did (25.0%), and higher-grade intracranial hemorrhage was the predominant etiology in the VLBW group (18.0%), while the etiology in the LBW group was more heterogeneous and included central nervous system malformations and genetic syndromes. At the mean age of 6.2 ± 2.0, years, 25/54 patients were assessed and 44.4% of the VLBW group and 71.4% of the LBW group showed intellectual impairment. Infantile cerebral palsy was present in 22% of VLBW and 42.9% of LBW infants, respectively. SIGNIFICANCE The present analysis of long-term neurodevelopmental outcomes of preterm neonates who experienced seizures shows that the risk for intellectual impairment is not limited only to VLBW infants but may significantly affect LBW infants as well. The etiological spectrum differs in relation to gestational age.
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Affiliation(s)
- S C Schüssler
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - M Schmidt
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - L Deiters
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - A Candova
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - F B Fahlbusch
- Department of Pediatrics, Division of Neonatology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - R Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Erlangen, Germany.
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19
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Shipley L, Mistry A, Sharkey D. Outcomes of neonatal hypoxic-ischaemic encephalopathy in centres with and without active therapeutic hypothermia: a nationwide propensity score-matched analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:6-12. [PMID: 34045283 DOI: 10.1136/archdischild-2020-320966] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 05/12/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Therapeutic hypothermia (TH) for neonatal hypoxic-ischaemic encephalopathy (HIE), delivered mainly in tertiary cooling centres (CCs), reduces mortality and neurodisability. It is unknown if birth in a non-cooling centre (non-CC), without active TH, impacts short-term outcomes. DESIGN Retrospective cohort study using National Neonatal Research Database and propensity score-matching. SETTING UK neonatal units. PATIENTS Infants ≥36 weeks gestational age with moderate or severe HIE admitted 2011-2016. INTERVENTIONS Birth in non-CC compared with CC. MAIN OUTCOME MEASURES Primary outcome was survival to discharge without recorded seizures. Secondary outcomes were recorded seizures, mortality and temperature on arrival at CCs following transfer. RESULTS 5059 infants were included with 2364 (46.7%) born in non-CCs. Birth in a CC was associated with improved survival without seizures (35.1% vs 31.8%; OR 1.15, 95% CI 1.02 to 1.31; p=0.02), fewer seizures (60.7% vs 64.6%; OR 0.84, 95% CI 0.75 to 0.95, p=0.007) and similar mortality (15.8% vs 14.4%; OR 1.11, 95% CI 0.93 to 1.31, p=0.20) compared with birth in a non-CC. Matched infants from level 2 centres only had similar results, and birth in CCs was associated with greater seizure-free survival compared with non-CCs. Following transfer from a non-CC to a CC (n=2027), 1362 (67.1%) infants arrived with a recorded optimal therapeutic temperature but only 259 (12.7%) of these arrived within 6 hours of birth. CONCLUSIONS Almost half of UK infants with HIE were born in a non-CC, which was associated with suboptimal hypothermic treatment and reduced seizure-free survival. Provision of active TH in non-CC hospitals prior to upward transfer warrants consideration.
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Affiliation(s)
- Lara Shipley
- Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aarti Mistry
- Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Academic Child Health, School of Medicine, University of Nottingham, Nottingham, UK
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20
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Sun X, Xue F, Wen J, Gao L, Li Y, Jiang Q, Yang L, Cui H. Seizure Characteristics and Background Amplitude-Integrated Electroencephalography Activity in Neonatal Rats Subjected to Hypoxia-Ischemia. Front Pediatr 2022; 10:837909. [PMID: 35463911 PMCID: PMC9021695 DOI: 10.3389/fped.2022.837909] [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: 12/17/2021] [Accepted: 02/14/2022] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Perinatal hypoxic-ischemic encephalopathy (HIE) is a major cause of epilepsy and chronic neurologic morbidity in premature infants. This study aimed to investigate the characteristics of acute seizures and the pattern of background activity on amplitude-integrated electroencephalography (aEEG) in neonatal rats with HIE. METHODS Hypoxia-ischemia (HI) was induced in postnatal day (P) 3 neonatal rats (n = 12) by ligation of the left carotid artery and exposure to airtight hypoxia for 2 h. Data regarding seizure type, frequency, and duration and those related to neurobehavioral development were collected, and the integrated power of background EEG was analyzed to evaluate the effect of HI. RESULTS All neonatal rats in the HI group experienced frequent seizures during hypoxia, and 83.3% of rats (10/12) experienced seizures immediately after hypoxia. Seizure frequency and duration gradually decreased with increasing age. The mortality rate of the HI group was 8.33% (1/12); 120 h after HI induction, only 27.3% (3/11) of pups had low-frequency and short-duration electrographic seizures, respectively. HI rats, which presented seizure activities 96 h after HI insult, exhibited an increase in righting reflex time and a decrease in forelimb grip reflex time. Background EEG was significantly inhibited during HI induction and immediately after hypoxia and gradually recovered 72 h after hypoxia. CONCLUSION Seizures caused by HI brain damage in premature infants can be simulated in the P3 neonatal rat model.
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Affiliation(s)
- Xiaowei Sun
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Fenqin Xue
- Core Facility Center, Capital Medical University, Beijing, China
| | - Jialin Wen
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Limin Gao
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yang Li
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Qianqian Jiang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Lijun Yang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hong Cui
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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21
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Fitzgerald MP, Massey SL, Fung FW, Puopolo KM, Posencheg M, Allen-Napoli L, Malcolm M, Abend NS. Expanding Access to Continuous EEG Monitoring in Neonatal Intensive Care Units. J Clin Neurophysiol 2021; 38:525-529. [PMID: 32541608 DOI: 10.1097/wnp.0000000000000730] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Neonatal seizures are common and difficult to identify clinically because the majority are subclinical and correct identification of electroclinical seizures based on semiology is unreliable. Therefore, continuous EEG monitoring (CEEG) is critical for seizure identification in neonates and is recommended as the gold standard method in American Clinical Neurophysiology Society guidelines. Despite these recommendations, barriers to implementing widespread CEEG exist. METHODS To expand access to CEEG for at-risk neonates, a framework for providing remote CEEG was established at two network hospital neonatal intensive care units. Utilization and clinical impact were tracked as a quality improvement study. RESULTS In a 27-month period from June 2017 through September 2019, 76 neonates underwent CEEG between the two network neonatal intensive care units. Electrographic seizures occurred in about one quarter of records (18/76; 24%), though their incidence varied by CEEG indication. Care notes indicated that CEEG impacted clinical care in three quarters of cases (57/76; 75%). Continuous EEG impacted decisions to treat with anti-seizure medications in approximately one half of patients (impact: 28/57 [49%]; no impact 29/57 [51%]), and CEEG impacted prognostic discussions in approximately two thirds of patients (impact: 39/57 [68%]; no impact 18/57 [32%]). CONCLUSIONS Establishment of a remote CEEG program for neonates is feasible, effective at identifying seizures, and improves the quality of care provided to neonates hospitalized at these network hospitals.
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Affiliation(s)
- Mark P Fitzgerald
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
| | - Shavonne L Massey
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
| | - France W Fung
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
| | - Karen M Puopolo
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Michael Posencheg
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
| | - Linda Allen-Napoli
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
| | - Marissa Malcolm
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
| | - Nicholas S Abend
- Division of Neurology, Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A.; and
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Davidson JO, Gonzalez F, Gressens P, Gunn AJ. Update on mechanisms of the pathophysiology of neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101267. [PMID: 34274259 DOI: 10.1016/j.siny.2021.101267] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Therapeutic hypothermia is now well established to significantly improve survival without disability after neonatal encephalopathy (NE). To further improve outcomes, we need to better understand the mechanisms of brain injury. The central finding, which offers the potential for neuroprotective and neurorestorative interventions, is that brain damage after perinatal hypoxia-ischemia evolves slowly over time. Although brain cells may die during profound hypoxia-ischemia, even after surprisingly severe insults many cells show transient recovery of oxidative metabolism during a "latent" phase characterized by actively suppressed neural metabolism and activity. Critically, after moderate to severe hypoxia-ischemia, this transient recovery is followed after ~6 h by a phase of secondary deterioration, with delayed seizures, failure of mitochondrial function, cytotoxic edema, and cell death over ~72 h. This is followed by a tertiary phase of remodeling and recovery. This review discusses the mechanisms of injury that occur during the primary, latent, secondary and tertiary phases of injury and potential treatments that target one or more of these phases. By analogy with therapeutic hypothermia, treatment as early as possible in the latent phase is likely to have the greatest potential to prevent injury ("neuroprotection"). In the secondary phase of injury, anticonvulsants can attenuate seizures, but show limited neuroprotection. Encouragingly, there is now increasing preclinical evidence that late, neurorestorative interventions have potential to improve long-term outcomes.
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Affiliation(s)
- Joanne O Davidson
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
| | - Fernando Gonzalez
- Department of Pediatrics, University of California, San Francisco, CA, USA.
| | | | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand.
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23
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Tetorou K, Sisa C, Iqbal A, Dhillon K, Hristova M. Current Therapies for Neonatal Hypoxic-Ischaemic and Infection-Sensitised Hypoxic-Ischaemic Brain Damage. Front Synaptic Neurosci 2021; 13:709301. [PMID: 34504417 PMCID: PMC8421799 DOI: 10.3389/fnsyn.2021.709301] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
Neonatal hypoxic-ischaemic brain damage is a leading cause of child mortality and morbidity, including cerebral palsy, epilepsy, and cognitive disabilities. The majority of neonatal hypoxic-ischaemic cases arise as a result of impaired cerebral perfusion to the foetus attributed to uterine, placental, or umbilical cord compromise prior to or during delivery. Bacterial infection is a factor contributing to the damage and is recorded in more than half of preterm births. Exposure to infection exacerbates neuronal hypoxic-ischaemic damage thus leading to a phenomenon called infection-sensitised hypoxic-ischaemic brain injury. Models of neonatal hypoxia-ischaemia (HI) have been developed in different animals. Both human and animal studies show that the developmental stage and the severity of the HI insult affect the selective regional vulnerability of the brain to damage, as well as the subsequent clinical manifestations. Therapeutic hypothermia (TH) is the only clinically approved treatment for neonatal HI. However, the number of HI infants needed to treat with TH for one to be saved from death or disability at age of 18-22 months, is approximately 6-7, which highlights the need for additional or alternative treatments to replace TH or increase its efficiency. In this review we discuss the mechanisms of HI injury to the immature brain and the new experimental treatments studied for neonatal HI and infection-sensitised neonatal HI.
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Affiliation(s)
| | | | | | | | - Mariya Hristova
- Perinatal Brain Repair Group, Department of Maternal and Fetal Medicine, UCL Institute for Women’s Health, London, United Kingdom
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24
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DeLaGarza-Pineda O, Mailo JA, Boylan G, Chau V, Glass HC, Mathur AM, Shellhaas RA, Soul JS, Wusthoff CJ, Chang T. Management of seizures in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101279. [PMID: 34563467 DOI: 10.1016/j.siny.2021.101279] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Neonatal encephalopathy (NE) is the most common etiology of acute neonatal seizures - about half of neonates treated with therapeutic hypothermia for NE have EEG-confirmed seizures. These seizures are best identified with continuous EEG monitoring, as clinical diagnosis leads to under-diagnosis of subclinical seizures and over-treatment of events that are not seizures. High seizure burden, especially status epilepticus, is thought to augment brain injury. Treatment, therefore, is aimed at minimizing seizure burden. Phenobarbital remains the mainstay of treatment, as it is more effective than levetiracetam and easier to administer than fosphenytoin. Emerging evidence suggests that, for many neonates, it is safe to discontinue the phenobarbital after acute seizures resolve and prior to hospital discharge.
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Affiliation(s)
- Oscar DeLaGarza-Pineda
- Department of Neurology, University Hospital "Dr. Jose E. Gonzalez", Monterrey, Nuevo León, Mexico.
| | - Janette A Mailo
- Neurology & Pediatrics, Stollery Children's Hospital and Glenrose Rehabilitation Hospital University of Alberta, Alberta, Canada.
| | - Geraldine Boylan
- Department of Pediatrics & Child Health University College Cork, Cork, Ireland.
| | - Vann Chau
- Division of Neurology, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Saint Louis University School of Medicine, SSM-Health Cardinal Glennon Children's Hospital, Saint Louis, MO, USA.
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Janet S Soul
- Neurology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics-Neonatal and Developmental Medicine Stanford Children's Health, Palo Alto, CA, USA.
| | - Taeun Chang
- Neurology & Pediatrics, George Washington University School of Medicine & Health Sciences, Children's National Hospital, Washington, DC, USA.
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25
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Pospelov AS, Ala-Kurikka T, Kurki S, Voipio J, Kaila K. Carbonic anhydrase inhibitors suppress seizures in a rat model of birth asphyxia. Epilepsia 2021; 62:1971-1984. [PMID: 34180051 DOI: 10.1111/epi.16963] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Seizures are common in neonates recovering from birth asphyxia but there is general consensus that current pharmacotherapy is suboptimal and that novel antiseizure drugs are needed. We recently showed in a rat model of birth asphyxia that seizures are triggered by the post-asphyxia recovery of brain pH. Here our aim was to investigate whether carbonic anhydrase inhibitors (CAIs), which induce systemic acidosis, block the post-asphyxia seizures. METHODS The CAIs acetazolamide (AZA), benzolamide (BZA), and ethoxzolamide (EZA) were administered intraperitoneally or intravenously to 11-day-old rats exposed to intermittent asphyxia (30 min; three 7+3 min cycles of 9% and 5% O2 at 20% CO2 ). Electrode measurements of intracortical pH, Po2 , and local field potentials (LFPs) were made under urethane anesthesia. Convulsive seizures and blood acid-base parameters were examined in freely behaving animals. RESULTS The three CAIs decreased brain pH by 0.14-0.17 pH units and suppressed electrographic post-asphyxia seizures. AZA, BZA, and EZA differ greatly in their lipid solubility (EZA > AZA > BZA) and pharmacokinetics. However, there were only minor differences in the delay (range 0.8-3.7 min) from intraperitoneal application to their action on brain pH. The CAIs induced a modest post-asphyxia elevation of brain Po2 that had no effect on LFP activity. AZA was tested in freely behaving rats, in which it induced a respiratory acidosis and decreased the incidence of convulsive seizures from 9 of 20 to 2 of 17 animals. SIGNIFICANCE AZA, BZA, and EZA effectively block post-asphyxia seizures. Despite the differences in their pharmacokinetics, they had similar effects on brain pH, which indicates that their antiseizure mode of action was based on respiratory (hypercapnic) acidosis resulting from inhibition of blood-borne and extracellular vascular carbonic anhydrases. AZA has been used for several indications in neonates, suggesting that it can be safely repurposed for the treatment of neonatal seizures as an add-on to the current treatment regimen.
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Affiliation(s)
- Alexey S Pospelov
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Tommi Ala-Kurikka
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Samu Kurki
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
| | - Juha Voipio
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland
| | - Kai Kaila
- Faculty of Biological and Environmental Sciences, Molecular and Integrative Biosciences, University of Helsinki, Helsinki, Finland.,Neuroscience Center (HiLIFE), University of Helsinki, Helsinki, Finland
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26
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Abstract
OBJECTIVE This study aims to describe the frequency and characteristics of anticonvulsant medication treatments initiated in the neonatal period. STUDY DESIGN We analyzed a cohort of neonates with a seizure diagnosis who were discharged from institutions in the Pediatric Health Information System between 2007 and 2016. Adjusted risk ratios and 95% confidence intervals for characteristics associated with neonatal (≤ 28 days postnatal) anticonvulsant initiation were calculated via modified Poisson regression. RESULTS A total of 6,245 infants from 47 institutions were included. There was a decrease in both phenobarbital initiation within the neonatal period (96.9 to 91.3%, p = 0.015) and continuation at discharge (90.6 to 68.6%, p <0.001). Levetiracetam (7.9 to 39.6%, p < 0.001) initiation within the neonatal period and continuation at discharge (9.4 to 49.8%, p < 0.001) increased. Neonates born at ≥ 37 weeks' gestation and those diagnosed with intraventricular hemorrhage, ischemic/thrombotic stroke, other hemorrhagic stroke, and hypoxic ischemic encephalopathy (HIE) had a higher probability of anticonvulsant administration. The most prevalent diagnosis was HIE (n = 2,223, 44.4%). CONCLUSION Phenobarbital remains the most widely used neonatal seizure treatment. Levetiracetam is increasingly used as a second line therapy. Increasing levetiracetam use indicates a need for additional study to determine its effectiveness in reducing seizure burden and improving long-term outcomes.
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27
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Abstract
Seizures are the most common neurological emergency in the neonates, and this age group has the highest incidence of seizures compared with any other period of life. The author provides a narrative review of recent advances in the genetics of neonatal epilepsies, new neonatal seizure classification system, diagnostics, and treatment of neonatal seizures based on a comprehensive literature review (MEDLINE using PubMED and OvidSP vendors with appropriate keywords to incorporate recent evidence), personal practice, and experience. Knowledge regarding various systemic and postzygotic genetic mutations responsible for neonatal epilepsy has been exploded in recent times, as well as better delineation of clinical phenotypes associated with rare neonatal epilepsies. An International League Against Epilepsy task force on neonatal seizure has proposed a new neonatal seizure classification system and also evaluated the specificity of semiological features related to particular etiology. Although continuous video electroencephalogram (EEG) is the gold standard for monitoring neonatal seizures, amplitude-integrated EEGs have gained significant popularity in resource-limited settings. There is tremendous progress in the automated seizure detection algorithm, including the availability of a fully convolutional neural network using artificial machine learning (deep learning). There is a substantial need for ongoing research and clinical trials to understand optimal medication selection (first line, second line, and third line) for neonatal seizures, treatment duration of antiepileptic drugs after cessation of seizures, and strategies to improve neuromorbidities such as cerebral palsy, epilepsy, and developmental impairments. Although in recent times, levetiracetam use has been significantly increased for neonatal seizures, a multicenter, randomized, blinded, controlled phase IIb trial confirmed the superiority of phenobarbital over levetiracetam in the acute suppression of neonatal seizures. While there is no single best choice available for the management of neonatal seizures, institutional guidelines should be formed based on a consensus of local experts to mitigate wide variability in the treatment and to facilitate early diagnosis and treatment.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Section, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States
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28
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Basiri B, Sabzehei M, Sabahi M. Predictive factors of death in neonates with hypoxic-ischemic encephalopathy receiving selective head cooling. Clin Exp Pediatr 2021; 64:180-187. [PMID: 32882782 PMCID: PMC8024121 DOI: 10.3345/cep.2019.01382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 08/11/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Severe perinatal asphyxia results in multiple organ involvement, neonate hospitalization, and eventual death. PURPOSE This study aimed to investigate the predictive factors of death in newborns with hypoxic-ischemic encephalopathy (HIE) receiving selective head cooling. METHODS This cross-sectional descriptive-retrospective study was conducted from 2013 to 2018 in Fatemieh Hospital of Hamadan and included 51 newborns who were admitted to the neonatal intensive care unit with a diagnosis of HIE. Selective head cooling for patients with moderate to severe HIE began within 6 hours of birth and continued for 72 hours. The required data for the predictive factors of death were extracted from the patients' medical files, recorded on a premade form, and analyzed using SPSS ver. 16. RESULTS Of the 51 neonates with moderate to severe HIE who were treated with selective head cooling, 16 (31%) died. There were significant relationships between death and the need for advanced neonatal resuscitation (P=0.002), need for mechanical ventilation (P=0.016), 1-minute Apgar score (P=0.040), and severely abnormal amplitude-integrated electroencephalography (a-EEG) (P=0.047). Multiple regression of variables or data showed that the need for advanced neonatal resuscitation was an independent predictive factor of death (P=0.0075) and severely abnormal a-EEG was an independent predictive factor of asphyxia severity (P=0.0001). CONCLUSION All cases of neonatal death in our study were severe HIE (stage 3). Advanced neonatal resuscitation was an independent predictor of death, while a severely abnormal a-EEG was an independent predictor of asphyxia severity in infants with HIE.
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Affiliation(s)
- Behnaz Basiri
- Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
| | | | - Mohammadmahdi Sabahi
- Neurosurgery Research Group (NRG), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
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29
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Trollmann R. Neuromonitoring in Neonatal-Onset Epileptic Encephalopathies. Front Neurol 2021; 12:623625. [PMID: 33603712 PMCID: PMC7884638 DOI: 10.3389/fneur.2021.623625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/12/2021] [Indexed: 12/31/2022] Open
Abstract
Considering the wide spectrum of etiologies of neonatal-onset epileptic encephalopathies (EE) and their unfavorable consequences for neurodevelopmental prognoses, neuromonitoring at-risk neonates is increasingly important. EEG is highly sensitive for early identification of electrographic seizures and abnormal background activity. Amplitude-integrated EEG (aEEG) is recommended as a useful bedside monitoring method but as a complementary tool because of methodical limitations. It is of special significance in monitoring neonates with acute symptomatic as well as structural, metabolic and genetic neonatal-onset EE, being at high risk of electrographic-only and prolonged seizures. EEG/aEEG monitoring is established as an adjunctive tool to confirm perinatal hypoxic-ischemic encephalopathy (HIE). In neonates with HIE undergoing therapeutic hypothermia, burst suppression pattern is associated with good outcomes in about 40% of the patients. The prognostic specificity of EEG/aEEG is lower compared to cMRI. As infants with HIE may develop seizures after cessation of hypothermia, recording for at least 24 h after the last seizure is recommended. Progress in the identification of genetic etiology of neonatal EE constantly increases. However, presently, no specific EEG changes indicative of a genetic variant have been characterized, except for individual variants associated with typical EEG patterns (e.g., KCNQ2, KCNT1). Long-term monitoring studies are necessary to define and classify electro-clinical patterns of neonatal-onset EE.
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Affiliation(s)
- Regina Trollmann
- Department of Pediatrics and Pediatric Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Huang W, Xiao F, Huang W, Wei Q, Li X. RETRACTED: MicroRNA-29a-3p strengthens the effect of dexmedetomidine on improving neurologic damage in newborn rats with hypoxic-ischemic brain damage by inhibiting HDAC4. Brain Res Bull 2021; 167:71-79. [PMID: 33232741 DOI: 10.1016/j.brainresbull.2020.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/16/2020] [Accepted: 11/17/2020] [Indexed: 01/05/2023]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. Concern was raised about the reliability of the Western blot results in Figs. 2B+E, which appear to have the same eyebrow shaped phenotype as many other publications tabulated here (https://docs.google.com/spreadsheets/d/149EjFXVxpwkBXYJOnOHb6RhAqT4a2llhj9LM60MBffM/edit#gid=0). The journal requested the corresponding author comment on these concerns and provide the raw data. However, the authors were not responsive to the request for comment. Since original data could not be provided, the overall validity of the results could not be confirmed. Therefore, the Editor-in-Chief decided to retract the article.
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Affiliation(s)
- Wei Huang
- Department of Anesthesiology, People's Hospital of Baise, Baise, 533000, China.
| | - Faling Xiao
- Department of Anesthesiology, People's Hospital of Baise, Baise, 533000, China
| | - Weijun Huang
- Department of Anesthesiology, People's Hospital of Baise, Baise, 533000, China
| | - Qiaosong Wei
- Department of Anesthesiology, People's Hospital of Baise, Baise, 533000, China
| | - Xisong Li
- Department of Anesthesiology, People's Hospital of Baise, Baise, 533000, China
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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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Massaro AN, Lee JK, Vezina G, Glass P, O'Kane A, Li R, Chang T, Brady K, Govindan R. Exploratory Assessment of the Relationship Between Hemoglobin Volume Phase Index, Magnetic Resonance Imaging, and Functional Outcome in Neonates with Hypoxic-Ischemic Encephalopathy. Neurocrit Care 2020; 35:121-129. [PMID: 33215394 DOI: 10.1007/s12028-020-01150-8] [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] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE Near-infrared spectroscopy (NIRS)-based measures of cerebral autoregulation (CAR) can potentially identify neonates with hypoxic-ischemic encephalopathy (HIE) who are at greatest risk of irreversible brain injury. However, modest predictive abilities have precluded previously described metrics from entering clinical care. We previously validated a novel autoregulation metric in a piglet model of induced hypotension called the hemoglobin volume phase index (HVP). The objective of this study was to evaluate the clinical ability of the HVP to predict adverse outcomes neonates with HIE. METHODS This is a prospective study of neonates with HIE who underwent therapeutic hypothermia (TH) at a level 4 neonatal intensive care unit (NICU). Continuous cerebral NIRS and mean arterial blood pressure (MAP) from indwelling arterial catheters were measured during TH and through rewarming. Multivariate autoregressive process was used to calculate the coherence between MAP and the sum total of the oxy- and deoxygenated Hb densities (HbT), a surrogate measure of cerebral blood volume (CBV). The HVP was calculated as the cosine-transformed phase shift at the frequency of maximal MAP-HbT coherence. Brain injury was assessed by neonatal magnetic resonance imaging (MRI), and developmental outcomes were assessed by the Bayley Scales of Infant Development (BSID-III) at 15-30 months. The ability of the HVP to predict (a) death or severe brain injury by MRI and (b) death or significant developmental delay was assessed using logistic regression analyses. RESULTS In total, 50 neonates with moderate or severe HIE were monitored. Median HVP was higher, representing more dysfunctional autoregulation, in infants who had adverse outcomes. After adjusting for sex and encephalopathy grade at presentation, HVP at 21-24 and 24-27 h of life predicted death or brain injury by MRI (21-24 h: OR 8.8, p = 0.037; 24-27 h: OR 31, p = 0.011) and death or developmental delay at 15-30 months (21-24 h: OR 11.8, p = 0.05; 24-27 h: OR 15, p = 0.035). CONCLUSIONS Based on this pilot study of neonates with HIE, HVP merits further study as an indicator of death or severe brain injury on neonatal MRI and neurodevelopmental delay in early childhood. Larger studies are warranted for further clinical validation of the HVP to evaluate cerebral autoregulation following HIE.
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Affiliation(s)
- An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA. .,The George Washington University School of Medicine, Washington, DC, USA.
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gilbert Vezina
- Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Penny Glass
- Psychology and Behavioral Health, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | | | - Ruoying Li
- Neurology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Kenneth Brady
- Department of Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rathinaswamy Govindan
- Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
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Intranasal administration of Cytoglobin modifies human umbilical cord‑derived mesenchymal stem cells and improves hypoxic‑ischemia brain damage in neonatal rats by modulating p38 MAPK signaling‑mediated apoptosis. Mol Med Rep 2020; 22:3493-3503. [PMID: 32945464 PMCID: PMC7453519 DOI: 10.3892/mmr.2020.11436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/17/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal hypoxic‑ischemic brain damage (HIBD) is a common clinical syndrome in newborns. Hypothermia is the only approved therapy for the clinical treatment; however, the therapeutic window of hypothermia is confined to 6 h after birth and even then, >40% of the infants either die or survive with various impairments, including cerebral palsy, seizure disorder and intellectual disability following hypothermic treatment. The aim of the present study was to determine whether nasal transplantation of Cytoglobin (CYGB) genetically modified human umbilical cord‑derived mesenchymal stem cells (CYGB‑HuMSCs) exhibited protective effects in neonatal rats with HIBD compared with those treated without genetically modified CYGB. A total of 120 neonatal Sprague‑Dawley rats (postnatal day 7) were assigned to either a Sham, HIBD, HuMSCs or CYGB‑HuMSCs group (n = 30 rats/group). For HIBD modeling, rats underwent left carotid artery ligation and were exposed to 8% oxygen for 2.5 h. A total of 30 min after HI, HuMSCs (or CYGB‑HuMSCs) labeled with enhanced‑green fluorescent protein (eGFP) were intranasally administered. After modeling for 3, 14 and 29 days, five randomly selected rats were sacrificed in each group, and the expression levels of CYGB, ERK, JNK and p38 in brain tissues were determined. Nissl staining of the cortex and hippocampal Cornu Ammonis 1 area of rats in each group were compared after 3 days of modeling. TUNEL assay and immunofluorescence were performed 3 days after modeling. Long term memory in rats was assessed using a Morris‑water maze 29 days after modeling. The HIBD group demonstrated significant deficiencies compared with the Sham group based on Nissl staining, TUNEL assay and the Morris‑water maze test. HuMSC treated rats exhibited improvement on in all the tests, and CYGB‑HuMSCs treatment resulted in further improvements. PCR and western blotting results indicated that the CYGB mRNA and protein levels were increased from day 3 to day 29 after transplantation of CYGB‑HuMSCs. Furthermore, it was identified that CYGB‑HuMSC transplantation suppressed p38 signaling at all experimental time points. Immunofluorescence indicated the scattered presence of HuMSCs or CYGB‑HuMSCs in damaged brain tissue. No eGFP and glial fibrillary acidic protein or eGFP and neuron‑specific enolase double‑stained positive cells were found in the brain tissues. Therefore, CYGB‑HuMSCs may serve as a gene transporter, as well as exert a neuroprotective and antiapoptotic effect in HIBD, potentially via the p38 mitogen‑activated protein kinase signaling pathway.
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McPherson C, O'Mara K. Provision of Sedation and Treatment of Seizures During Neonatal Therapeutic Hypothermia. Neonatal Netw 2020; 39:227-235. [PMID: 32675319 DOI: 10.1891/0730-0832.39.4.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2020] [Indexed: 06/11/2023]
Abstract
Hypoxic-ischemic encephalopathy (HIE) produces a high rate of long-term neurodevelopmental disability in survivors. Therapeutic hypothermia dramatically improves the incidence of intact survival, but does not eliminate adverse outcomes. The ideal provision of sedation and treatment of seizures during therapeutic hypothermia represent therapeutic targets requiring optimization in practice. Physiologic stress from therapeutic hypothermia may obviate some of the benefits of this therapy. Morphine is commonly utilized to provide comfort, despite limited empiric evidence supporting safety and efficacy. Dexmedetomidine represents an interesting alternative, with preclinical data suggesting direct efficacy against shivering during induced hypothermia and neuroprotection in the setting of HIE. Pharmacokinetic properties must be considered when utilizing either agent, with safety dependent on conservative dosing and careful monitoring. HIE is the leading cause of neonatal seizures. Traditional therapies, including phenobarbital, fosphenytoin, and benzodiazepines, control seizures in the vast majority of neonates. Concerns about the acute and long-term effects of these agents have led to the exploration of alternative anticonvulsants, including levetiracetam. Unfortunately, levetiracetam is inferior to phenobarbital as first-line therapy for neonatal seizures. Considering both the benefits and risks of traditional anticonvulsant agents, treatment should be limited to the shortest duration indicated, with maintenance therapy reserved for neonates at high risk for recurrent seizures.
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Sharpe C, Reiner GE, Davis SL, Nespeca M, Gold JJ, Rasmussen M, Kuperman R, Harbert MJ, Michelson D, Joe P, Wang S, Rismanchi N, Le NM, Mower A, Kim J, Battin MR, Lane B, Honold J, Knodel E, Arnell K, Bridge R, Lee L, Ernstrom K, Raman R, Haas RH. Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial. Pediatrics 2020; 145:peds.2019-3182. [PMID: 32385134 PMCID: PMC7263056 DOI: 10.1542/peds.2019-3182] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There are no US Food and Drug Administration-approved therapies for neonatal seizures. Phenobarbital and phenytoin frequently fail to control seizures. There are concerns about the safety of seizure medications in the developing brain. Levetiracetam has proven efficacy and an excellent safety profile in older patients; therefore, there is great interest in its use in neonates. However, randomized studies have not been performed. Our objectives were to study the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment of neonatal seizures. METHODS The study was a multicenter, randomized, blinded, controlled, phase IIb trial investigating the efficacy and safety of levetiracetam compared with phenobarbital as a first-line treatment for neonatal seizures of any cause. The primary outcome measure was complete seizure freedom for 24 hours, assessed by independent review of the EEGs by 2 neurophysiologists. RESULTS Eighty percent of patients (24 of 30) randomly assigned to phenobarbital remained seizure free for 24 hours, compared with 28% of patients (15 of 53) randomly assigned to levetiracetam (P < .001; relative risk 0.35 [95% confidence interval: 0.22-0.56]; modified intention-to-treat population). A 7.5% improvement in efficacy was achieved with a dose escalation of levetiracetam from 40 to 60 mg/kg. More adverse effects were seen in subjects randomly assigned to phenobarbital (not statistically significant). CONCLUSIONS In this phase IIb study, phenobarbital was more effective than levetiracetam for the treatment of neonatal seizures. Higher rates of adverse effects were seen with phenobarbital treatment. Higher-dose studies of levetiracetam are warranted, and definitive studies with long-term outcome measures are needed.
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Affiliation(s)
- Cynthia Sharpe
- Department of Paediatric Neurology, Starship Children’s Health, Auckland, New Zealand;,Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Gail E. Reiner
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Suzanne L. Davis
- Department of Paediatric Neurology, Starship Children’s Health, Auckland, New Zealand
| | - Mark Nespeca
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Jeffrey J. Gold
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | | | - Rachel Kuperman
- Pediatric Neurology, University of California, San Francisco Benioff Children’s Hospital Oakland, Oakland, California
| | - Mary Jo Harbert
- Department of Neurosciences, School of Medicine, University of California, San Diego and Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - David Michelson
- Division of Pediatric Neurology, Department of Pediatrics, Loma Linda University Children’s Hospital, Loma Linda, California
| | - Priscilla Joe
- Division of Neonatology, Departments of Pediatrics and
| | - Sonya Wang
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Neggy Rismanchi
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
| | - Ngoc Minh Le
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Andrew Mower
- Department of Neurology, Children’s Hospital of Orange County, Orange, California
| | - Jae Kim
- Division of NeoNatology, Departments of Pediatrics and
| | - Malcolm R. Battin
- Department of Neonatology, Auckland District Health Board, Auckland, New Zealand; and
| | - Brian Lane
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Jose Honold
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Ellen Knodel
- Division of Neonatology, Departments of Pediatrics, University of California, San Diego and Rady Children's Hospital San Diego, San Diego, California
| | - Kathy Arnell
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, California
| | - Renee Bridge
- Division of NeoNatology, Departments of Pediatrics and
| | - Lilly Lee
- Neurosciences, School of Medicine, University of California, San Diego, San Diego, California
| | - Karin Ernstrom
- Alzheimer’s Therapeutic Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rema Raman
- Alzheimer’s Therapeutic Research Institute, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Richard H. Haas
- Department of Neurosciences, School of Medicine, University of California, San Diego and Rady Children’s Hospital–San Diego, San Diego, California
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Benedetti GM, Vartanian RJ, McCaffery H, Shellhaas RA. Early Electroencephalogram Background Could Guide Tailored Duration of Monitoring for Neonatal Encephalopathy Treated with Therapeutic Hypothermia. J Pediatr 2020; 221:81-87.e1. [PMID: 32222256 DOI: 10.1016/j.jpeds.2020.01.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/05/2019] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate whether features of the early electroencephalographic (EEG) background could guide the optimal duration of continuous video EEG monitoring for seizure detection in newborn infants treated with therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 114 consecutive infants treated with therapeutic hypothermia for moderate to severe HIE at a level IV neonatal intensive care unit (NICU) between 2012 and 2018. All infants were monitored with continuous video EEG through cooling and rewarming. Archived samples from the first 24 hours of these EEG traces were reviewed systematically and classified by background characteristics. RESULTS Electrographic seizures occurred in 56 of the 114 infants (49%). Seizure onset was within the first 24 hours after initiation of continuous video EEG in 49 if these 56 infants (88%), between 24 and 48 hours in 4 infants (7%), and >72 hours in 3 infants (5%). Infants with a normal or mildly abnormal EEG background either had seizure onset within the first 24 hours or never developed seizures. Four patients with seizure onset between 24 and 48 hours had markedly abnormal EEG backgrounds. The 3 patients with seizure onset beyond 72 hours had moderate or severely abnormal early continuous video EEG backgrounds. CONCLUSIONS The use of early continuous video EEG background categorization may be appropriate to guide the duration of continuous video EEG for infants with HIE treated with therapeutic hypothermia. Some infants may reasonably be monitored for 24 hours rather than throughout cooling and rewarming without a significant risk of missed seizures. This could have significant implications for continuous video EEG resource utilization.
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Affiliation(s)
| | - Rebecca J Vartanian
- Division of Neonatology, Department of Pediatrics, CS Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI
| | - Harlan McCaffery
- Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Ann Arbor, MI; Center for Human Growth and Development, University of Michigan, Ann Arbor, MI
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Kotagal P. Continuous EEG Monitoring in Neonates: One Size Does Not Fit All. Epilepsy Curr 2020; 20:189-190. [PMID: 34025224 PMCID: PMC7427170 DOI: 10.1177/1535759720923292] [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] [Indexed: 11/16/2022] Open
Abstract
[Box: see text]
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Chacko A, Andronikou S, Mian A, Gonçalves FG, Vedajallam S, Thai NJ. Cortical ischaemic patterns in term partial-prolonged hypoxic-ischaemic injury-the inter-arterial watershed demonstrated through atrophy, ulegyria and signal change on delayed MRI scans in children with cerebral palsy. Insights Imaging 2020; 11:53. [PMID: 32232679 PMCID: PMC7105592 DOI: 10.1186/s13244-020-00857-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/05/2020] [Indexed: 12/24/2022] Open
Abstract
The inter-arterial watershed zone in neonates is a geographic area without discernible anatomic boundaries and difficult to demarcate and usually not featured in atlases. Schematics currently used to depict the areas are not based on any prior anatomic mapping, compared to adults.Magnetic resonance imaging (MRI) of neonates in the acute to subacute phase with suspected hypoxic-ischaemic injury (HII) can demonstrate signal abnormality and restricted diffusion in the cortical and subcortical parenchyma of the watershed regions.In the chronic stage of partial-prolonged hypoxic-ischaemic injury, atrophy and ulegyria can make the watershed zone more conspicuous as a region. Our aim is to use images extracted from a sizable medicolegal database (approximately 2000 cases), of delayed MRI scans in children with cerebral palsy, to demonstrate the watershed region.To achieve this, we have selected cases diagnosed on imaging as having sustained a term pattern of partial-prolonged HII affecting the hemispheric cortex, based on the presence of bilateral, symmetric atrophy with ulegyria. From these, we have identified those patients demonstrating injury along the whole watershed continuum as well as those demonstrating selective anterior or posterior watershed predominant injury for demonstration.Recognition of this zone is essential for diagnosing partial-prolonged hypoxic-ischaemic injury sustained in term neonates. The images presented in this pictorial review provide a template for identifying the cortical watershed distribution when there is milder regional (anterior, parasagittal, peri-Sylvian and posterior) watershed injury and for more severe injury where multiple regions are injured in combination or as a continuum.
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Affiliation(s)
- Anith Chacko
- Clinical Research & Imaging Centre, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK.
| | - Savvas Andronikou
- Clinical Research & Imaging Centre, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
- Department of Radiology, Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Ali Mian
- Department of Radiology, Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | | | - Schadie Vedajallam
- Clinical Research & Imaging Centre, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Ngoc Jade Thai
- Clinical Research & Imaging Centre, Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
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Jung S, Ballheimer YE, Brackmann F, Zoglauer D, Geppert CI, Hartmann A, Trollmann R. Seizure-induced neuronal apoptosis is related to dysregulation of the RNA-edited GluR2 subunit in the developing mouse brain. Brain Res 2020; 1735:146760. [PMID: 32142720 DOI: 10.1016/j.brainres.2020.146760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 12/28/2022]
Abstract
Ca2+-permeable AMPA receptors (AMPAR) which crucially modify maturational programs of the developing brain are involved in seizure-induced glutamate excitotoxicity and apoptosis. Regulatory effects on AMPAR subunit composition and RNA-editing in the developing brain and their significance as therapeutic targets are not well understood. Here, we analyzed acute effects of recurrent pilocarpine-induced neonatal seizures on age- and region-specific expression of AMPAR subunits and adenosine deaminases (ADAR) in the developing mouse brain (P10). After recurrent seizure activity and regeneration periods of 6-72 h cerebral mRNA levels of GluR (glutamate receptor subunit) 1, GluR2, GluR3, and GluR4 were unaffected compared to controls. However, ratio of GluR2 and GluR4 to pooled GluR1-4 mRNA concentration significantly decreased in seizure-exposed brains in comparison to controls. After a regeneration period of 24-72 h ADAR1 and ADAR2 mRNA expression was significantly lower in seizure-exposed brains than in those of controls. This was confirmed at the protein level in the hippocampal CA3 region. We observed a regionally increased apoptosis (TUNEL+ and CC3+ cells) in the hippocampus, parietal cortex and subventricular zone of seizure-exposed brains in comparison to controls. Together, present in vivo data demonstrate the maturational age-specific, functional role of RNA-edited GluR2 in seizure-induced excitotoxicity in the developing mouse brain. In response to recurrent seizure activity, we observed reduced expression of GluR2 and the GluR2 mRNA-editing enzymes ADAR1 and ADAR2 accompanied by increased apoptosis in a region-specific manner. Thus, AMPA receptor subtype-specific mRNA editing is assessed as a promising target of novel neuroprotective treatment strategies in consideration of age-related developmental mechanisms.
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Affiliation(s)
- Susan Jung
- Department of Pediatrics, Division of Neuropediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Yili E Ballheimer
- Department of Pediatrics, Division of Neuropediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Florian Brackmann
- Department of Pediatrics, Division of Neuropediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Daniel Zoglauer
- Department of Pediatrics, Division of Neuropediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Carol-Immanuel Geppert
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Regina Trollmann
- Department of Pediatrics, Division of Neuropediatrics, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany.
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Abstract
Seizures are an important sign of neurologic dysfunction in neonates, and they most often represent acute brain injury such as hypoxic-ischemic encephalopathy, stroke, or intracranial hemorrhage (acute symptomatic seizures). Clinical identification of seizures is not reliable since seizures in neonates often do not have an apparent clinical correlate; therefore, electroencephalography should be used to accurately diagnose and manage neonatal seizures. Seizures are refractory to initial loading doses of standard medications in >50% of cases. Since seizures are commonly associated with adverse acute and long-term outcomes, and the seizures themselves may result in additional brain injury, it is important to quickly recognize, diagnose, and treat seizures in neonates. Local practice pathways may optimize efficiency in assessment and treatment for affected newborns. Herein, we review the etiology, methods of diagnosis, treatment, and current knowledge gaps for neonatal seizures.
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Lan XB, Wang Q, Yang JM, Ma L, Zhang WJ, Zheng P, Sun T, Niu JG, Liu N, Yu JQ. Neuroprotective effect of Vanillin on hypoxic-ischemic brain damage in neonatal rats. Biomed Pharmacother 2019; 118:109196. [PMID: 31310955 DOI: 10.1016/j.biopha.2019.109196] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 12/25/2022] Open
Abstract
Neonatal hypoxic-ischemic brain damage (HIBD) is a leading cause of death and perpetual neurological dysfunction in neonates. Vanillin (Van), a natural phenolic compound with neuroprotective properties, exerts neuroprotection on a gerbil model of global ischemia by inhibiting oxidative damage. This study aimed to explore the potential neuroprotective roles of Van in neonatal rats suffering from hypoxic-ischemic (HI). An HI model of 7-day-old SD rats was induced by left carotid artery ligation followed by exposure to 8% oxygen (balanced with nitrogen) for 2.5 h at 37 °C. At 48 h after intraperitoneal injection with Van (20, 40, and 80 mg/kg) or saline, neurobehavioral function, cerebral infract volume, brain water content, and histomorphological changes were performed to evaluate brain injury. Transmission electron microscopy and immunoglobulin G (IgG) staining were conducted to evaluate the integrity of the blood-brain barrier (BBB). The levels of oxidative stress and tight junction proteins, as well as the activities of matrix metalloproteinases (MMPs), were also determined in the ipsilateral hemisphere. Results showed that Van post-treatment significantly ameliorated early neurobehavioral deficits, decreased infarct volume and brain edema, as well as attenuated histopathologic injury and IgG extravasation. Furthermore, Van markedly increased the activities of endogenous antioxidant enzymes and decreased malondialdehyde content. Meanwhile, the activation of MMP-2 and MMP-9 induced by HI was partially blocked by Van. Finally, Van obviously increased the expression of ZO-1, Occludin, and Claudin-5 compared with the HI group. Collectively, Van can provide neuroprotective effects against neonatal HIBD possibly by attenuating oxidative damage and preserving BBB integrity.
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Affiliation(s)
- Xiao-Bing Lan
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Qing Wang
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Jia-Mei Yang
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Lin Ma
- Ningxia Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Wen-Jin Zhang
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Ping Zheng
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Tao Sun
- Ningxia Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China
| | - Jian-Guo Niu
- Ningxia Key Laboratory of Craniocerebral Diseases of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China.
| | - Ning Liu
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China.
| | - Jian-Qiang Yu
- Department of Pharmacology, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China; Ningxia Hui Medicine Modern Engineering Research Center and Collaborative Innovation Center, Ningxia Medical University, Yinchuan, Ningxia Hui Autonomous Region 750004, People's Republic of China.
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Dwivedi D, Lin N, Venkatesan C, Kline-Fath B, Holland K, Schapiro M. Clinical, Neuroimaging, and Electrographic Predictors of Phenobarbital Failure in Newborns With Hypoxic Ischemic Encephalopathy and Seizures. J Child Neurol 2019; 34:458-463. [PMID: 30966848 DOI: 10.1177/0883073819838171] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many neonates with hypoxic ischemic encephalopathy and seizures do not respond to the first line antiepileptic drug, phenobarbital. Little is known about what factors are associated with its failure. OBJECTIVE To examine factors associated with failure of phenobarbital therapy in neonates with hypoxic ischemic encephalopathy and seizures. DESIGN/METHODS A single-center retrospective review of 50 term (>35 weeks) neonates with hypoxic ischemic encephalopathy and seizures treated with phenobarbital as the first-line antiepileptic. Neonates were classified into either responders (n = 30) or nonresponders (n = 20). Nonresponse was defined as continued seizures after maximum dosing of phenobarbital or an additional antiepileptic. Subjects with acceptable magnetic resonance imaging (MRI) scans obtained within 2 weeks of birth were included in the study and rated using an MRI injury scoring system. Charts were reviewed for demographic, clinical, and laboratory variables. Resuscitation and seizure scores were also calculated. Electroencephalographic (EEG) background activity was reviewed in 2 different time epochs (12-24 hours and 24-36 hours of life) and graded as per ACNS guidelines. RESULTS There were no significant group differences in demographic, clinical, and laboratory variables except nonresponders, who had higher mean seizure score (P = .01) and significantly more injury on MRI scan for white matter (P = .004), parenchymal cortex (P = .027), and watershed (P = .009) regions. Neonates with moderately abnormal or severely abnormal background EEG responded poorly to phenobarbital. CONCLUSION In the presence of above factors, one can anticipate that additional antiepileptic medication may be needed. These data also support that larger studies should be done to look prospectively at using alternative agents first line in patients with severe injury.
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Affiliation(s)
- Deepak Dwivedi
- 1 Department of Paediatrics, SS Medical College, Rewa, Madhya Pradesh, India
| | - Nan Lin
- 2 Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charu Venkatesan
- 2 Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - B Kline-Fath
- 3 Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katherine Holland
- 2 Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark Schapiro
- 2 Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,4 Department of Paediatrics, University of Cincinnati School of Medicine, Cincinnati, OH, USA
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Differences in patient characteristics and care practices between two trials of therapeutic hypothermia. Pediatr Res 2019; 85:1008-1015. [PMID: 30862961 PMCID: PMC6857796 DOI: 10.1038/s41390-019-0371-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 02/28/2019] [Accepted: 03/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Induced Hypothermia (IH) and Optimizing Cooling (OC) trials for hypoxic-ischemic encephalopathy (HIE) had similar inclusion criteria. The rate of death/moderate-severe disability differed for the subgroups treated with therapeutic hypothermia (TH) at 33.5 °C for 72 h (44% vs. 29%, unadjusted p = 0.03). We aimed to evaluate differences in patient characteristics and care practices between the trials. METHODS We compared pre/post-randomization characteristics and care practices between IH and OC. RESULTS There were 208 patients in the IH trial, 102 cooled, and 364 in the OC trial, 95 cooled to 33.5 °C for 72 h. In OC, neonates were less ill, fewer had severe HIE, and the majority were cooled prior to randomization. Differences between IH and OC were observed in the adjusted difference in the lowest PCO2 (+3.08 mmHg, p = 0.005) and highest PO2 (-82.7 mmHg, p < 0.001). In OC, compared to IH, the adjusted relative risk (RR) of exposure to anticonvulsant prior to randomization was decreased (RR 0.58, (0.40-0.85), p = 0.005) and there was increased risk of exposure during cooling to sedatives/analgesia (RR 1.86 (1.21-2.86), p = 0.005). CONCLUSION Despite similar inclusion criteria, there were differences in patient characteristics and care practices between trials. Change in care practices over time should be considered when planning future neuroprotective trials.
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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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Boylan GB, Kharoshankaya L, Mathieson SR. Diagnosis of seizures and encephalopathy using conventional EEG and amplitude integrated EEG. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:363-400. [PMID: 31324321 DOI: 10.1016/b978-0-444-64029-1.00018-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Seizures are more common in the neonatal period than at any other time of life, partly due to the relative hyperexcitability of the neonatal brain. Brain monitoring of sick neonates in the NICU using either conventional electroencephalography or amplitude integrated EEG is essential to accurately detect seizures. Treatment of seizures is important, as evidence increasingly indicates that seizures damage the brain in addition to that caused by the underlying etiology. Prompt treatment has been shown to reduce seizure burden with the potential to ameliorate seizure-mediated damage. Neonatal encephalopathy most commonly caused by a hypoxia-ischemia results in an alteration of mental status and problems such as seizures, hypotonia, apnea, and feeding difficulties. Confirmation of encephalopathy with EEG monitoring can act as an important adjunct to other investigations and the clinical examination, particularly when considering treatment strategies such as therapeutic hypothermia. Brain monitoring also provides useful early prognostic indicators to clinicians. Recent use of machine learning in algorithms to continuously monitor the neonatal EEG, detect seizures, and grade encephalopathy offers the exciting prospect of real-time decision support in the NICU in the very near future.
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Affiliation(s)
- Geraldine B Boylan
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.
| | - Liudmila Kharoshankaya
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Sean R Mathieson
- Department of Paediatrics and Child Health, Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
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Benedetti GM, Silverstein FS. Targeted Temperature Management in Pediatric Neurocritical Care. Pediatr Neurol 2018; 88:12-24. [PMID: 30309737 DOI: 10.1016/j.pediatrneurol.2018.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 07/14/2018] [Indexed: 12/19/2022]
Abstract
Targeted temperature management encompasses a range of clinical interventions to regulate systemic temperature, and includes both induction of varying degrees of hypothermia and fever prevention ("targeted normothermia"). Targeted temperature management plays a key role in the contemporary management of critically ill neonates and children with acute brain injury. Yet, many unanswered questions remain regarding optimal temperature management in pediatric neurocritical care. The introduction highlights experimental studies that have evaluated the neuroprotective efficacy of therapeutic hypothermia and explored possible mechanisms of action in several brain injury models. The next section focuses on three major clinical conditions in which therapeutic hypothermia has been evaluated in randomized controlled trials in pediatric populations: neonatal hypoxic-ischemic encephalopathy, postcardiac arrest encephalopathy, and traumatic brain injury. Clinical implications of targeted temperature management in pediatric neurocritical care are also discussed. The final section examines some of the factors that may underlie the limited neuroprotective efficacy of hypothermia that has been observed in several major pediatric clinical trials, and outlines important directions for future research.
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Affiliation(s)
- Giulia M Benedetti
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois.
| | - Faye S Silverstein
- Departments of Pediatrics and Neurology, University of Michigan, Ann Arbor, Michigan
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Zubcevic S, Heljic S, Catibusic F, Uzicanin S, Sadikovic M, Krdzalic B. Neurodevelopmental Follow Up After Therapeutic Hypothermia for Perinatal Asphyxia. Med Arch 2018; 69:362-6. [PMID: 26843725 PMCID: PMC4720461 DOI: 10.5455/medarh.2015.69.362-366] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Neuroprotective benefit of therapeutic hypothermia in term newborns with hypoxic-ischemic encephalopathy (HIE) was assessed by analyzing survival and neurodevelopmental outcome of neonates subjected to this procedure. Material and methods: Newborns with gestational age > 36 weeks and < 6 hours of age with moderate to severe asphyxial encephalopathy underwent cooling protocol at a temperature of 33.5 °C for 72 hours and rewarming period of 6 hours. Outcome measures assessed were death and neurodevelopmental characteristics, which were compared at the different age using ASQ-3. Twenty-five children were assessed at age 3-6, 12-18 and 24-36 months. Median gestational age was 40 weeks, birth weight 3470 g, Apgar score 2/4 and pH on admission to the hospital 7.02. Four (16%) children died. Results: At the first assessment developmental categories of communication were normal in 78.9%, problem solving in 63.2%, personal-social in 68.4%, gross motor in 68.4%, and fine motor in 42.1% with a high need of retesting in this area. Second assessment was done in 17 patients: developmental categories of communication normal in 58.8%, problem solving in 70.6%, personal-social in 64.7%, gross motor in 64.7%, and fine motor in 35.3%. Third evaluation was done in 14 patients: developmental categories of communication were normal in 64.3%, problem solving in 71.4%, personal-social in 57.1%, gross motor in 64.3%, and fine motor in 42.9%. Conclusion: There was no correlation between baseline parameters and outcome. Results of the study are showing that therapeutic hypothermia in term newborns can provide better survival and less neurologic sequels in HIE patients.
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Affiliation(s)
- Smail Zubcevic
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Suada Heljic
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Feriha Catibusic
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Sajra Uzicanin
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Mirna Sadikovic
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Belma Krdzalic
- Pediatric hospital, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
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Kline-Fath BM, Horn PS, Yuan W, Merhar S, Venkatesan C, Thomas CW, Schapiro MB. Conventional MRI scan and DTI imaging show more severe brain injury in neonates with hypoxic-ischemic encephalopathy and seizures. Early Hum Dev 2018; 122:8-14. [PMID: 29803998 DOI: 10.1016/j.earlhumdev.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/09/2018] [Accepted: 05/17/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neonates with hypoxic-ischemic encephalopathy (HIE) and seizures have poorer outcome for undetermined reasons. AIMS Our aim was to determine if brain imaging was more abnormal in neonates with HIE and electrographically confirmed seizures and whether this was impacted by seizure burden. STUDY DESIGN Single center retrospective review. SUBJECTS Forty-eight term neonates with HIE (with and without seizures) underwent MRI brain scans before age 14 days between the years 2008 and 2013. OUTCOME MEASURES Images were rated using a MRI injury score and fractional anisotropy (FA) values were extracted from diffusion tensor imaging (DTI). RESULTS The seizure group (n = 25) had significantly more injury within white matter, basal ganglia, posterior limb of internal capsule, and watershed areas compared to the group without seizures (n = 23). The severity of injury in all measured areas increased with increasing seizure severity. The seizure group also had lower FA values in posterior limb of the internal capsule and the splenium of corpus callosum. CONCLUSIONS Neonates with HIE and seizures had more brain injury that occurred in areas typically affected by HIE and was greater with higher seizure burden. Seizures may be a marker of more severe brain injury or seizures themselves may amplify brain damage from HIE.
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Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, USA
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Weihong Yuan
- Neuroimaging Research Consortium, Cincinnati Children's Hospital Medical Center, USA
| | - Stephanie Merhar
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Charu Venkatesan
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Cameron W Thomas
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Mark B Schapiro
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA.
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Glass HC, Grinspan ZM, Shellhaas RA. Outcomes after acute symptomatic seizures in neonates. Semin Fetal Neonatal Med 2018; 23:218-222. [PMID: 29454756 DOI: 10.1016/j.siny.2018.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute symptomatic seizures are a common sign of neurological dysfunction and brain injury in neonates and occur in approximately one to three per 1000 live births. Seizures in neonates are usually a sign of underlying brain injury and, as such, are commonly associated with adverse outcomes. Neurological morbidities in survivors often co-occur; epilepsy, cerebral palsy, and intellectual disability often occur together in the most severely affected children. Risk factors for adverse outcome include prematurity, low Apgar scores, low pH on the first day of life, seizure onset <24 or >72 h after birth, abnormal neonatal neurological examination, abnormal neonatal electroencephalographic background, status epilepticus, and presence and pattern of brain injury (particularly deep gray or brainstem injury). Despite this list of potential indicators, accurate prediction of outcome in a given child remains challenging. There is great need for long-term, multicenter studies to examine risk factors for, and pathogenesis of, adverse outcomes following acute symptomatic seizures in neonates.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Zachary M Grinspan
- Department of Healthcare Policy, Department of Research and Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Department of Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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Abstract
Neonatal seizures are widely considered a neurological emergency with a need for prompt treatment, yet they are known to present a highly elusive target for bedside clinicians. Recent studies have suggested that the design of a neonatal seizure treatment trial will profoundly influence the sample size, which may readily increase to hundreds or even thousands as the achieved effect size diminishes to clinical irrelevance. The self-limiting and rapidly resolving nature of neonatal seizures diminishes the measurable treatment effect every hour after seizure onset and any effect may potentially be confused with spontaneous resolution, precluding the value of many observational studies. The large individual variability in seizure occurrence over time and between etiologies challenges group comparisons, while the absence of clinical signs mandates quantification of seizure occurrence with continuous multi-channel EEG monitoring. A biologically sound approach that views neonatal seizures as a functional cot-side biomarker rather than an object to treat can overcome these challenges.
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Affiliation(s)
- Nathan J Stevenson
- Department of Neurological Sciences, Clinicum, University of Helsinki, Helsinki, Finland; BABA Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sampsa Vanhatalo
- Department of Neurological Sciences, Clinicum, University of Helsinki, Helsinki, Finland; BABA Center, Children's Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Clinical Neurophysiology, HUS Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland; Columbia University Medical Center, Department of Pediatrics, Nurture Science Program, New York, NY, USA.
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