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Berja ED, Kwon H, Walsh KG, Bates SV, Kramer MA, Chu CJ. Infant sleep spindle measures from EEG improve prediction of cerebral palsy. Clin Neurophysiol 2024; 167:51-60. [PMID: 39278086 DOI: 10.1016/j.clinph.2024.08.017] [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: 11/07/2023] [Revised: 06/25/2024] [Accepted: 08/26/2024] [Indexed: 09/17/2024]
Abstract
OBJECTIVE Early identification of infants at risk of cerebral palsy (CP) enables interventions to optimize outcomes. Central sleep spindles reflect thalamocortical sensorimotor circuit function. We hypothesized that abnormal infant central spindle activity would predict later contralateral CP. METHODS We trained and validated an automated detector to measure spindle rate, duration, and percentage from central electroencephalogram (EEG) channels in high-risk infants (n = 35) and age-matched controls (n = 42). Neonatal magnetic resonance imaging (MRI) findings, infant motor exam, and CP outcomes were obtained from chart review. Using univariable and multivariable logistic regression models, we examined whether spindle activity, MRI abnormalities, and/or motor exam predicted future contralateral CP. RESULTS The detector had excellent performance (F1 = 0.50). Spindle rate (p = 0.005, p = 0.0004), duration (p < 0.001, p < 0.001), and percentage (p < 0.001, p < 0.001) were decreased in hemispheres corresponding to future CP compared to those without. In this cohort, PLIC abnormality (p = 0.004) and any MRI abnormality (p = 0.004) also predicted subsequent CP. After controlling for MRI findings, spindle features remained significant predictors and improved model fit (p < 0.001, all tests). Using both spindle duration and MRI findings had highest accuracy to classify hemispheres corresponding to future CP (F1 = 0.98, AUC 0.999). CONCLUSION Decreased central spindle activity improves the prediction of future CP in high-risk infants beyond early MRI or clinical exam alone. SIGNIFICANCE Decreased central spindle activity provides an early biomarker for CP.
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Affiliation(s)
- Erin D Berja
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Hunki Kwon
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Katherine G Walsh
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Sara V Bates
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Mark A Kramer
- Department of Mathematics and Statistics and Center for Systems Neuroscience, Boston University, Boston, MA, United States
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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2
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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] [Grants] [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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Chourasia N, Dohmeier J, Curry J, Parkhurst S, Mudigoudar B, Rivas-Coppola M, Wheless J. Clinical Experience With Lacosamide as an Adjunct Treatment for Neonatal Seizures: A Retrospective Single-Center Study. Pediatr Neurol 2024; 157:134-140. [PMID: 38917517 DOI: 10.1016/j.pediatrneurol.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 03/10/2024] [Accepted: 05/27/2024] [Indexed: 06/27/2024]
Abstract
BACKGROUND Lacosamide (LCM) is a third-generation antiseizure medication (ASM) currently approved for the treatment of focal seizures in children aged greater than one month. There are limited data on its efficacy in the neonatal age group. We describe our experience with LCM as an adjunct ASM for the treatment of neonatal seizures. METHODS A retrospective chart review over a five-year period (2018 to 2022) was conducted at Le Bonheur Children's Hospital to identify neonates with electroencephalography (EEG)-proven seizures who were treated with LCM. Data were collected on electroclinical seizure characteristics, underlying etiology, ASMs, treatment response, and any adverse effects. RESULTS A total of 15 neonates with EEG-confirmed seizures who were treated with LCM were included. Ten neonates achieved seizure cessation after LCM was added to their ASM regimen consisting of phenobarbital, levetiracetam, or both. No new treatment-related adverse effects were noted. CONCLUSIONS LCM is effective as an adjunct treatment for neonatal seizures. Randomized controlled studies are needed to establish its effectiveness and adequate dosing regimen in this population.
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Affiliation(s)
- Nitish Chourasia
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Jacob Dohmeier
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - JuleLayne Curry
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Samantha Parkhurst
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Basangoud Mudigoudar
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Marianna Rivas-Coppola
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - James Wheless
- Le Bonheur Comprehensive Epilepsy Program, Le Bonheur Children's Hospital, Memphis, Tennessee; Division of Pediatric Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
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4
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Peers de Nieuwburgh M, Dave A, Khan SA, Ngo M, Hayes KB, Slipenchuk M, Lieberman E, Youssef MR, Crompton D, Choudhry AM, Guo N, Tian Z, Rychik J, Davey MG, Flake AW. Assessment of extremely premature lambs supported by the Extrauterine Environment for Neonatal Development (EXTEND). Pediatr Res 2024:10.1038/s41390-024-03287-0. [PMID: 38834782 DOI: 10.1038/s41390-024-03287-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 03/28/2024] [Accepted: 05/07/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Our team has previously reported physiologic support by the EXTra-uterine Environment for Neonatal Development (EXTEND) of 105 to 117 days gestational age (GA) lambs for up to 28 days with normal organ maturation. However, the fetal lamb brain matures more rapidly, requiring the study of 90-105 day GA fetal lambs to assess more neurodevelopmentally equivalent lambs to the 23-25 week GA extreme premature infant. METHODS Extremely preterm lambs (90-95 days of GA) were delivered by C-section and supported by EXTEND. Estimated circuit flows were maintained at around 325 ml/kg/min. After support on EXTEND, MRI and histopathologic analysis were performed and compared to 105-112 days GA control lambs. RESULTS The extremely preterm group includes 10 animals with a mean GA of 91.6 days, a mean weight at cannulation of 0.98 kg and a mean length of stay on EXTEND of 13.5 days (10-21 days). Hemodynamics and oxygenation showed stable parameters. Animals showed growth and physiologic cardiac function. MRI volumetric and diffusion analysis was comparable to controls. Histologic brain analysis revealed no difference between study groups. CONCLUSION EXTEND appears to support brain and cardiac development in an earlier gestation, less mature, lamb model. IMPACT Prolonged (up to 21 days) physiological support of extremely preterm lambs of closer neurodevelopmental equivalence to the 24-28 gestational week human was achieved using the EXTEND system. EXTEND treatment supported brain growth and development in extremely preterm fetal lambs and was not associated with intraventricular hemorrhage or white matter injury. Daily echocardiography demonstrated physiologic heart function, absence of cardiac afterload, and normal developmental increase in cardiac chamber dimensions. This study demonstrates hemodynamic and metabolic support by the EXTEND system in the extremely preterm ovine model.
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Affiliation(s)
| | - Apeksha Dave
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sameer A Khan
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Ngo
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin B Hayes
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Evan Lieberman
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mohanad R Youssef
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Alia Mohsin Choudhry
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nan Guo
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Zhiyun Tian
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Alan W Flake
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Kaur M, Utidjian L, Abend NS, Dickinson K, Roebling R, McDonald J, Maltenfort MG, Foskett N, Elmoufti S, Guerriero RM, Jain BG, Pajor NM, Rao S, Shellhaas RA, Slaughter L, Forrest CB. Retrospective Multicenter Cohort Study on Safety and Electroencephalographic Response to Lacosamide for Neonatal Seizures. Pediatr Neurol 2024; 155:18-25. [PMID: 38579433 DOI: 10.1016/j.pediatrneurol.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 02/06/2024] [Accepted: 03/07/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND There is growing evidence supporting the safety and effectiveness of lacosamide in older children. However, minimal data are available for neonates. We aimed to determine the incidence of adverse events associated with lacosamide use and explore the electroencephalographic seizure response to lacosamide in neonates. METHODS A retrospective cohort study was conducted using data from seven pediatric hospitals from January 2009 to February 2020. For safety outcomes, neonates were followed for ≤30 days from index date. Electroencephalographic response of lacosamide was evaluated based on electroencephalographic reports for ≤3 days. RESULTS Among 47 neonates, 98% received the first lacosamide dose in the intensive care units. During the median follow-up of 12 days, 19% of neonates died, and the crude incidence rate per 1000 patient-days (95% confidence interval) of the adverse events by diagnostic categories ranged from 2.8 (0.3, 10.2) for blood or lymphatic system disorders and nervous system disorders to 10.5 (4.2, 21.6) for cardiac disorders. Electroencephalographic seizures were observed in 31 of 34 patients with available electroencephalographic data on the index date. There was seizure improvement in 29% of neonates on day 1 and also in 29% of neonates on day 2. On day 3, there was no change in 50% of neonates and unknown change in 50% of neonates. CONCLUSIONS The results are reassuring regarding the safety of lacosamide in neonates. Although some neonates had fewer seizures after lacosamide administration, the lack of a comparator arm and reliance on qualitative statements in electroencephalographic reports limit the preliminary efficacy results.
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Affiliation(s)
- Moninder Kaur
- RWE Neurology, UCB Pharma Ltd, Slough, UK; Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK.
| | - Levon Utidjian
- The Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kimberley Dickinson
- The Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert Roebling
- Epilepsy and Rare Syndrome Organisation, UCB Pharma, Monheim am Rhein, Germany
| | - Jill McDonald
- The Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mitchell G Maltenfort
- The Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Sami Elmoufti
- Biometric & Quantitative Services-Launch Statistics, UCB Pharma, Morrisville, North Carolina
| | - Rejean M Guerriero
- Division of Pediatric Neurology, Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Badal G Jain
- Division of Neurology, Department of Pediatrics, Nemours Children's Health, Wilmington, Delaware
| | - Nathan M Pajor
- Divisions of Pulmonary Medicine and Biomedical Informatics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Suchitra Rao
- Department of Pediatrics (Infectious Diseases, Epidemiology and Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Laurel Slaughter
- Division of Child Neurology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Christopher B Forrest
- The Applied Clinical Research Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Krishnan V, Ujjanappa V, Vegda H, Annayappa MK, Wali P, Fattepur S, Chandriah S, Devadas S, Kariappa M, Gireeshan VK, Thamunni AV, Montaldo P, Burgod C, Garegrat R, Muraleedharan P, Pant S, Newton CR, Cross JH, Bassett P, Shankaran S, Thayyil S, Pressler RM. Sequential levetiracetam and phenytoin in electroencephalographic neonatal seizures unresponsive to phenobarbital: a multicenter prospective observational study in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2024; 25:100371. [PMID: 39021480 PMCID: PMC467079 DOI: 10.1016/j.lansea.2024.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/09/2024] [Accepted: 02/06/2024] [Indexed: 07/20/2024]
Abstract
Background Although levetiracetam and phenytoin are widely used antiseizure medications (ASM) in neonates, their efficacy on seizure freedom is unclear. We evaluated electroencephalographic (EEG) seizure freedom following sequential levetiracetam and phenytoin in neonatal seizures unresponsive to phenobarbital. Methods We recruited neonates born ≥35 weeks and aged <72 h who had continued electrographic seizures despite phenobarbital, from three Indian hospitals, between 20 June 2020 and 31 July 2022. The neonates were treated with intravenous levetiracetam (20 mg/kg x 2 doses, second line) followed by phenytoin (20 mg/kg x 2 doses, third line) if seizures persisted. The primary outcome was complete seizure freedom, defined as an absence of seizures on EEG for at least 60 min within 40 min from the start of infusion. Findings Of the 206 neonates with continued seizures despite phenobarbital, 152 received levetiracetam with EEG. Of these one EEG was missing, 47 (31.1%) were in status epilepticus, and primary outcome data were available in 145. Seizure freedom occurred in 20 (13.8%; 95% CI 8.6%-20.5%) after levetiracetam; 16 (80.0%) responded to the first dose and 4 (20.0%) to the second dose. Of the 125 neonates with persisting seizures after levetiracetam, 114 received phenytoin under EEG monitoring. Of these, the primary outcome data were available in 104. Seizure freedom occurred in 59 (56.7%; 95% CI 46.7%-66.4%) neonates; 54 (91.5%) responded to the first dose and 5 (8.5%) to the second dose. Interpretation With the conventional doses, levetiracetam was associated with immediate EEG seizure cessation in only 14% of phenobarbital unresponsive neonatal seizures. Additional treatment with phenytoin along with levetiracetam attained seizure freedom in further 57%. Safety and efficacy of higher doses of levetiracetam should be evaluated in well-designed randomised controlled trials. Funding National Institute for Health and Care Research (NIHR) Research and Innovation for Global Health Transformation (NIHR200144).
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Affiliation(s)
- Vaisakh Krishnan
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Vidya Ujjanappa
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Hemadri Vegda
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Pooja Wali
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Savitha Chandriah
- Department of Obstetrics and Gynecology, Bangalore Medical College and Research Institute, Bengaluru, India
| | - Sahana Devadas
- Department of Pediatrics, Bangalore Medical College and Research Institute, Bengaluru, India
| | - Mallesh Kariappa
- Department of Pediatrics, Bangalore Medical College and Research Institute, Bengaluru, India
| | | | | | - Paolo Montaldo
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
- Department of Neonatology, Università Degli Studi della Campania Luigi Vanvitelli, Naples, Italy
| | - Constance Burgod
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Reema Garegrat
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - Stuti Pant
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | | | - J Helen Cross
- UCL Great Ormond Street Institute of Child Health & Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Seetha Shankaran
- Department of Neonatal-Perinatal Medicine, Wayne State University, Detroit, MI, USA
- University of Texas at Austin, Dell Children’s Hospital, Austin, USA
| | - Sudhin Thayyil
- Centre for Perinatal Neuroscience, Imperial College, London, United Kingdom
| | - Ronit M. Pressler
- Department of Neurophysiology, Great Ormond Street Hospital, United Kingdom
- Department of Clinical Neuroscience, UCL-Great Ormond Street Institute of Child Health, London, United Kingdom
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Ryan MAJ, Malhotra A. Electrographic monitoring for seizure detection in the neonatal unit: current status and future direction. Pediatr Res 2024:10.1038/s41390-024-03207-2. [PMID: 38684885 DOI: 10.1038/s41390-024-03207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 03/20/2024] [Accepted: 04/01/2024] [Indexed: 05/02/2024]
Abstract
Neonatal neurocritical intensive care is dedicated to safeguarding the newborn brain by prioritising clinical practices that promote early identification, diagnosis and treatment of brain injuries. The most common newborn neurological emergency is neonatal seizures, which may also be the initial clinical indication of neurological disease. A high seizure burden in the newborn period independently contributes to increased mortality and morbidity. The majority of seizures in newborns are subclinical (without clinical presentation), and hence identification may be difficult. Neuromonitoring techniques most frequently used to monitor brain wave activity include conventional electroencephalography (cEEG) or amplitude-integrated EEG (aEEG). cEEG with video is the gold standard for diagnosing and treating seizures. Many neonatal units do not have access to cEEG, and frequently those that do, have little access to real-time interpretation of monitoring. IMPACT: EEG monitoring is of no benefit to an infant without expert interpretation. Whilst EEG is a reliable cot-side tool and of diagnostic and prognostic use, both conventional EEG and amplitude-integrated EEG have strengths and limitations, including sensitivity to seizure activity and ease of interpretation. Automated seizure detection requires a sensitive and specific algorithm that can interpret EEG in real-time and identify seizures, including their intensity and duration.
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Affiliation(s)
- Mary Anne J Ryan
- INFANT Research Centre, University College Cork, Cork, Ireland.
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland.
| | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
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Fukao T, Sano F, Nemoto A, Naito A, Yanagisawa T, Imai K, Hiroma T, Inaba Y, Kanemura H, Aihara M, Inukai T, Kaga Y. Factors associated with the development of epilepsy in very low birth weight infants. Pediatr Neonatol 2023; 64:637-643. [PMID: 37117074 DOI: 10.1016/j.pedneo.2022.12.019] [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: 04/25/2022] [Revised: 12/10/2022] [Accepted: 12/21/2022] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND The survival rate of very low birth weight (VLBW) infants has recently improved. However, the occurrence of and factors associated with epilepsy in VLBW infants remain unknown. This study aimed to clarify the incidence, characteristics, and factors associated with epilepsy development in VLBW infants. METHODS All VLBW infants admitted to our hospital between 2012 and 2017 were included in this study. VLBW infants with a follow-up period of <1 year were excluded. Chromosomal abnormalities, brain anomalies, severe intraventricular hemorrhage (IVH), cystic periventricular leukomalacia (PVL), and hypoxic ischemic encephalopathy (HIE) were considered to be risk factors. RESULTS Epilepsy occurred in 21/526 (4.0%) VLBW infants. Chromosomal abnormalities, brain anomalies, severe IVH, cystic PVL, HIE, neonatal seizures, advanced maternal age, maternal diabetes mellitus, no administration of antenatal corticosteroids, and low Apgar scores at 1 and 5 min were associated with a risk of epilepsy. The median time to epilepsy onset was 8 months (range: 0-59 months), and the onset occurred within 2 years in 15/21 patients (71.4%) and within 4 years in 18/21 patients (85.7%). VLBW infants with risk factors developed epilepsy earlier and at a significantly higher rate than those without risk factors. Among infants who had risk factors and who developed epilepsy, 86.7% did so within 2 years of age, compared to 33.3% of those who developed epilepsy but did not have risk factors. CONCLUSION These findings regarding factors associated with a risk of development of epilepsy and temporal feature of epilepsy may contribute to the development of monitoring and treatment protocols for epilepsy in VLBW infants.
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Affiliation(s)
- Toshimichi Fukao
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan; Department of Neonatology, Perinatal Medical Center, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Fumikazu Sano
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan.
| | - Atsushi Nemoto
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan; Department of Neonatology, Perinatal Medical Center, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | - Atsushi Naito
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan; Department of Neonatology, Perinatal Medical Center, Yamanashi Prefectural Central Hospital, Yamanashi, Japan
| | | | - Ken Imai
- Division of Neuropediatrics, Nagano Children's Hospital, Azumino, Japan
| | - Takehiko Hiroma
- Division of Neonatology, Nagano Children's Hospital, Azumino, Japan
| | - Yuji Inaba
- Division of Neuropediatrics, Nagano Children's Hospital, Azumino, Japan
| | - Hideaki Kanemura
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan; Department of Pediatrics, Toho University Medical Center Sakura Hospital, Chiba, Japan
| | - Masao Aihara
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Takeshi Inukai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Yoshimi Kaga
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
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9
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Almuqbil M, Alrumayyan Y, Alattas S, Baarmah D, AlTuwaijri W, AlRumayyan A, AlRifai MT, Al Madhi A, Al-shehri H, Alsaif S. Neonatal seizures: Etiologies, clinical characteristics, and radiological features: A cross-sectional study. Medicine (Baltimore) 2023; 102:e35185. [PMID: 37713864 PMCID: PMC10508452 DOI: 10.1097/md.0000000000035185] [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: 04/01/2023] [Accepted: 08/21/2023] [Indexed: 09/17/2023] Open
Abstract
Seizures are a common clinical indication of central nervous system damage or abnormality in neonates. We aimed to identify the etiologies, clinical characteristics, and radiological features of neonatal seizures. This is a cross-sectional, retrospective, descriptive study using data obtained from the neonatal intensive care unit in King Abdulaziz Medical City (KAMC), a governmental, academic tertiary hospital in Riyadh, Saudi Arabia. The population of interest were neonates diagnosed with a neonatal seizure at KAMC between April 2015 and March 2019. A total of 61 patients with neonatal seizures were included in the study. The most common etiology was hypoxic-ischemic encephalopathy (43%). A total of 32 patients were full-term (52.5%). Around one-fifth of the study sample (21.3%) had a family history of neonatal seizures. Around 43.0% of the patients had epilepsy episodes. More than half of the patients (57.0%) were on one anti-seizure medication. Patients were followed up after 1 year, they had multiple comorbidities, including developmental delay, epilepsy, and cerebral palsy. Developmental delay was identified in 62.3% of the patients. A total of 19 patients have passed away (31%). Neonatal seizures are a common manifestation of neurologic disorders in neonates and are associated with high morbidity and mortality. Therefore, early identification of seizure etiology and proper management may help to improve the outcome.
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Affiliation(s)
- Mohammed Almuqbil
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Ministry of National Guard, Riyadh, Saudi Arabia
| | - Yousof Alrumayyan
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Shahad Alattas
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Duaa Baarmah
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Waleed AlTuwaijri
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Ahmed AlRumayyan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Mohammed Tala AlRifai
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Pediatrics, King Abdullah Specialist Children Hospital (KASCH), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
| | - Asma Al Madhi
- Department of Pediatric Neurology, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hassan Al-shehri
- Department of Pediatrics, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Saif Alsaif
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- Department of Neonatology, King Abdulaziz Medical City (KAMC), National Guard Health Affairs (NGHA), Riyadh, Saudi Arabia
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Millevert C, Weckhuysen S. ILAE Genetic Literacy Series: Self-limited familial epilepsy syndromes with onset in neonatal age and infancy. Epileptic Disord 2023; 25:445-453. [PMID: 36939707 DOI: 10.1002/epd2.20026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/13/2022] [Accepted: 12/22/2022] [Indexed: 03/21/2023]
Abstract
The self-limited (familial) epilepsies with onset in neonates or infants, formerly called benign familial neonatal and/or infantile epilepsies, are autosomal dominant disorders characterized by neonatal- or infantile-onset focal motor seizures and the absence of neurodevelopmental complications. Seizures tend to remit during infancy or early childhood and are therefore called "self-limited". A positive family history for epilepsy usually suggests the genetic etiology, but incomplete penetrance and de novo inheritance occur. Here, we review the phenotypic spectrum and the genetic architecture of self-limited (familial) epilepsies with onset in neonates or infants. Using an illustrative case study, we describe important clues in recognition of these syndromes, diagnostic steps including genetic testing, management, and genetic counseling.
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Affiliation(s)
- Charissa Millevert
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Antwerp, Belgium
- Department of Neurology, University Hospital, Antwerp, Belgium
| | - Sarah Weckhuysen
- Applied & Translational Neurogenomics Group, VIB Center for Molecular Neurology, VIB, Antwerp, Belgium
- Department of Neurology, University Hospital, Antwerp, Belgium
- μNEURO Research Centre of Excellence, University of Antwerp, Antwerp, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
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Alharbi HM, Pinchefsky EF, Tran MA, Salazar Cerda CI, Parokaran Varghese J, Kamino D, Widjaja E, Mamak E, Ly L, Nevalainen P, Hahn CD, Tam EWY. Seizure Burden and Neurologic Outcomes After Neonatal Encephalopathy. Neurology 2023; 100:e1976-e1984. [PMID: 36990719 PMCID: PMC10186227 DOI: 10.1212/wnl.0000000000207202] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/03/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Seizures are common during neonatal encephalopathy (NE), but the contribution of seizure burden (SB) to outcomes remains controversial. This study aims to examine the relationship between electrographic SB and neurologic outcomes after NE. METHODS This prospective cohort study recruited newborns ≥36 weeks postmenstrual age around 6 hours of life between August 2014 and November 2019 from a neonatal intensive care unit (NICU). Participants underwent continuous electroencephalography for at least 48 hours, brain MRI within 3-5 days of life, and structured follow-up at 18 months. Electrographic seizures were identified by board-certified neurophysiologists and quantified as total SB and maximum hourly SB. A medication exposure score was calculated based on all antiseizure medications given during NICU admission. Brain MRI injury severity was classified based on basal ganglia and watershed scores. Developmental outcomes were measured using the Bayley Scales of Infant Development, Third Edition. Multivariable regression analyses were performed, adjusting for significant potential confounders. RESULTS Of 108 enrolled infants, 98 had continuous EEG (cEEG) and MRI data collected, of which 5 were lost to follow-up, and 6 died before age 18 months. All infants with moderate-severe encephalopathy completed therapeutic hypothermia. cEEG-confirmed neonatal seizures occurred in 21 (24%) newborns, with a total SB mean of 12.5 ± 36.4 minutes and a maximum hourly SB mean of 4 ± 10 min/h. After adjusting for MRI brain injury severity and medication exposure, total SB was significantly associated with lower cognitive (-0.21, 95% CI -0.33 to -0.08, p = 0.002) and language (-0.25, 95% CI -0.39 to -0.11, p = 0.001) scores at 18 months. Total SB of 60 minutes was associated with 15-point decline in language scores and 70 minutes for cognitive scores. However, SB was not significantly associated with epilepsy, neuromotor score, or cerebral palsy (p > 0.1). DISCUSSION Higher SB during NE was independently associated with worse cognitive and language scores at 18 months, even after adjusting for exposure to antiseizure medications and severity of brain injury. These observations support the hypothesis that neonatal seizures occurring during NE independently contribute to long-term outcomes.
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Affiliation(s)
- Huda M Alharbi
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Elana F Pinchefsky
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - My-An Tran
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Carlos Ivan Salazar Cerda
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Jessy Parokaran Varghese
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Daphne Kamino
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Elysa Widjaja
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Eva Mamak
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Linh Ly
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland.
| | - Päivi Nevalainen
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Cecil D Hahn
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland
| | - Emily W Y Tam
- From the Department of Pediatrics (H.M.A.), King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia; Department of Pediatrics (E.F.P.), Centre Hospitalier Universitaire Sainte-Justine and the University of Montreal, Quebec; Neurosciences and Mental Health Program (M.-A.T., J.P.V., E.W., C.D.H., E.W.Y.T.), Hospital for Sick Children Research Institute; Department of Paediatrics (C.I.S.C., D.K., E.W., L.L., C.D.H., E.W.Y.T.), Department of Radiology (E.W.), and Department of Psychology (E.M.), The Hospital for Sick Children and the University of Toronto, Ontario, Canada; and Epilepsia Helsinki (P.N.), Department of Clinical Neurophysiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Finland.
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Doandes FM, Manea AM, Lungu N, Brandibur T, Cioboata D, Costescu OC, Zaharie M, Boia M. The Role of Amplitude-Integrated Electroencephalography (aEEG) in Monitoring Infants with Neonatal Seizures and Predicting Their Neurodevelopmental Outcome. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050833. [PMID: 37238381 DOI: 10.3390/children10050833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023]
Abstract
Newborn monitoring in neonatal intensive care units (NICU) is mandatory, but neurological and especially electroencephalographic (EEG) monitoring can be overlooked or delayed until the newborn is clinically stable. However, the neonatal period is associated with the highest risk of seizures in humans, and the clinical symptoms may often be discrete, but the evolution and long-term neurodevelopmental disorders in these patients may be important. In response to this issue, we conducted a study to evaluate newborns who experienced neonatal seizures (NS) in the NICU and monitored their long-term neurological development. We enrolled 73 term and preterm newborns who underwent EEG monitoring using amplitude-integrated electroencephalography (aEEG). We then followed their neurological development until around 18 months of age, with 59 patients remaining in the long-term study. A total of 22% of patients with NS developed epilepsy, 12% cerebral palsy, 19% severe neurodevelopmental disabilities, and 8.5% died within the first 18 months of life. Our findings indicate that aEEG background pattern is a strong predictor of unfavorable neurological outcomes, with an odds ratio of 20.4174 (p < 0.05). Additionally, higher Apgar scores were associated with better outcomes (p < 0.05), with the odds of unfavorable neurological outcomes decreasing by 0.7-fold for every point increase in Apgar score. Furthermore, we found a statistically significant association between preterm birth and unfavorable neurological outcomes (p = 0.0104). Our study highlights the importance of early EEG monitoring in the NICU and provides valuable insights into predictors of unfavorable neurological outcomes in newborns who experienced NS.
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Affiliation(s)
- Florina Marinela Doandes
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Aniko Maria Manea
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Nicoleta Lungu
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Timea Brandibur
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Daniela Cioboata
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Oana Cristina Costescu
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Mihaela Zaharie
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
| | - Marioara Boia
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
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Waak M, Laing J, Nagarajan L, Lawn N, Harvey AS. Continuous electroencephalography in the intensive care unit: A critical review and position statement from an Australian and New Zealand perspective. CRIT CARE RESUSC 2023; 25:9-19. [PMID: 37876987 PMCID: PMC10581281 DOI: 10.1016/j.ccrj.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objectives This article aims to critically review the literature on continuous electroencephalography (cEEG) monitoring in the intensive care unit (ICU) from an Australian and New Zealand perspective and provide recommendations for clinicians. Design and review methods A taskforce of adult and paediatric neurologists, selected by the Epilepsy Society of Australia, reviewed the literature on cEEG for seizure detection in critically ill neonates, children, and adults in the ICU. The literature on routine EEG and cEEG for other indications was not reviewed. Following an evaluation of the evidence and discussion of controversial issues, consensus was reached, and a document that highlighted important clinical, practical, and economic considerations regarding cEEG in Australia and New Zealand was drafted. Results This review represents a summary of the literature and consensus opinion regarding the use of cEEG in the ICU for detection of seizures, highlighting gaps in evidence, practical problems with implementation, funding shortfalls, and areas for future research. Conclusion While cEEG detects electrographic seizures in a significant proportion of at-risk neonates, children, and adults in the ICU, conferring poorer neurological outcomes and guiding treatment in many settings, the health economic benefits of treating such seizures remain to be proven. Presently, cEEG in Australian and New Zealand ICUs is a largely unfunded clinical resource that is subsequently reserved for the highest-impact patient groups. Wider adoption of cEEG requires further research into impact on functional and health economic outcomes, education and training of the neurology and ICU teams involved, and securement of the necessary resources and funding to support the service.
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Affiliation(s)
- Michaela Waak
- Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Brisbane, Australia
- Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Joshua Laing
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, Australia
- Comprehensive Epilepsy Program, Alfred Health, Melbourne, Australia
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lakshmi Nagarajan
- Department of Neurology, Perth Children's Hospital, Perth, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
- Telethon Kids Institute, Perth Children's Hospital, Perth, Australia
| | - Nicholas Lawn
- Western Australian Adult Epilepsy Service, Sir Charles Gardiner Hospital, Perth, Australia
| | - A. Simon Harvey
- Department of Neurology, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Neurosciences Research Group, Murdoch Children's Research Institute, Melbourne, Australia
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Gyandeep G, Behura SS, Sahu SK, Panda SK. Comparison between Phenobarbitone and Levetiracetam as the initial anticonvulsant in preterm neonatal seizures - a pilot randomized control trial in developing country setup. Eur J Pediatr 2023; 182:2133-2138. [PMID: 36823477 PMCID: PMC9950002 DOI: 10.1007/s00431-023-04864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/29/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
This study aimed to compare the efficacy and safety of intravenous Levetiracetam and Phenobarbitone in the treatment of seizures in preterm neonates. It was an open-labeled, parallel randomized controlled trial conducted in a tertiary Neonatal Intensive Care Unit, India. Total 48 preterm neonates (28-36+6 weeks) with clinical seizures were randomized to receive either Levetiracetam (LEV; 40 mg/kg, then 20 mg/kg) or Phenobarbitone (PB; 15 mg/kg, then 10 mg/kg) intravenously as first loading dose in ratio 1:1; second loading was given for persistent seizure. Efficacy was denoted by cessation of clinical seizures with first or second doses of the allotted antiepileptic, and remaining seizure-free for the next 24 h. The demographic characteristics of preterm neonates and seizure types were comparable between both groups. Clinical seizure was controlled in 19 (79%) neonates in LEV group and 17 (70%) neonates in PB group, RR 1.12 (95% CI: 0.80 to 1.55), p = 0.504. There was increased respiratory support in PB group 9 (38%) vs. 3 (13%) in LEV group, RR 3.0 (95% CI: 0.92 to 9.74), p = 0.06. Conclusion: Levetiracetam and Phenobarbitone were equally efficacious for clinical neonatal seizure control, but increased respiratory support was found with Phenobarbitone use. What is Known: • Preterm neonates are at higher risk of neonatal seizure and Phenobarbitone is commonly used as the first line antiepileptic drugs in treating them. What is New: • Levetiracetam found equally efficacious as Phenobarbitone for cessation of clinical seizures in preterm neonates, with less adverse effect.
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Affiliation(s)
- Gummalla Gyandeep
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Sushree Smita Behura
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Sanjay Kumar Sahu
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
| | - Santosh Kumar Panda
- Department of Paediatrics, Kalinga Institute of Medical Sciences, KIIT DU, 751024 Bhubaneswar, Odisha India
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15
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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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Miller SL, Bennet L, Sutherland AE, Pham Y, McDonald C, Castillo‐Melendez M, Allison BJ, Mihelakis J, Nitsos I, Boyd BJ, Hirst JJ, Walker DW, Hunt RW, Jenkin G, Wong F, Malhotra A, Fahey MC, Yawno T. Ganaxolone versus Phenobarbital for Neonatal Seizure Management. Ann Neurol 2022; 92:1066-1079. [PMID: 36054160 PMCID: PMC9828769 DOI: 10.1002/ana.26493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Seizures are more common in the neonatal period than at any other stage of life. Phenobarbital is the first-line treatment for neonatal seizures and is at best effective in approximately 50% of babies, but may contribute to neuronal injury. Here, we assessed the efficacy of phenobarbital versus the synthetic neurosteroid, ganaxolone, to moderate seizure activity and neuropathology in neonatal lambs exposed to perinatal asphyxia. METHODS Asphyxia was induced via umbilical cord occlusion in term lambs at birth. Lambs were treated with ganaxolone (5mg/kg/bolus then 5mg/kg/day for 2 days) or phenobarbital (20mg/kg/bolus then 5mg/kg/day for 2 days) at 6 hours. Abnormal brain activity was classified as stereotypic evolving (SE) seizures, epileptiform discharges (EDs), and epileptiform transients (ETs) using continuous amplitude-integrated electroencephalographic recordings. At 48 hours, lambs were euthanized for brain pathology. RESULTS Asphyxia caused abnormal brain activity, including SE seizures that peaked at 18 to 20 hours, EDs, and ETs, and induced neuronal degeneration and neuroinflammation. Ganaxolone treatment was associated with an 86.4% reduction in the number of seizures compared to the asphyxia group. The total seizure duration in the asphyxia+ganaxolone group was less than the untreated asphyxia group. There was no difference in the number of SE seizures between the asphyxia and asphyxia+phenobarbital groups or duration of SE seizures. Ganaxolone treatment, but not phenobarbital, reduced neuronal degeneration within hippocampal CA1 and CA3 regions, and cortical neurons, and ganaxolone reduced neuroinflammation within the thalamus. INTERPRETATION Ganaxolone provided better seizure control than phenobarbital in this perinatal asphyxia model and was neuroprotective for the newborn brain, affording a new therapeutic opportunity for treatment of neonatal seizures. ANN NEUROL 2022;92:1066-1079.
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Affiliation(s)
- Suzanne L. Miller
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Laura Bennet
- Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Amy E. Sutherland
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Yen Pham
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Courtney McDonald
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Margie Castillo‐Melendez
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Beth J. Allison
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Jamie Mihelakis
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ilias Nitsos
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Ben J. Boyd
- Monash Institute of Pharmaceutical SciencesMonash UniversityParkvilleVictoriaAustralia
| | - Jonathan J. Hirst
- School of Biomedical Sciences and Pharmacy, University of NewcastleNewcastleNew South WalesAustralia
| | - David W. Walker
- School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia
| | - Rodney W. Hunt
- Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Graham Jenkin
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia
| | - Flora Wong
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,School of Health and Biomedical Sciences, RMIT UniversityBundooraVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
| | - Atul Malhotra
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Michael C. Fahey
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia,Monash Children's HospitalClaytonVictoriaAustralia
| | - Tamara Yawno
- Ritchie Centre, Department of Obstetrics and GynaecologyMonash University and Hudson Institute of Medical ResearchClaytonVictoriaAustralia,Department of PaediatricsMonash UniversityClaytonVictoriaAustralia
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17
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Kim EH, Shin J, Lee BK. Neonatal seizures: diagnostic updates based on new definition and classification. Clin Exp Pediatr 2022; 65:387-397. [PMID: 35381171 PMCID: PMC9348949 DOI: 10.3345/cep.2021.01361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022] Open
Abstract
Neonatal seizures are the most common neurological symptoms caused by various etiologies in the neonatal period, but their diagnosis and treatment are challenging because their pathophysiology and electroclinical manifestations differ from those of patients in older age groups. Many seizures present as electrographic-only events without clinical signs or as obscure clinical manifestations that are difficult to distinguish from other neonatal behaviors. Accordingly, a new definition and classification of neonatal seizures was recently proposed by the International League Against Epilepsy Task Force on neonatal seizures, highlighting the role of electroencephalography in diagnosing and treating neonatal seizures. Neonatal seizures are defined as electrographic events with sudden, paroxysmal, and abnormal alteration of activity and divided into electroclinical seizures and electrographic-only seizures according to their clinical signs, thus excluding clinical events without an electrographic correlation. Seizure types are described by their predominant clinical features and divided into motor (automatisms, clonic, epileptic spasms, myoclonic, tonic, and sequential), nonmotor (autonomic and behavioral arrest), and unclassified. Although many neonatal seizures are acute reactive events caused by hypoxic-ischemic encephalopathy or vascular insults, structural, genetic, or metabolic etiologies of neonatal-onset epilepsy should also be thoroughly evaluated to determine their appropriate management.
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Affiliation(s)
- Eun-Hee Kim
- Department of Pediatrics, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Jeongmin Shin
- Department of Pediatrics, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
| | - Byoung Kook Lee
- Department of Pediatrics, Chungnam National University Sejong Hospital, Chungnam National University School of Medicine, Sejong, Korea
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18
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Westergren H, Marell Hesla H, Altman M, Wickström R. Validation of central nervous system-induced seizures and other neurological variables in the Swedish Neonatal Quality Register. Acta Paediatr 2022; 111:1331-1337. [PMID: 35298855 PMCID: PMC9314797 DOI: 10.1111/apa.16336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/06/2022] [Accepted: 03/15/2022] [Indexed: 12/03/2022]
Abstract
Aim We sought to validate neurological variables and relevant International Classification of Diseases, Tenth Revision (ICD‐10) codes in the Swedish Neonatal Quality (SNQ) Register. Methods Register data were collected for 351 neonates, born between January 2009 and December 2016, who were treated at a neonatal unit in the Stockholm region on 385 occasions. They were eligible if the check‐box for central nervous system (CNS)‐induced seizures was ticked. The Register data, including relevant ICD‐10 codes, were validated by checking the patients' electronic medical charts. Results Most of the neonates were born at term (76%) and weighed >2500 g (80%). The variable CNS‐induced seizures had a positive predictive value of 46%. The ICD‐10 diagnosis P90.9A had a positive predictive value of 90%. This comprises seizures validated with electroencephalography, amplitude‐integrated electroencephalography or continuous function monitoring. The majority of the associated neurological variables in the Register had positive predictive values above 85%. Conclusion When the check‐box was ticked for central nervous system‐induced seizures, most of the neurological variables in the Register had high validity. However, the CNS‐induced seizures variable per se had a lower positive predictive value. Future SNQ Register‐based studies of such neonatal seizures should also include ICD‐10 P90.9A.
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Affiliation(s)
- Hanna Westergren
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
| | - Helena Marell Hesla
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
| | - Maria Altman
- Paediatric Rheumatology Unit Department of Clinical Epidemiology Unit Department of Medicine Karolinska Institute Solna Sweden
| | - Ronny Wickström
- Neuropaediatric Unit Department of Women´s and Children´s Health Karolinska Institute Solna Sweden
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19
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Gomez-Quintana S, O'Shea A, Factor A, Popovici E, Temko A. A method for AI assisted human interpretation of neonatal EEG. Sci Rep 2022; 12:10932. [PMID: 35768501 PMCID: PMC9243143 DOI: 10.1038/s41598-022-14894-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/14/2022] [Indexed: 12/03/2022] Open
Abstract
The study proposes a novel method to empower healthcare professionals to interact and leverage AI decision support in an intuitive manner using auditory senses. The method’s suitability is assessed through acoustic detection of the presence of neonatal seizures in electroencephalography (EEG). Neurophysiologists use EEG recordings to identify seizures visually. However, neurophysiological expertise is expensive and not available 24/7, even in tertiary hospitals. Other neonatal and pediatric medical professionals (nurses, doctors, etc.) can make erroneous interpretations of highly complex EEG signals. While artificial intelligence (AI) has been widely used to provide objective decision support for EEG analysis, AI decisions are not always explainable. This work developed a solution to combine AI algorithms with a human-centric intuitive EEG interpretation method. Specifically, EEG is converted to sound using an AI-driven attention mechanism. The perceptual characteristics of seizure events can be heard using this method, and an hour of EEG can be analysed in five seconds. A survey that has been conducted among targeted end-users on a publicly available dataset has demonstrated that not only does it drastically reduce the burden of reviewing the EEG data, but also the obtained accuracy is on par with experienced neurophysiologists trained to interpret neonatal EEG. It is also shown that the proposed communion of a medical professional and AI outperforms AI alone by empowering the human with little or no experience to leverage AI attention mechanisms to enhance the perceptual characteristics of seizure events.
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Affiliation(s)
| | - Alison O'Shea
- Department of Computer Science, Munster Technological University, Cork, Ireland
| | - Andreea Factor
- Department of Anatomy and Neuroscience, University College Cork, Cork, Ireland
| | - Emanuel Popovici
- Electrical and Electronic Engineering, University College Cork, Cork, Ireland
| | - Andriy Temko
- Electrical and Electronic Engineering, University College Cork, Cork, Ireland
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20
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Verwoerd C, Limjoco J, Rajamanickam V, Knox A. Efficacy of Levetiracetam and Phenobarbital as First-Line Treatment for Neonatal Seizures. J Child Neurol 2022; 37:401-409. [PMID: 35311411 DOI: 10.1177/08830738221086107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High neonatal seizure burden is associated with worsened neurodevelopmental outcomes. We compared the efficacy of initial treatment with levetiracetam vs phenobarbital for maintaining low seizure burden in a retrospective cohort of 25 neonates monitored with video electroencephalography (EEG). Video EEG tracing were reviewed and paired with medication bolus times to determine seizure burden after treatment. Initial cumulative dose of phenobarbital was 20 mg/kg in all but 1 case; initial cumulative dose of levetiracetam ranged from 50 to 100 mg/kg. Eleven of 17 (65%) patients sustained seizure burden <10% following initial treatment with levetiracetam, compared with 5 of 8 (63%) with phenobarbital. Thirteen (76%) patients treated with levetiracetam had sustained seizure burden <20% compared with 6 (75%) treated with phenobarbital. The phenobarbital group showed a larger absolute reduction in average seizure burden in the hour before and after treatment (-24.3 vs -14.2 minutes/h). Six of 17 (35%) patients treated with levetiracetam remained seizure free after initial treatment, compared with 2 of 8 (25%) patients treated with phenobarbital. Initial treatment with levetiracetam was associated with shorter average time to seizure freedom (15 vs 21 hours). None of these results were statistically significant. Cumulative doses of levetiracetam 100 mg/kg were well tolerated and associated with substantial decrease in seizure burden in several cases. Levetiracetam remains a promising first-line treatment for neonatal seizures; additional randomized controlled trials evaluating the effects of high-dose levetiracetam on seizure burden and long-term outcomes are warranted.
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Affiliation(s)
- Carmen Verwoerd
- Department of Pediatrics, Division of Neonatology, 5228University of Wisconsin, Madison, WI, USA
| | - Jamie Limjoco
- Department of Pediatrics, Division of Neonatology, 5228University of Wisconsin, Madison, WI, USA
| | - Victoria Rajamanickam
- Department of Biostatistics and Medical Informatices, 5228University of Wisconsin, Madison, WI, USA
| | - Andrew Knox
- Department of Neurology, Division of Pediatric Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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21
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Chalia M, Hartmann H, Pressler R. Practical Approaches to the Treatment of Neonatal Seizures. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00711-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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22
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Hunt RW, Liley HG, Wagh D, Schembri R, Lee KJ, Shearman AD, Francis-Pester S, deWaal K, Cheong JYL, Olischar M, Badawi N, Wong FY, Osborn DA, Rajadurai VS, Dargaville PA, Headley B, Wright I, Colditz PB. Effect of Treatment of Clinical Seizures vs Electrographic Seizures in Full-Term and Near-Term Neonates: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2139604. [PMID: 34919132 PMCID: PMC8683963 DOI: 10.1001/jamanetworkopen.2021.39604] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Seizures in the neonatal period are associated with increased mortality and morbidity. Bedside amplitude-integrated electroencephalography (aEEG) has facilitated the detection of electrographic seizures; however, whether these seizures should be treated remains uncertain. OBJECTIVE To determine if the active management of electrographic and clinical seizures in encephalopathic term or near-term neonates improves survival free of severe disability at 2 years of age compared with only treating clinically detected seizures. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was conducted in tertiary newborn intensive care units recruited from 2012 to 2016 and followed up until 2 years of age. Participants included neonates with encephalopathy at 35 weeks' gestation or more and younger than 48 hours old. Data analysis was completed in April 2021. INTERVENTIONS Randomization was to an electrographic seizure group (ESG) in which seizures detected on aEEG were treated in addition to clinical seizures or a clinical seizure group (CSG) in which only seizures detected clinically were treated. MAIN OUTCOMES AND MEASURES Primary outcome was death or severe disability at 2 years, defined as scores in any developmental domain more than 2 SD below the Australian mean assessed with Bayley Scales of Neonate and Toddler Development, 3rd ed (BSID-III), or the presence of cerebral palsy, blindness, or deafness. Secondary outcomes included magnetic resonance imaging brain injury score at 5 to 14 days, time to full suck feeds, and individual domain scores on BSID-III at 2 years. RESULTS Of 212 randomized neonates, the mean (SD) gestational age was 39.2 (1.7) weeks and 122 (58%) were male; 152 (72%) had moderate to severe hypoxic-ischemic encephalopathy (HIE) and 147 (84%) had electrographic seizures. A total of 86 neonates were included in the ESG group and 86 were included in the CSG group. Ten of 86 (9%) neonates in the ESG and 4 of 86 (4%) in the CSG died before the 2-year assessment. The odds of the primary outcome were not significantly different in the ESG group compared with the CSG group (ESG, 38 of 86 [44%] vs CSG, 27 of 86 [31%]; odds ratio [OR], 1.83; 95% CI, 0.96 to 3.49; P = .14). There was also no significant difference in those with HIE (OR, 1.77; 95% CI, 0.84 to 3.73; P = .26). There was evidence that cognitive outcomes were worse in the ESG (mean [SD] scores, ESG: 97.4 [17.7] vs CSG: 103.8 [17.3]; mean difference, -6.5 [95% CI, -1.2 to -11.8]; P = .01). There was little evidence of a difference in secondary outcomes, including time to suck feeds, seizure burden, or brain injury score. CONCLUSIONS AND RELEVANCE Treating electrographic and clinical seizures with currently used anticonvulsants did not significantly reduce the rate of death or disability at 2 years in a heterogeneous group of neonates with seizures. TRIAL REGISTRATION http://anzctr.org.au Identifier: ACTRN12611000327987.
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Affiliation(s)
- Rod W. Hunt
- Department of Paediatrics, Monash University, Melbourne, Australia
- Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
- Cerebral Palsy Alliance, University of Sydney, Sydney, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia
| | - Helen G. Liley
- Mater Mother’s Hospital, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | | | - Rachel Schembri
- Clinical Epidemiology Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Katherine J. Lee
- Clinical Epidemiology Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | | | | | - Koert deWaal
- Department of Neonatal Medicine, John Hunter Children’s Hospital, Newcastle, Australia
- University of Newcastle, Callaghan, Australia
| | - Jeanie Y. L. Cheong
- Clinical Sciences, Murdoch Children’s Research Institute, Melbourne, Australia
- Neonatal Services, The Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | | | - Nadia Badawi
- Cerebral Palsy Alliance, University of Sydney, Sydney, Australia
- Grace Newborn Intensive Care, The Children’s Hospital, Westmead, Australia
| | - Flora Y. Wong
- Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia
| | - David A. Osborn
- Newborn Medicine, Royal Prince Alfred Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | | | - Peter A. Dargaville
- Neonatal and Paediatric Intensive Care Unit, Royal Hobart Hospital, Hobart, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Bevan Headley
- Department of Neonatal Medicine, Women’s and Children’s Hospital, Adelaide, Australia
| | - Ian Wright
- James Cook University, Cairns, Australia
| | - Paul B. Colditz
- University of Queensland, Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, Australia
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23
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Glass HC, Soul JS, Chang T, Wusthoff CJ, Chu CJ, Massey SL, Abend NS, Lemmon M, Thomas C, Numis AL, Guillet R, Sturza J, McNamara NA, Rogers EE, Franck LS, McCulloch CE, Shellhaas RA. Safety of Early Discontinuation of Antiseizure Medication After Acute Symptomatic Neonatal Seizures. JAMA Neurol 2021; 78:817-825. [PMID: 34028496 PMCID: PMC8145161 DOI: 10.1001/jamaneurol.2021.1437] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Question Is discontinuation of antiseizure medication (ASM) after resolution of acute symptomatic neonatal seizures and prior to discharge from the hospital associated with functional neurodevelopment or epilepsy at 24 months? Findings In this comparative effectiveness study of 303 children with neonatal seizures from 9 centers, 64% had ASM maintained at hospital discharge. No difference was found between ASM maintenance and discontinuation groups in functional neurodevelopment or epilepsy; 13% of children developed epilepsy, including more than one-third with infantile spasms. Meaning These results support discontinuing ASMs for most neonates with acute symptomatic seizures prior to discharge from the hospital, an approach that may represent an evidence-based change in practice for many clinicians. Importance Antiseizure medication (ASM) treatment duration for acute symptomatic neonatal seizures is variable. A randomized clinical trial of phenobarbital compared with placebo after resolution of acute symptomatic seizures closed early owing to low enrollment. Objective To assess whether ASM discontinuation after resolution of acute symptomatic neonatal seizures and before hospital discharge is associated with functional neurodevelopment or risk of epilepsy at age 24 months. Design, Setting, and Participants This comparative effectiveness study included 303 neonates with acute symptomatic seizures (282 with follow-up data and 270 with the primary outcome measure) from 9 US Neonatal Seizure Registry centers, born from July 2015 to March 2018. The centers all had level IV neonatal intensive care units and comprehensive pediatric epilepsy programs. Data were analyzed from June 2020 to February 2021. Exposures The primary exposure was duration of ASM treatment dichotomized as ASM discontinued vs ASM maintained at the time of discharge from the neonatal seizure admission. To enhance causal association, each outcome risk was adjusted for propensity to receive ASM at discharge. Propensity for ASM maintenance was defined by a logistic regression model including seizure cause, gestational age, therapeutic hypothermia, worst electroencephalogram background, days of electroencephalogram seizures, and discharge examination (all P ≤ .10 in a joint model except cause, which was included for face validity). Main Outcomes and Measures Functional neurodevelopment was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS) at 24 months powered for propensity-adjusted noninferiority of early ASM discontinuation. Postneonatal epilepsy, a prespecified secondary outcome, was defined per International League Against Epilepsy criteria, determined by parent interview, and corroborated by medical records. Results Most neonates (194 of 303 [64%]) had ASM maintained at the time of hospital discharge. Among 270 children evaluated at 24 months (mean [SD], 23.8 [0.7] months; 147 [54%] were male), the WIDEA-FS score was similar for the infants whose ASMs were discontinued (101 of 270 [37%]) compared with the infants with ASMs maintained (169 of 270 [63%]) at discharge (median score, 165 [interquartile range, 150-175] vs 161 [interquartile range, 129-174]; P = .09). The propensity-adjusted average difference was 4 points (90% CI, −3 to 11 points), which met the a priori noninferiority limit of −12 points. The epilepsy risk was similar (11% vs 14%; P = .49), with a propensity-adjusted odds ratio of 1.5 (95% CI, 0.7-3.4; P = .32). Conclusions and Relevance In this comparative effectiveness study, no difference was found in functional neurodevelopment or epilepsy at age 24 months among children whose ASM was discontinued vs maintained at hospital discharge after resolution of acute symptomatic neonatal seizures. These results support discontinuation of ASM prior to hospital discharge for most infants with acute symptomatic neonatal seizures.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Epidemiology & Biostatistics; University of California, San Francisco
| | - Janet S Soul
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Taeun Chang
- Department of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Courtney J Wusthoff
- Department of Neurology, Stanford University, Palo Alto, California.,Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
| | - Catherine J Chu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shavonne L Massey
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Nicholas S Abend
- Department of Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Monica Lemmon
- Departments of Pediatrics, Duke University School of Medicine, Durham, North Carolina.,Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Cameron Thomas
- Department of Pediatrics, University of Cincinnati, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco.,Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Julie Sturza
- Department of Pediatrics, University of Michigan, Ann Arbor
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco
| | - Linda S Franck
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco.,Department of Family Health Care Nursing, University of California, San Francisco
| | - Charles E McCulloch
- Department of Epidemiology & Biostatistics; University of California, San Francisco
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24
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Ziobro JM, Eschbach K, Shellhaas RA. Novel Therapeutics for Neonatal Seizures. Neurotherapeutics 2021; 18:1564-1581. [PMID: 34386906 PMCID: PMC8608938 DOI: 10.1007/s13311-021-01085-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2021] [Indexed: 02/04/2023] Open
Abstract
Neonatal seizures are a common neurologic emergency for which therapies have not significantly changed in decades. Improvements in diagnosis and pathophysiologic understanding of the distinct features of acute symptomatic seizures and neonatal-onset epilepsies present exceptional opportunities for development of precision therapies with potential to improve outcomes. Herein, we discuss the pathophysiology of neonatal seizures and review the evidence for currently available treatment. We present emerging therapies in clinical and preclinical development for the treatment of acute symptomatic neonatal seizures. Lastly, we discuss the role of precision therapies for genetic neonatal-onset epilepsies and address barriers and goals for developing new therapies for clinical care.
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Affiliation(s)
- Julie M Ziobro
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA.
| | - Krista Eschbach
- Department of Pediatrics, Section of Neurology, Denver Anschutz School of Medicine, Children's Hospital Colorado, University of Colorado, Aurora, CO, 80045, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Michigan Medicine, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr, Ann Arbor, MI, USA
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25
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Garg A, Suthar R, Sundaram V, Kumar P, Angurana SK. Clinical profile, aetiology, short-term outcome and predictors of poor outcome of neonatal seizures among out-born neonates admitted to a neonatal unit in Paediatric emergency of a tertiary care hospital in North India: A prospective observational study. Trop Doct 2021; 51:365-371. [PMID: 34018889 DOI: 10.1177/00494755211016226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neonatal seizures are common manifestations of several neurological or systemic disorders and associated with high morbidity, mortality and poor short- and long-term developmental outcomes. It is important to determine the aetiology and factors that determine the poor outcome, more so in a newly developed setting. The early detection of predictors of poor outcome will help in planning acute management, counselling, follow-up and rehabilitation services. In this prospective observational study, we looked at the clinical profile, aetiology, short-term outcomes and predictors of poor outcome of neonatal seizures among out-born neonates. The common causes were hypoxic ischaemic encephalopathy, sepsis and metabolic disturbances. One-third of neonates had poor outcome. Abnormal neurological and cardiorespiratory examination at admission; low oxygen saturation, glucose and pH; and hypoxic ischemic encephalopathy-III were predictors of poor outcome.
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Affiliation(s)
- Ashish Garg
- Junior Resident, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Renu Suthar
- Associate Professor, Pediatric Neurology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Venkataseshan Sundaram
- Additional Professor, Neonatology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Praveen Kumar
- Professor and Unit Head, Neonatology Unit, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
| | - Suresh K Angurana
- Assistant Professor, Division of Paediatric Critical Care, Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research (29751PGIMER), Chandigarh, India
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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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Macdonald-Laurs E, Sharpe C, Nespeca M, Rismanchi N, Gold JJ, Kuperman R, Wang S, Lee NMD, Michelson DJ, Haas R, Reed P, Davis SL. Does the first hour of continuous electroencephalography predict neonatal seizures? Arch Dis Child Fetal Neonatal Ed 2021; 106:162-167. [PMID: 32928896 DOI: 10.1136/archdischild-2020-318985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 07/18/2020] [Accepted: 07/26/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Prolonged continuous video-electroencephalography (cEEG) is recommended for neonates at risk of seizures. The cost and expertise required to provide a real-time response to detected seizures often limits its utility. We hypothesised that the first hour of cEEG could predict subsequent seizures. DESIGN AND SETTING Retrospective multicentre diagnostic accuracy study. PATIENTS 266 term neonates at risk of seizure or with suspected seizures. INTERVENTION The first hour of cEEG was graded by expert and novice interpreters as normal, mildly, moderately or severely abnormal; seizures were identified. MAIN OUTCOME MEASURES Association between abnormalities in the first hour of cEEG and the presence of seizures during total cEEG monitoring. RESULTS 50/98 (51%) of neonates who developed seizures had their first seizure in the first hour of cEEG monitoring. The 'time-to-event' risk of seizure from 0 to 96 hours was 0.38 (95% CI 0.32 to 0.44) while the risk in the first hour was 0.19 (95% CI 0.15 to 0.24). cEEG background was normal in 48% of neonates, mildly abnormal in 30%, moderately abnormal in 13% and severely abnormal in 9%. Inter-rater agreement for determination of background was very good (weighted kappa=0.81, 95% CI 0.72 to 0.91). When neonates with seizures during the first hour were excluded, an abnormal background resulted in 2.4 times increased risk of seizures during the subsequent monitoring period (95% CI 1.3 to 4.4, p<0.003) while a severely abnormal background resulted in a sevenfold increased risk (95% CI 3.4 to 14.3, p<0.0001). CONCLUSIONS The first hour of cEEG in at-risk neonates is useful in identifying and predicting whether seizures occur during cEEG monitoring up to 96 hours. This finding enables identification of high-risk neonates who require closer observation.
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Affiliation(s)
- Emma Macdonald-Laurs
- The Department of Paediatric Neurology, Starship Children's Health, Newmarket, New Zealand
| | - Cynthia Sharpe
- The Department of Paediatric Neurology, Starship Children's Health, Newmarket, New Zealand
| | - Mark Nespeca
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Neggy Rismanchi
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Jeffrey J Gold
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Rachel Kuperman
- The Department of Pediatric Neurology, UCSF Benioff Children's Hospital Oakland, Oakland, California, USA
| | - Sonya Wang
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Ngoc Minh D Lee
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - David J Michelson
- Division of Pediatric Neurology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Richard Haas
- The Department of Neurosciences, Rady Children's Hospital San Diego, San Diego, California, USA.,The Department of Neurosciences, University of California San Diego, La Jolla, California, USA
| | - Peter Reed
- The Department of Paediatric Neurology, Starship Children's Health, Newmarket, New Zealand
| | - Suzanne L Davis
- The Department of Paediatric Neurology, Starship Children's Health, Newmarket, New Zealand
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Shellhaas RA. Neonatal seizures reach the mainstream: The ILAE classification of seizures in the neonate. Epilepsia 2021; 62:629-631. [PMID: 33634848 DOI: 10.1111/epi.16857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 01/24/2023]
Affiliation(s)
- Renée A Shellhaas
- Division of Pediatric Neurology, Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Smyrni N, Koutsaki M, Petra M, Nikaina E, Gontika M, Strataki H, Davora F, Bouza H, Damianos G, Skouteli H, Mastroyianni S, Dalivigka Z, Dinopoulos A, Tzaki M, Papavasiliou A. Moderately and Late Preterm Infants: Short- and Long-Term Outcomes From a Registry-Based Cohort. Front Neurol 2021; 12:628066. [PMID: 33643206 PMCID: PMC7907517 DOI: 10.3389/fneur.2021.628066] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/08/2021] [Indexed: 11/24/2022] Open
Abstract
Background: While most studies on the association of preterm birth and cerebral palsy (CP) have focused on very preterm infants, lately, attention has been paid to moderately preterm [32 to <34 weeks gestational age (GA)] and late preterm infants (34 to <37 weeks GA). Methods: In order to report on the outcomes of a cohort of moderately and late preterm infants, derived from a population-based CP Registry, a comparative analysis of data on 95 moderately preterm infants and 96 late preterm infants out of 1,016 with CP, was performed. Results: Moderately preterm neonates with CP were more likely to have a history of N-ICU admission (p = 0.001) and require respiratory support (p < 0.001) than late preterm neonates. Birth weight was significantly related to early neonatal outcome with children with lower birth weight being more likely to have a history of N-ICU admission [moderately preterm infants (p = 0.006)/late preterm infants (p < 0.001)], to require ventilator support [moderately preterm infants (p = 0.025)/late preterm infants (p = 0.014)] and not to have neonatal seizures [moderately preterm infants (p = 0.044)/late preterm infants (p = 0.263)]. In both subgroups, the majority of children had bilateral spastic CP with moderately preterm infants being more likely to have bilateral spastic CP and less likely to have ataxic CP as compared to late preterm infants (p = 0.006). The prevailing imaging findings were white matter lesions in both subgroups, with statistically significant difference between moderately preterm infants who required ventilator support and mainly presented with this type of lesion vs. those who did not and presented with gray matter lesions, maldevelopments or miscellaneous findings. Gross motor function was also assessed in both subgroups without significant difference. Among late preterm infants, those who needed N-ICU admission and ventilator support as neonates achieved worse fine motor outcomes than those who did not. Conclusions: Low birth weight is associated with early neonatal problems in both moderately and late preterm infants with CP. The majority of children had bilateral spastic CP and white matter lesions in neuroimaging. GMFCS levels were comparable in both subgroups while BFMF was worse in late preterm infants with a history of N-ICU admission and ventilator support.
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Affiliation(s)
- Nikoletta Smyrni
- Second Department of Neurology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Maria Koutsaki
- Third Pediatric Department, University General Hospital Attikon, Athens, Greece
| | - Marianna Petra
- Department of Orthopedics, Penteli Children's Hospital, Athens, Greece
| | - Eirini Nikaina
- Department of Pediatrics, Agia Sophia Children's Hospital, Athens, Greece
| | - Maria Gontika
- Department of Neurology, Evaggelismos General Hospital, Athens, Greece
| | - Helen Strataki
- First Department of Neurology, Aeginition Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Fotini Davora
- Department of Neurology, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Helen Bouza
- Department of Neonatal Intensive Care Unit, Agia Sophia Children's Hospital, Athens, Greece
| | - George Damianos
- Department of Neurology, Penteli Children's Hospital, Athens, Greece
| | - Helen Skouteli
- Department of Pediatric Neurology, IASO General Hospital, Athens, Greece
| | | | - Zoi Dalivigka
- Rehabilitation Center, Children's Hospital Aglaia Kyriakou, Athens, Greece
| | - Argyris Dinopoulos
- Third Pediatric Department, University General Hospital Attikon, Athens, Greece
| | - Margarita Tzaki
- Neonatal Intensive Care Unit, Elena Venizelou General Hospital, Athens, Greece
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Kumar J, Meena J, Yadav J, Saini L. Efficacy and Safety of Phenobarbitone as First-Line Treatment for Neonatal Seizure: A Systematic Review and Meta-Analysis. J Trop Pediatr 2021; 67:6141527. [PMID: 33598701 DOI: 10.1093/tropej/fmab008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVE Phenobarbitone is used as a first-line drug for neonatal seizures. However, its poor short- and long-term safety profile is concerning. We aim to systematically synthesize the data on the efficacy and safety of phenobarbitone as a first-line agent and compare it against other anti-epileptic drugs (AEDs) in neonates. METHODS Using keywords related to the study population (neonatal seizure) and intervention (phenobarbitone), we searched CENTRAL, Embase, PubMed and Web of Science until 15 December 2020. Randomized controlled trials (RCTs) comparing phenobarbitone with any other AED as first-line therapy for seizure control in the neonates were considered eligible. The random-effect meta-analysis was done using RevMan 5.3 software. RESULTS We screened through 443 records and identified nine eligible studies (719 participants). Five RCTs comparing phenobarbitone with levetiracetam did not find any difference in seizure control with the first dose [risk ratio (RR) 1.43, 95% CI 0.79-2.57] or adverse effects (RR 4.66; 95% CI 0.33-65.83). Two trials comparing phenobarbitone and phenytoin also did not find any difference in seizure control with the first dose (RR 2.09; 95% CI 0.31-14.03) and other outcomes. Only one RCT compared phenobarbitone and lorazepam and found lorazepam to be more efficacious in seizure control with the first dose (RR 0.71; 95% CI 0.53-0.94). Three trials compared neurodevelopmental outcomes, in which levetiracetam was better in two, whereas one did not find any difference. CONCLUSION Phenobarbitone is at least as efficacious and safe as other drugs like phenytoin and levetiracetam. The data over the long-term neurodevelopmental outcome are lacking. The existing evidence is insufficient to recommend other drugs over phenobarbitone.
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Affiliation(s)
- Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jitendra Meena
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Jaivinder Yadav
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - Lokesh Saini
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
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32
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Ophelders DR, Gussenhoven R, Klein L, Jellema RK, Westerlaken RJ, Hütten MC, Vermeulen J, Wassink G, Gunn AJ, Wolfs TG. Preterm Brain Injury, Antenatal Triggers, and Therapeutics: Timing Is Key. Cells 2020; 9:E1871. [PMID: 32785181 PMCID: PMC7464163 DOI: 10.3390/cells9081871] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
With a worldwide incidence of 15 million cases, preterm birth is a major contributor to neonatal mortality and morbidity, and concomitant social and economic burden Preterm infants are predisposed to life-long neurological disorders due to the immaturity of the brain. The risks are inversely proportional to maturity at birth. In the majority of extremely preterm infants (<28 weeks' gestation), perinatal brain injury is associated with exposure to multiple inflammatory perinatal triggers that include antenatal infection (i.e., chorioamnionitis), hypoxia-ischemia, and various postnatal injurious triggers (i.e., oxidative stress, sepsis, mechanical ventilation, hemodynamic instability). These perinatal insults cause a self-perpetuating cascade of peripheral and cerebral inflammation that plays a critical role in the etiology of diffuse white and grey matter injuries that underlies a spectrum of connectivity deficits in survivors from extremely preterm birth. This review focuses on chorioamnionitis and hypoxia-ischemia, which are two important antenatal risk factors for preterm brain injury, and highlights the latest insights on its pathophysiology, potential treatment, and future perspectives to narrow the translational gap between preclinical research and clinical applications.
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Affiliation(s)
- Daan R.M.G. Ophelders
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Ruth Gussenhoven
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Luise Klein
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Reint K. Jellema
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
| | - Rob J.J. Westerlaken
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Matthias C. Hütten
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Jeroen Vermeulen
- Department of Pediatric Neurology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands;
| | - Guido Wassink
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Alistair J. Gunn
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Private bag 92019, Auckland 1023, New Zealand; (G.W.); (A.J.G.)
| | - Tim G.A.M. Wolfs
- Department of Pediatrics, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands; (D.R.M.G.O.); (R.G.); (L.K.); (R.K.J.); (R.J.J.W.); (M.C.H.)
- School for Oncology and Developmental Biology (GROW), Maastricht University, 6229 ER Maastricht, The Netherlands
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Abstract
Neonatal seizures are common, occurring in 2 to 5 of 1,000 live births in the United States. The neonatal brain is thought to be predisposed toward seizures due to a combination of excessive excitatory and deficient inhibitory neuronal activity. The seizures tend to be focal or multifocal without secondary generalization, resulting in subtle seizure appearance. There are five main categories of neonatal seizures: focal clonic, focal tonic, myoclonic, subtle, and generalized tonic. An electroencephalogram is recommended to diagnose and treat neonatal seizures due to poor reliability of the clinical examination. Causes of neonatal seizures are broad, including trauma, structural brain anomalies, infections, metabolic disorders, drug withdrawal or intoxication, and neonatal epilepsy syndromes. Treatment of neonatal seizures involves management of cardiorespiratory status, correction of metabolic derangements, and antiepileptics as needed. The most common antiepileptics used in neonates are phenobarbital, levetiracetam, and fosphenytoin. The long-term risk of neurodevelopmental disability varies depending upon the etiology of neonatal seizures. Close attention to developmental milestones and neurology follow-up is recommended for all neonates with seizures. [Pediatr Ann. 2020;49(7):e292-e298.].
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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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Abbasi H, Unsworth CP. Applications of advanced signal processing and machine learning in the neonatal hypoxic-ischemic electroencephalogram. Neural Regen Res 2020; 15:222-231. [PMID: 31552887 PMCID: PMC6905345 DOI: 10.4103/1673-5374.265542] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/24/2019] [Indexed: 01/15/2023] Open
Abstract
Perinatal hypoxic-ischemic-encephalopathy significantly contributes to neonatal death and life-long disability such as cerebral palsy. Advances in signal processing and machine learning have provided the research community with an opportunity to develop automated real-time identification techniques to detect the signs of hypoxic-ischemic-encephalopathy in larger electroencephalography/amplitude-integrated electroencephalography data sets more easily. This review details the recent achievements, performed by a number of prominent research groups across the world, in the automatic identification and classification of hypoxic-ischemic epileptiform neonatal seizures using advanced signal processing and machine learning techniques. This review also addresses the clinical challenges that current automated techniques face in order to be fully utilized by clinicians, and highlights the importance of upgrading the current clinical bedside sampling frequencies to higher sampling rates in order to provide better hypoxic-ischemic biomarker detection frameworks. Additionally, the article highlights that current clinical automated epileptiform detection strategies for human neonates have been only concerned with seizure detection after the therapeutic latent phase of injury. Whereas recent animal studies have demonstrated that the latent phase of opportunity is critically important for early diagnosis of hypoxic-ischemic-encephalopathy electroencephalography biomarkers and although difficult, detection strategies could utilize biomarkers in the latent phase to also predict the onset of future seizures.
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Affiliation(s)
- Hamid Abbasi
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
| | - Charles P. Unsworth
- Department of Engineering Science, The University of Auckland, Auckland, New Zealand
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He Y, Tang J, Zhang M, Xiong T, Ojha S, Choonara I, Mu D. Efficacy of antiepileptic drugs in neonatal seizures: a systematic review protocol. BMJ Paediatr Open 2020; 4:e000683. [PMID: 32626827 PMCID: PMC7326240 DOI: 10.1136/bmjpo-2020-000683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Seizures are one of the most common neurological disorders of neonates, which is also an emergency in the neonatal intensive care unit. For neonates, the recommended first-line antiepileptic drugs (AEDs) include phenobarbitone, which may be effective in only 50% of seizures. Some new AEDs, such as levetiracetam, have been shown to be effective in adults and older children. However, their efficacy for neonatal seizures remains uncertain. The aim of this investigation is to conduct a systematic review to evaluate the efficacy of all AEDs in neonates. Additionally, the long-term outcomes following neonatal seizures, in relation to the development of cerebral palsy and epilepsy, will be studied. METHOD We will perform a systematic review including randomised controlled studies (RCTs), cohort studies, case-controlled studies and case series studies which evaluated the efficacy of AEDs and short-term and long-term outcomes in neonatal seizures. PubMed, Embase, Web of Science, Cochrane Library and Clinical trial.gov will be searched. There will be no language restriction. Risk bias in RCTs will be evaluated by the Cochrane risk-of-bias tool, while cohort and case-control studies will be evaluated by the Newcastle-Ottawa Scale. A network meta-analysis will be performed by the Bayesian model using WinBUGS V.1.4.3 and R software if there is a high degree of homogeneity among studies. Otherwise, we will perform a narrative review without pooling. Subgroup analyses will be performed in different AEDs and dosage groups. OUTCOME The primary outcomes will be seizure cessation confirmed by electroencephalogram and long-term neurodevelopmental outcome. Secondary outcomes will be neonatal mortality during hospitalisation and suspected drug toxicity. ETHICS AND DISSEMINATION Formal ethical approval is not required as no primary data are collected. This systematic review will be disseminated through a peer-reviewed publication.
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Affiliation(s)
- Yang He
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jun Tang
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Meng Zhang
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Tao Xiong
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Shalini Ojha
- Academic Child Health, University of Nottingham, Nottingham, UK
| | - Imti Choonara
- School of Medicine, University of Nottingham, Derby, UK
| | - Dezhi Mu
- Key Laboratory of Obstetrics & Gynecologic and Pediatric Diseases and Birth Defects of the Ministry of Education, Sichuan University, Chengdu, China.,Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Pittet-Metrailler MP, Almazrooei AM, Tam EW. Sensory assessment: Neurophysiology in neonates and neurodevelopmental outcome. HANDBOOK OF CLINICAL NEUROLOGY 2020; 174:183-203. [DOI: 10.1016/b978-0-444-64148-9.00014-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Liu F, Wu M, Kai J, Dong J, Zhang B, Liu L, Zhu F, Zeng LH. Effectiveness of low dose of rapamycin in preventing seizure-induced anxiety-like behaviour, cognitive impairment, and defects in neurogenesis in developing rats. Int J Neurosci 2019; 130:9-18. [PMID: 29883228 DOI: 10.1080/00207454.2018.1486827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Aims: Previous studies have demonstrated that rapamycin prevents seizure-induced anxiety-like behaviors. However, rapamycin had been used at a higher dose of 3 mg/kg and resulted in side effects in immature animals. This work was designed to explore whether a lower dose of rapamycin has similar efficacy but has milder side effects.Methods: Acute seizures were induced by injection of pilocarpine at postnatal 10-day Sprague-Dawley rats. Western blot analysis was used to detect changes in mammalian target of rapamycin (mTOR) pathway after seizure. Immunofluorescent intensity of doublecortin (DCX) was conducted to evaluate the development of neurons in hippocampus. Morris water maze and Y-maze test were used to assess cognitive functions and open-field test and elevated plus maze were used to detect anxiety-like behaviors 4 weeks after seizure onset.Results: mTOR pathway was abnormally activated with two peaks after pilocarpine-induced seizures, and no difference of DCX-positive cells and body weight were noticed between control and pilocarpine-induced seizure rats. Pilocarpine-induced seizure in postnatal 10 days rats did not exert impairment on cognitive functions, but resulted in obvious anxiety-like behaviors. Low dose of rapamycin at 0.3 mg/kg significantly reversed seizure-induced increase of p-S6 levels as well as abnormal anxiety-like behaviors. In addition, rapamycin at the dose of 0.3mg/kg did not affect normal development and cognitive functions.Conclusion: lower doses of rapamycin should be used in infants compared with older children or adults.
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Affiliation(s)
- Furong Liu
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China.,Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Meiling Wu
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China.,Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jiejing Kai
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China.,Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jingyin Dong
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China
| | - Binbin Zhang
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China
| | - Luna Liu
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China
| | - Feng Zhu
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China
| | - Ling-Hui Zeng
- Department of Pharmacy, School of Medicine, Zhejiang University City College, Hangzhou, Zhejiang, China.,Department of Pharmacology, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Rennie JM, de Vries LS, Blennow M, Foran A, Shah DK, Livingstone V, van Huffelen AC, Mathieson SR, Pavlidis E, Weeke LC, Toet MC, Finder M, Pinnamaneni RM, Murray DM, Ryan AC, Marnane WP, Boylan GB. Characterisation of neonatal seizures and their treatment using continuous EEG monitoring: a multicentre experience. Arch Dis Child Fetal Neonatal Ed 2019; 104:F493-F501. [PMID: 30472660 PMCID: PMC6788873 DOI: 10.1136/archdischild-2018-315624] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The aim of this multicentre study was to describe detailed characteristics of electrographic seizures in a cohort of neonates monitored with multichannel continuous electroencephalography (cEEG) in 6 European centres. METHODS Neonates of at least 36 weeks of gestation who required cEEG monitoring for clinical concerns were eligible, and were enrolled prospectively over 2 years from June 2013. Additional retrospective data were available from two centres for January 2011 to February 2014. Clinical data and EEGs were reviewed by expert neurophysiologists through a central server. RESULTS Of 214 neonates who had recordings suitable for analysis, EEG seizures were confirmed in 75 (35%). The most common cause was hypoxic-ischaemic encephalopathy (44/75, 59%), followed by metabolic/genetic disorders (16/75, 21%) and stroke (10/75, 13%). The median number of seizures was 24 (IQR 9-51), and the median maximum hourly seizure burden in minutes per hour (MSB) was 21 min (IQR 11-32), with 21 (28%) having status epilepticus defined as MSB>30 min/hour. MSB developed later in neonates with a metabolic/genetic disorder. Over half (112/214, 52%) of the neonates were given at least one antiepileptic drug (AED) and both overtreatment and undertreatment was evident. When EEG monitoring was ongoing, 27 neonates (19%) with no electrographic seizures received AEDs. Fourteen neonates (19%) who did have electrographic seizures during cEEG monitoring did not receive an AED. CONCLUSIONS Our results show that even with access to cEEG monitoring, neonatal seizures are frequent, difficult to recognise and difficult to treat. OBERSERVATION STUDY NUMBER NCT02160171.
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Affiliation(s)
- Janet M Rennie
- Institute of Women’s Health University College London, London, UK
| | | | - Mats Blennow
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden,CLINTEC, Karolinska Institute, Solna, Sweden
| | | | - Divyen K Shah
- Royal London Hospital, London, UK,Queen Mary University of London, London, UK
| | - Vicki Livingstone
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | | | - Sean R Mathieson
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Elena Pavlidis
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Lauren C Weeke
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mona C Toet
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mikael Finder
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Deirdre M Murray
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Anthony C Ryan
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - William P Marnane
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland
| | - Geraldine B Boylan
- Irish Centre for Fetal and Neonatal Translational Research (INFANT), Cork, Ireland,Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
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Soul JS, Pressler R, Allen M, Boylan G, Rabe H, Portman R, Hardy P, Zohar S, Romero K, Tseng B, Bhatt-Mehta V, Hahn C, Denne S, Auvin S, Vinks A, Lantos J, Marlow N, Davis JM. Recommendations for the design of therapeutic trials for neonatal seizures. Pediatr Res 2019; 85:943-954. [PMID: 30584262 PMCID: PMC6760680 DOI: 10.1038/s41390-018-0242-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 12/01/2022]
Abstract
Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from well-designed clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population.
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Affiliation(s)
- Janet S Soul
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA.
| | - Ronit Pressler
- UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Geraldine Boylan
- INFANT Research Centre & Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Heike Rabe
- Brighton and Sussex Medical School, Brighton, England
| | | | | | - Sarah Zohar
- INSERM, UMRS1138, University Paris V and University Paris VI, Paris, France
| | | | | | - Varsha Bhatt-Mehta
- C.S.Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Cecil Hahn
- Division of Neurology, The Hospital for Sick Children and Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Scott Denne
- Riley Children's Hospital, Indiana University, Indianapolis, Indiana, USA
| | - Stephane Auvin
- Pediatric Neurology Department & INSERM U1141, APHP, Robert Debré University Hospital, Paris, France
| | - Alexander Vinks
- College of Medicine & Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - John Lantos
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Neil Marlow
- UCL Institute for Women's Health, University College London, London, UK
| | - Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
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Abstract
Most neonatal seizures in preterm newborns are of acute symptomatic origin with a prevalence higher than in full-term infants. To date, recommendations for management of seizures in preterm newborns are scarce and do not differ from those in full-term newborns. Mortality in preterm newborns with seizures has significantly declined over the last decades, from figures of 84%-94% in the 1970s and 1980s to 22%-45% in the last years. However, mortality is significantly higher in those with a birth weight<1000g and a gestational age<28 weeks. Seizures are a strong predictor of unfavorable outcomes, including not only cerebral palsy, epilepsy, and intellectual disability, but also vision, hearing impairment, and microcephaly. The majority of patients with developmental delay are severely affected and this is usually associated with cerebral palsy. Furthermore, the incidence of epilepsy after neonatal seizures seems to be lower in preterm than in full-term infants but the risk is approximately 40 times greater than in the general population. Clinical studies cannot disentangle the specific and independent contributions of seizure-induced functional changes and the role of etiology and brain damage severity in determining the long-term outcomes in these newborns.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Department of Medicine & Surgery, University of Parma, Parma, Italy.
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Santa Maria Nuova Hospital, AUSL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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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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Abstract
The first weeks of life are a time of heightened risk for seizures due to age-dependent physiologic features of the developing brain that lead to increased neuronal excitation and decreased inhibition. Usually, seizures in neonates are a symptom of an acute brain injury; seizures are only rarely due to neonatal-onset epilepsy syndromes. Neonatal seizures are harmful to the developing brain; early and accurate diagnosis is critical. For suspected seizures, EEG monitoring should be initiated as soon as is feasible, in order to evaluate for events of concern, screen for subclinical seizures, and assess the EEG background. Amplitude-integrated EEG can provide excellent complementary data, particularly with regard to evolution of background patterns, but has limited sensitivity to detect individual neonatal seizures. An urgent and systematic approach to precise etiologic diagnosis is key for optimal management and estimates of prognosis. Evaluation of the seizure etiology must occur in parallel with initiation of appropriate treatment. It is critical that neonatologists and neurologists develop hospital-specific, consensus-based practice pathways for neonatal seizure evaluation and treatment. Such practice pathways can streamline medical decision making, facilitate rapid medication administration, and potentially decrease seizure burden and optimize outcomes. Herein, the pathophysiology, epidemiology, treatment, and long-term management considerations for neonatal seizures are presented.
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Affiliation(s)
- Renée A Shellhaas
- Department of Pediatrics, Division of Pediatric Neurology, University of Michigan, Ann Arbor, MI, United States.
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Malmqvist O, Ohlin A, Ågren J, Jonsson M. Seizures in newborn infants without hypoxic ischemic encephalopathy - antenatal and labor-related risk factors: a case-control study. J Matern Fetal Neonatal Med 2018; 33:799-805. [PMID: 30373414 DOI: 10.1080/14767058.2018.1505853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: To identify antepartum and intrapartum risk factors for neonatal seizures in the absence of hypoxic ischemic encephalopathy (HIE).Methods: Population-based case-control study. Of 98 484 births, 40 newborns at 34 gestational weeks or later had seizures within the first 7 days of life. Cases (n = 40) and controls (n = 160) were retrieved from the University hospitals of Örebro for 1994-2013 and Uppsala for 2003-2013. Demographics and characteristics of pregnancy, labor, delivery, and neonatal data were analyzed. Crude odds ratio (OR) and adjusted odds ratios (AOR) with 95% confidence intervals (CIs) for antenatal and intrapartum factors were calculated using logistic regression analysis. Main outcome measure was neonatal seizures within the first 7 days of life.Results: The incidence of neonatal seizures without HIE was 0.41/1000 live births. Antenatal risk factors for neonatal seizures were as follows: short maternal stature (AOR: 5.4; 1.8-16.5); previous caesarean section (AOR: 4.8; 1.5-15.0); and assisted fertilization (AOR: 6.8; 1.3-35.2). Intrapartum risk factors were as follows: induction of labor (AOR: 5.7; 1.8-17.7); preterm birth (AOR: 13.5; 3.7-48.9); and head circumference >37 cm (AOR: 6.9; 1.4-34.8).Conclusions: Preterm birth was the strongest risk factor for neonatal seizures in the absence of HIE. The results also indicate that feto-pelvic disproportion is associated with the occurrence of seizures.Rationale: Antepartum and intrapartum risk factors for newborn seizures in the absence of HIE were investigated in a case-control study. Out of 98 484 births at 34 gestational weeks or more, 40 newborns had seizures without HIE. All had a normal Apgar score although they later presented with seizures. Preterm birth was the strongest risk factor (OR: 13.5; 95% CI: 3.7-48.9). Our results also indicate that feto-pelvic disproportion is of importance. Furthermore, a history of prior caesarean was associated with seizures. This is the first study to assess obstetric risk factors for newborn seizures separate from those with seizures and concomitant HIE. The distinction is of importance due to different etiologies, treatments, and preventive strategies.
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Affiliation(s)
- Olle Malmqvist
- Department of Pediatrics, Faculty of Medicine and Health, Örebro Universitet, Örebro, Sweden
| | - Andreas Ohlin
- Department of Pediatrics, Faculty of Medicine and Health, Örebro Universitet, Örebro, Sweden
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Statello R, Carnevali L, Alinovi D, Pisani F, Sgoifo A. Heart rate variability in neonatal patients with seizures. Clin Neurophysiol 2018; 129:2534-2540. [PMID: 30384023 DOI: 10.1016/j.clinph.2018.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Seizures are frequently observed in neurological conditions affecting newborns. Since autonomic alterations are commonly associated with neonatal seizures (NS), we investigated the utility of heart rate variability (HRV) indexes of cardiac autonomic regulation for NS detection. METHODS HRV analysis was conducted on ECG tracings recorded during video-EEG monitoring in newborns with NS and matched-controls. The effects of gestational age on HRV were also evaluated. RESULTS Newborns with NS showed lower resting state HRV compared to controls. Moreover, seizure episodes were characterized by a short-lasting increase in vagal indexes of HRV. Pre-term newborns with NS had a lower HRV than full-term at rest. In pre-term newborns, no changes in HRV were observed before and during NS. On the contrary, full-term newborns showed significantly higher HRV before and during NS compared to the respective baseline values. CONCLUSION Our data point to resting autonomic impairment in newborns with NS. In addition, an increment in HRV has been observed during NS only in full term newborns. SIGNIFICANCE Although these findings do not allow validation of HRV measures for NS prediction and detection, they suggest that a putative protective vagal mechanism might be adopted when an advanced maturation of autonomic nervous system is achieved.
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Affiliation(s)
- Rosario Statello
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Luca Carnevali
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy
| | - Davide Alinovi
- Department of Engineering and Architecture, Information Engineering Unit, University of Parma, Italy
| | - Francesco Pisani
- Child Neuropsychiatry Unit, Neuroscience Unit, Department of Medicine and Surgery, University of Parma, Italy
| | - Andrea Sgoifo
- Department of Chemistry, Life Sciences and Environmental Sustainability, Stress Physiology Lab, University of Parma, Italy.
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Cornet MC, Pasupuleti A, Fang A, Gonzalez F, Shimotake T, Ferriero DM, Glass HC, Cilio MR. Predictive value of early EEG for seizures in neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. Pediatr Res 2018; 84:399-402. [PMID: 29895836 DOI: 10.1038/s41390-018-0040-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To assess the prognostic significance of an early normal/mildly abnormal conventional EEG (cEEG) on seizure risk in neonates undergoing therapeutic hypothermia. METHODS We reviewed the video-EEG recordings from a large cohort of neonates treated with therapeutic hypothermia for hypoxic-ischemic encephalopathy from 2008 to 2017 in a single tertiary center. Continuous video-EEG was started as soon as possible (median 8.2 h) and continued throughout hypothermia and rewarming. We studied those neonates with a normal/mildly abnormal EEG during the first 24 h of monitoring. RESULTS A total of 331 neonates were treated with hypothermia and 323 had cEEG recordings available for review; 99 were excluded because of a moderately/severely abnormal cEEG background and/or seizure during the first 24 h of recording, and an additional eight because of early rewarming. The remaining 216 had a normal/mildly abnormal cEEG in the first 24 h. None of these patients subsequently developed seizures. CONCLUSION A normal/mildly abnormal cEEG during the first 24 h indicates a very low risk of subsequent seizures. This suggests that cEEG monitoring can be safely discontinued after 24 h if it has remained normal or excessively discontinuous and no seizures are detected, limiting the need for this resource-intensive and expensive tool.
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Affiliation(s)
| | - Archana Pasupuleti
- Department of Neurology, University of California San Francisco, California, USA
| | - Annie Fang
- Department of Pediatrics, University of California San Francisco, California, USA
| | - Fernando Gonzalez
- Department of Pediatrics, University of California San Francisco, California, USA
| | - Thomas Shimotake
- Department of Pediatrics, University of California San Francisco, California, USA
| | - Donna Marie Ferriero
- Departments of Neurology and Pediatrics, University of California San Francisco, California, USA
| | - Hannah Cranley Glass
- Departments of Neurology, Pediatrics, and Epidemiology and Biostatistics, University of California San Francisco, California, USA
| | - Maria Roberta Cilio
- Departments of Neurology and Pediatrics, University of California San Francisco, California, USA.
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Pisani F, Facini C, Bianchi E, Giussani G, Piccolo B, Beghi E. Incidence of neonatal seizures, perinatal risk factors for epilepsy and mortality after neonatal seizures in the province of Parma, Italy. Epilepsia 2018; 59:1764-1773. [PMID: 30132843 DOI: 10.1111/epi.14537] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 06/07/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Information about the incidence of neonatal seizures (NS) is scarce. Previous studies relied primarily on a clinical diagnosis of seizures. This population-based, retrospective study evaluated the incidence of electroencephalography (EEG)-confirmed seizures in neonates born in the province of Parma and the perinatal risk factors for mortality and epilepsy. METHODS All neonates with suspected seizures or with medical conditions at high risk for seizures from the study area were recorded in the neonatal intensive care unit (NICU) of the Parma University Hospital. NS were EEG confirmed. Perinatal risk factors for mortality and epilepsy after NS were evaluated with Cox's proportional hazards models. RESULTS In a 13-year period, 112 patients presented with NS: 102 newborns had electroclinical seizures (46 full-term and 56 preterm), whereas 10 presented only electrical seizures. The incidence was 2.29/1000 live births (95% confidence interval [CI] 1.87-2.72), with higher rates in preterm neonates (14.28/1000 in preterm vs 1.10/1000 in full-term infants). The incidence increased with decreasing gestational age (31-36 weeks of gestation: 5.01/1000, 28-30: 54.9/1000, and <28: 85.6/1000) and with decreasing birth weight (≥2500 g: 1.19/1000, <1000 g: 127.57/1000). Twenty-eight patients (25%) died, 16 (14.3%) had a diagnosis of epilepsy, 33 (29.5%) had cerebral palsy, and 39 (34.8%) had a developmental delay. Among the perinatal risk factors considered, the multivariate analysis showed an association between a 5-minute Apgar score of 0-7 and etiology with increased mortality and between female gender and status epilepticus with epilepsy. SIGNIFICANCE The incidence of NS is inversely associated with gestational age and birth weight. The etiology and a low Apgar score are strongly related to mortality; female gender and status epilepticus are risk factors for the development of epilepsy.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Carlotta Facini
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Elisa Bianchi
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
| | - Giorgia Giussani
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
| | - Benedetta Piccolo
- Child Neuropsychiatric Unit, Medicine & Surgery Department, University of Parma, Parma, Italy
| | - Ettore Beghi
- Department of Neuroscience, IRCCS Istituto Mario Negri, Milan, Italy
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Glass HC, Numis AL, Gano D, Bali V, Rogers EE. Outcomes After Acute Symptomatic Seizures in Children Admitted to a Neonatal Neurocritical Care Service. Pediatr Neurol 2018; 84:39-45. [PMID: 29886041 DOI: 10.1016/j.pediatrneurol.2018.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Neonatal seizures due to acute brain injury are associated with high rates of death, disability, and epilepsy. Our objective was to examine incidence of and risk factors for epilepsy among survivors of acute symptomatic neonatal seizures who were cared for by a neonatal neurocritical care service. METHODS Neonates with acute symptomatic seizures who were admitted to UCSF Benioff Children's Hospital Neuro-Intensive Care Nursery from July 2008 to June 2014 were considered for inclusion. RESULTS A total of 144 children with acute symptomatic seizures met study criteria and 37 (26%) died before age one. Eighty-seven children (85% of eligible survivors) were followed up to one year or longer. Epilepsy was diagnosed in eight children at median age 4.9 (interquartile range 1.7, 6.1) years. The cumulative incidence risk of epilepsy at one year was 2% (95% confidence interval 0.6% to 9%) and at five years was 7% (95% confidence interval 3% to 20%). Cerebral palsy was diagnosed in 21%. Bayley-III cognitive subscale less than 85 was present in 13%. Children with epilepsy were more likely to be preterm, have brain injury, and be discharged home on antiseizure medication, although the results were not significant after adjusted analysis. CONCLUSIONS The risk of epilepsy was lower and age at onset was older than in previous reports, which may be related to multiple factors including a neurocritical care approach, treatment of hypoxic-ischemic encephalopathy with hypothermia, high rate of neonatal transition to palliative care, and the exclusion of neonatal onset epilepsies. Continuation of antiseizure medications in infancy did not decrease the risk of epilepsy. Long-term, multicenter studies are needed to understand whether neonatal seizure management can alter the risk of epilepsy.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Adam L Numis
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Dawn Gano
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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Pisani F, Spagnoli C. Acute symptomatic neonatal seizures in preterm neonates: etiologies and treatments. Semin Fetal Neonatal Med 2018; 23:191-196. [PMID: 29467102 DOI: 10.1016/j.siny.2017.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute symptomatic neonatal seizures in preterm newborns are a relevant clinical challenge due to the presence of many knowledge gaps. Etiology-wise, acute symptomatic seizures have an age-specific epidemiology, with intraventricular hemorrhage and its complications representing the first cause in extremely and very preterm neonates, whereas other etiologies have similar occurrence rates as in full-term infants. Specific treatment strategies for the premature neonates are not yet available. Studies suggest a similarly low response rate with even more unfavorable prognosis than in full-term infants. Pharmacodynamic and pharmacokinetic changes are likely under way during the preterm period, with the potential to affect both effectiveness and safety of antiepileptic drugs in these patients. However, due to the lack of clear evidence to guide prioritization of second-line drugs, off-label medications are frequently indicated by review papers and flow-charts, and are prescribed in clinical practice. We therefore conclude by exploring potential future lines of research.
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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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