Neonatal seizures and brain damage

Brain-Oriented Strategies for Neuroprotection of Asphyxiated Newborns in the First Hours of Life

Perinatal asphyxia represents the first cause of severe neurological disabilities and the second cause of neonatal death in term-born babies. Currently, no treatment can prevent immediate cell death from necrosis, but some therapeutic interventions, such as therapeutic hypothermia (TH), can reduce delayed cell death from apoptosis. TH significantly improves the combined outcome of mortality or major neurodevelopmental disability, but the number of patients to be treated is 7 to get 1 child with no adverse neurological outcome. The aim of this educational review is to analyze the other care strategies to be implemented to improve the neurological outcome of children with hypoxic ischemic encephalopathy (HIE). Hypocapnia, hypoglycemia, pain control, and functional brain monitoring are recognized as appropriate approaches to improve outcome in critically ill infants with HIE. Pharmacologic neuroprotective adjuncts are currently under investigation. New drugs such as allopurinol and melatonin seem to provide positive effects although more randomized controlled trials are required to establish the effective therapeutic scheme. In the meantime, sustaining the respiratory, metabolic, and cardiovascular system during TH can be a valuable aid in managing and treating the patient with HIE in an optimal way.

Current Overview of Neonatal Convulsions

Neonatal convulsions are one of the most common emergency neurological events in the early period after birth. The frequency has been reported to be 1.5 to 3 in 1000 live births. It has been established that the convulsion threshold is lower in infants due to immature neonatal neurons and differences in neurotransmitters. Hypoxic ischemic encephalopathy is the most common etiology in neonatal convulsions. Other causes vary, and may be related to the level of development of the country. Convulsions are classified into 4 different types according to the clinical findings. The most common is the subtle (undefined) type of seizure; the other types are defined as clonic, tonic, and myoclonic seizures. Non-epileptic paroxysmal movements frequently seen in the neonatal period, should not be confused with seizures. The most common non-epileptic paroxysmal movements are jitteriness, benign neonatal sleep myoclonus, and hyperekplexia. A newborn that experiences convulsions should be hospitalized and monitored with continuous video electroencephalogram, if possible. If an initial rapid evaluation detects an acute metabolic disorder, treatment is provided, and, if warranted, it will be followed by a plan for further treatment with anticonvulsant drugs. Phenobarbital is still currently recommended as first-line therapy, though there are studies of other anticonvulsant drugs. Levetiracetam and phenytoin are commonly used as second-step anticonvulsant drugs. The aim of treatment should be not only to stop acute symptomatic seizures, but also to reduce the risk of brain damage and to minimize the possible negative effects of epilepsy and neurological deficits.

Predictive factors and prognostic value for status epilepticus in newborns

OBJECTIVES

To evaluate the predictive factors for status epilepticus (SE) in neonates and prognostic factors for patient outcomes in newborns suffering either isolated seizures or SE.

METHODS

A retrospective single-center study from January 2010 to December 2014, included 91 newborns who had neonatal seizures. Among them, 50 newborns experienced SE and 41 newborns presented isolated seizures only. SE was defined as a single seizure lasting more than 15 min or repeated seizures without return to preictal neurological baseline for more than 15 min. Isolated seizures were defined as one single seizure lasting less than 15 min or more seizures with complete recovery of consciousness between seizures. Perinatal and electroclinical data were recorded. Outcomes were evaluated at one year follow up.

RESULTS

In multivariate analysis, the factors identified as being predictive of SE were a severely abnormal initial neurological examination (OR 15.7, 95% CI (3.8-109) p = 0.00075) and hypoglycaemia (OR 6.8, 95% CI (1.5-49.2) p = 0.024), found mostly in newborns with hypoxic-ischemic encephalopathy. When studying our global cohort, SE was found to be a negative prognostic factor for outcome only in univariate analysis. In newborns with isolated seizures only, the postictal clinical examination results were the only independent prognostic factor found, normal results being associated with a more favorable evolution (OR 48.9, 95% CI (7.16-571) p = 0.0003).

CONCLUSION

Two independent risk factors for SE in newborns have been identified: a severely abnormal initial neurological examination and hypoglycaemia. In newborns with isolated seizures, the only positive prognostic factor was found to be a normal postictal clinical examination.

Heart rate variability in neonatal patients with seizures

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.

Leptin treatment prevents long-term abnormalities in cognition, seizure threshold, hippocampal mossy fiber sprouting and ZnT3/CB-D28k expression in a rat developmental "twist" seizure model

The mechanism of linking neonatal seizures with long-term brain damage is unclear, and there is no effective drug to block this long-term pathological process. Recently, the fat-derived hormone leptin has been appreciated for its neuroprotective function in neurodegenerative processes, although less is known about the effects of leptin on neonatal seizure-induced brain damage. Here, we developed a "twist" seizure model by coupling pilocarpine-induced neonatal status epilepticus (SE) with later exposure to penicillin to test whether leptin treatment immediately after neonatal SE would exert neuroprotective effects on cognition, seizure threshold and hippocampal mossy fiber sprouting, as well if leptin had any influence on the expression of zinc transporter 3 (ZnT3) and calcium homeostasis-related CB-D28k in the hippocampus. Fifty Sprague-Dawley rats (postnatal day 6, P6) were randomly assigned to four groups: control (n = 10), control with intraperitoneal (i.p.) injection of leptin (Leptin, n = 10), pilocarpine-induced neonatal SE (RS), and RS i.p. leptin injection (RS+Leptin). At P6, all the rats in the RS group and RS+Leptin group were injected with lithium chloride i.p. (5 mEq/kg). Pilocarpine (320 mg/kg, i.p.) was administered 30 min after scopolamine methyl chloride (1 mg/kg) injection at P7 to block the peripheral effect of pilocarpine. From P8 to P14, the animals in the Leptin group and RS+Leptin group were given leptin (4 mg/kg, i.p.). The Morris water maze test was performed during P28-P33. Following routine seizure threshold detection and Timm staining procedures, Western blot analysis was performed for each group. Pilocarpine-induced neonatal SE severely impaired learning and memory abilities, reduced seizure threshold, and induced aberrant hippocampal CA3 mossy fiber sprouting. In parallel, there was a significantly down-regulated protein level of CB-D28k and an up-regulated protein level of ZnT3 in the hippocampus of the RS group. Furthermore, leptin treatment soon after neonatal SE for seven consecutive days counteracted these hyperexcitability-related alterations. These novel findings established that leptin has a neuroprotective role in the model of cholinergic neonatal SE and highlights ZnT3/CB-D28k associated-Zn (2+)/Ca (2+) signaling as a promising therapeutic target.

Seizures in Preterm Neonates: A Multicenter Observational Cohort Study

BACKGROUND

The purpose of this study was to characterize seizures among preterm neonates enrolled in the Neonatal Seizure Registry, a prospective cohort of consecutive neonates with seizures at seven pediatric centers that follow the American Clinical Neurophysiology Society's neonatal electroencephalography monitoring guideline.

STUDY DESIGN

Of 611 enrolled neonates with seizures, 92 (15%) were born preterm. Seizure characteristics were evaluated by gestational age at birth for extremely preterm (<28 weeks, N = 18), very preterm (28 to <32 weeks, N = 18), and moderate to late preterm (32 to <37 weeks, N = 56) and compared with term neonates.

RESULTS

Hypoxic-ischemic encephalopathy (33%) and intracranial hemorrhage (27%) accounted for the etiology in more than half of preterm neonates. Hypothermia therapy was utilized in 15 moderate to late preterm subjects with encephalopathy. The presence of subclinical seizures, monotherapy treatment failure, and distribution of seizure burden (including status epilepticus) was similar in preterm and term neonates. However, exclusively subclinical seizures occurred more often in preterm than term neonates (24% vs 14%). Phenobarbital was the most common initial medication for all gestational age groups, and failure to respond to an initial loading dose was 63% in both preterm and term neonates. Mortality was similar among the three preterm gestational age groups; however, preterm mortality was more than twice that of term infants (35% vs 15%).

CONCLUSIONS

Subclinical seizures were more common and mortality was higher for preterm than term neonates. These data underscore the importance of electroencephalographic monitoring and the potential for improved management in preterm neonates.

Prognostic factors of neurological outcomes in late-preterm and term infants with perinatal asphyxia

PURPOSE

This study aimed to identify prognostic factors of neurological outcomes, including developmental delay, cerebral palsy and epilepsy in late-preterm and term infants with perinatal asphyxia.

METHODS

All late-preterm and term infants with perinatal asphyxia or hypoxic-ischemic insults who admitted the neonatal intensive care unit of Inje University Sanggye Paik Hospital between 2006 and 2014 and were followed up for at least 2 years were included in this retrospective study. Abnormal neurological outcomes were defined as cerebral palsy, developmental delay and epilepsy.

RESULTS

Of the 114 infants with perinatal asphyxia, 31 were lost to follow-up. Of the remaining 83 infants, 10 died, 56 had normal outcomes, and 17 had abnormal outcomes: 14 epilepsy (82.4%), 13 cerebral palsy (76.5%), 16 developmental delay (94.1%). Abnormal outcomes were significantly more frequent in infants with later onset seizure, clinical seizure, poor electroencephalography (EEG) background activity, lower Apgar score at 1 and 5 minutes and abnormal brain imaging (P<0.05). Infants with and without epilepsy showed significant differences in EEG background activity, clinical and electrographic seizures on EEG, Apgar score at 5 minutes and brain imaging findings.

CONCLUSION

We should apply with long-term video EEG or amplitude integrated EEG in order to detect and management subtle clinical or electrographic seizures in neonates with perinatal asphyxia. Also, long-term, prospective studies with large number of patients are needed to evaluate more exact prognostic factors in neonates with perinatal asphyxia.

Contemporary Profile of Seizures in Neonates: A Prospective Cohort Study

OBJECTIVE

To determine the contemporary etiology, burden, and short-term outcomes of seizures in neonates monitored with continuous video-electroencephalogram (cEEG).

STUDY DESIGN

We prospectively collected data from 426 consecutive neonates (56% male, 88% term) ≤44 weeks' postmenstrual age with clinically suspected seizures and/or electrographic seizures. Subjects were assessed between January 2013 and April 2015 at 7 US tertiary care pediatric centers following the guidelines of the American Clinical Neurophysiology Society for cEEG for at-risk neonates. Seizure etiology, burden, management, and outcome were determined by chart review by the use of a case report form designed at study onset.

RESULTS

The most common seizure etiologies were hypoxic-ischemic encephalopathy (38%), ischemic stroke (18%), and intracranial hemorrhage (11%). Seizure burden was high, with 59% having ≥7 electrographic seizures and 16% having status epilepticus; 52% received ≥2 antiseizure medications. During the neonatal admission, 17% died; 49% of survivors had abnormal neurologic examination at hospital discharge. In an adjusted analysis, high seizure burden was a significant risk factor for mortality, length of hospital stay, and abnormal neurological examination at discharge.

CONCLUSIONS

In this large contemporary profile of consecutively enrolled newborns with seizures treated at centers that use cEEG per the guidelines of the American Clinical Neurophysiology Society, about one-half had high seizure burden, received ≥2 antiseizure medications, and/or died or had abnormal examination at discharge. Greater seizure burden was associated with increased morbidity and mortality. These findings underscore the importance of accurate determination of neonatal seizure frequency and etiology and a potential for improved outcome if seizure burden is reduced.

Neonatal seizures in preterm newborns: A predictive model for outcome

BACKGROUND

With a reported prevalence of 22.2%, seizures in preterm newborns represent an emergent challenge, because they are often related to adverse outcome. The electroclinical features of preterm infants with neonatal seizures were evaluated in order to predict outcome.

METHODS

From 154 newborns with video-EEG confirmed neonatal seizures admitted to Parma University Hospital between January 1999 and December 2012, we collected 76 preterm newborns with neonatal seizures. Outcome was assessed at least at one year. Student t-test for unpaired data was used to compare means of continuous variables. We applied the χ(2) test to compare nominal data between preterm newborns with favorable versus adverse outcome, and between those with seizures versus those with status epilepticus. Then we determined the independent risk factors for adverse outcome with multivariate logistic regression analysis.

RESULTS

Birth weight, Apgar at 1st minute, neurologic examination, EEG, US brain scans and the presence of neonatal status epilepticus were different between preterm newborns with favorable and adverse outcome (p ≤ .049). Furthermore, birth weight, seizure onset, neurologic examination and EEG were different between the group with or without status (p ≤ .031). None of the infants with status epilepticus had a favorable outcome compared to 22.3% of those with neonatal seizures (p = .004). We also identified a predictive model that correctly classified outcome in 85.5% of subjects, with a high sensitivity for adverse outcome (>91.5%).

CONCLUSION

The presence of neonatal seizures in preterm newborns is highly related to an adverse outcome that can be predicted since the first days of life.

Increased excitability and excitatory synaptic transmission during in vitro ischemia in the neonatal mouse hippocampus

OBJECTIVE

The present study tested the hypothesis that exposure to in vitro hypoxia-ischemia alters membrane properties and excitability as well as excitatory synaptic transmission of CA1 pyramidal neurons in the neonatal mouse.

METHODS

Experiments were conducted in hippocampal slices in P7-P9 C57Bl/6 mice using whole-cell patch clamp in current- and voltage-clamp mode. Passive membrane potential (Vm), input resistance (Rin) and active (action potential (AP) threshold and amplitude) membrane properties of CA1 pyramidal neurons were assessed at baseline, during 10 min in vitro ischemia (oxygen-glucose deprivation (OGD)) and during reoxygenation. Spontaneous and miniature excitatory post-synaptic currents (s and mEPSCs) were studied under similar conditions.

RESULTS

OGD caused significant depolarization of CA1 pyramidal neurons as well as decrease in AP threshold and increase in AP amplitude. These changes were blocked by the application of tetrodotoxin (TTX), indicating Na(+) channels' involvement. Following 10 min of reoxygenation, significant membrane hyperpolarization was noted and it was associated with a decrease in Rin. AP threshold and amplitude returned to baseline during that stage. sEPSC and mEPSC frequency increased during both OGD and reoxygenation but their amplitude remained unchanged. Additionally, we found that OGD decreases Ih (hyperpolarization activated current) in CA1 neurons from neonatal mice and this effect persists during reoxygenation.

SIGNIFICANCE

These results indicate that in vitro ischemia leads to changes in membrane excitability mediated by sodium and potassium channels. Further, it results in enhanced neurotransmitter release from presynaptic terminals. These changes are likely to represent one of the mechanisms of hypoxia/ischemia-mediated seizures in the neonatal period.

Early-life stress impacts the developing hippocampus and primes seizure occurrence: cellular, molecular, and epigenetic mechanisms

Early-life stress includes prenatal, postnatal, and adolescence stress. Early-life stress can affect the development of the hypothalamic-pituitary-adrenal (HPA) axis, and cause cellular and molecular changes in the developing hippocampus that can result in neurobehavioral changes later in life. Epidemiological data implicate stress as a cause of seizures in both children and adults. Emerging evidence indicates that both prenatal and postnatal stress can prime the developing brain for seizures and an increase in epileptogenesis. This article reviews the cellular and molecular changes encountered during prenatal and postnatal stress, and assesses the possible link between these changes and increases in seizure occurrence and epileptogenesis in the developing hippocampus. In addititon, the priming effect of prenatal and postnatal stress for seizures and epileptogenesis is discussed. Finally, the roles of epigenetic modifications in hippocampus and HPA axis programming, early-life stress, and epilepsy are discussed.

Prognostic factors of developmental outcome in neonatal seizures in term infants

BACKGROUND

The purpose of this study was to identify prognostic indicators of neurodevelopmental outcome in term infants who experienced clinical neonatal seizure.

METHODS

This is a retrospective, observational hospital-based study. Term infants who experienced clinical neonatal seizure between January 1999 and December 2009 were enrolled. Adverse outcomes were defined as death, cerebral palsy, global developmental delay, and/or epilepsy. The associations between adverse outcomes and 17 variables, including sex, mode of delivery, being small of gestational age, maternal illness, perinatal insults, meconium stained liquor, Apgar score at 1 and 5 minutes, seizure onset age, seizure type, etiology, electroencephalography (EEG) findings, antiepileptic drug efficacy, presence of metabolic acidosis, and cranial ultrasonographic findings, and presence of congenital heart disease were analyzed.

RESULTS

Among the 232 enrolled infants, 125 had a normal outcome and 14 had mild functional disability (59.9%), and 55 (23.7%) survived with one or more neurodevelopmental impairments (7 with cerebral palsy, 48 with global developmental delay), and 38 (16.4%) died. Forty-seven (23.0%) of the 204 patients who survived after the first discharge had epilepsy. Ten variables were associated with adverse outcome on univariate analysis, but only four variables, i.e., including abnormal cranial ultrasonography findings, abnormal anterior cerebral artery resistance index, abnormal EEG findings, and presence of congenital heart disease were independent predictors on multivariate logistic regression analysis.

CONCLUSION

In term infants with neonatal seizures, several risk factors related to adverse outcome were recognized. Physicians should pay more attention to these factors when handling patients with neonatal seizures.

Genetic factors that influence short-term neurodevelopmental outcome in term hypoxic-ischaemic encephalopathic neonates

It is difficult to predict outcome in neonates that experience perinatal hypoxic ischaemia. Morbidity and mortality may be affected by genetic factors that augment inflammatory and coagulative responses. This prospective study analysed the effects of proinflammatory cytokine gene polymorphisms (tumour necrosis factor-α [TNFA] 308G>A and interleukin-6 [IL6] 174G>C) and prothrombotic factor gene mutations (prothrombin G20210A, factor V Leiden G1691A and methylenetetra hydrofolate reductase [MTHFR] C677T) on the early neurological prognosis in 40 term hypoxic ischaemic encephalopathic neonates. There were significant relationships for Sarnat and Sarnat staging with electroencephalographic findings, transfontanelle ultrasound (US) results, early neonatal outcome and neurological morbidity. Genetic mutations in the prothrombotic proteins, the TNFA 308G>A polymorphism and the cerebrospinal fluid levels of TNF-α protein were not related to clinical stage, electroencephalography, transfontanelle US or neurological status at discharge or at postnatal months 6 and 12. The IL6 174GC genotype demonstrated a protective role, being significantly correlated with normal electroencephalography, transfontanelle US and normal neurological findings at discharge. In conclusion, the IL6 174GC gene polymorphism seems to play a role in determining the risk and/or severity of perinatal cerebral injury.

Nonepileptic motor phenomena in the neonate

The newborn infant is prone to clinical motor phenomena that are not epileptic in nature. These include tremors, jitteriness, various forms of myoclonus and brainstem release phenomena. They are frequently misdiagnosed as seizures, resulting in unnecessary investigations and treatment with anticonvulsants, which have potentially harmful side effects. Unfortunately, there is a paucity of literature about many of these phenomena in the newborn, and some of the major textbooks refer to these events as nonepileptic seizures, leading to further confusion for the practitioner. The present paper aims to review these phenomena with special emphasis on differentiating them from epileptic seizures, and offers information on treatment and prognosis wherever possible.

Effects of early life stress on neuroendocrine and neurobehavior: mechanisms and implications

Evidence continues to mount that adverse experiences early in life have an impact on brain functions. Early life stress can program the development of the hypothalamic-pituitary-adrenal axis and cause alterations of neurochemistry and signaling pathways involved in regulating neuroplasticity, with resultant neurobehavioral changes. Early life experiences and genetic factors appear to interact in determining the individual vulnerability to mental health disorders. We reviewed the effects of early life stress on neuroendocrine regulation and the relevance to neurobehavioral development.

Prognostic factors and development of a scoring system for outcome of neonatal seizures in term infants

OBJECTIVE

To identify independent prognostic indicators and design a predictive scoring system for neurodevelopmental outcome for term infants who experienced clinical neonatal seizures.

STUDY DESIGN

Retrospective analysis of 120 term infants who experienced clinical neonatal seizures between July 1991 and June 2007 in a single academic pediatric neurology practice. Logistic regression analysis was applied to determine the independent prognostic indicators of an adverse outcome, which was defined as death, cerebral palsy, global developmental delay, and/or epilepsy. These indicators were then used to develop a scoring system.

RESULTS

A total of 53 infants had a normal outcome, 56 survived with one or more neurodevelopmental impairments (31 had cerebral palsy, 41 had global developmental delay, and 29 had epilepsy), and 11 died. Eleven variables were associated with adverse outcome on univariate analysis, but only method of delivery, time of seizure onset, seizure type, EEG background findings, and etiology were independent predictors on logistic regression analysis. A five-point scoring system was devised using these independent predictors with a sensitivity of 81.1% and a specificity of 84.0%.

CONCLUSIONS

In term infants, delivery via cesarean section, experiencing a seizure during the first 24 h of life, presenting with a seizure other than focal clonic, showing a moderately or severely abnormal EEG background, and having certain specific etiologies were the apparent major determinants for an adverse outcome.

Cerebral palsy, developmental delay, and epilepsy after neonatal seizures

This study sought to identify clinical prognostic factors for cerebral palsy, global developmental delay, and epilepsy in term infants with neonatal seizures. We completed a retrospective analysis of 120 term infants who experienced clinical neonatal seizures at a single academic pediatric neurology practice. Logistic regression analysis determined the significant independent prognostic (P < 0.05) indicators of cerebral palsy, global developmental delay, and epilepsy. Fifty-four (45%) infants were never diagnosed with a neurodevelopmental abnormality, whereas 37 (31%) manifested cerebral palsy, 51 (43%) manifested global developmental delay, and 38 (32%) manifested epilepsy. Global developmental delay was present in 92% of the children who manifested spastic quadraparetic cerebral palsy. Seizure type, seizure onset, electroencephalographic background findings, and 5-minute Apgar scores constituted independent predictors of cerebral palsy. None of the children who manifested less than two predictors developed the disorder. For global developmental delay, predictors included method of delivery, seizure onset, electroencephalographic background findings, and etiology. Only one infant (2%) who manifested less than two predictors exhibited global developmental delay. For epilepsy, predictors included seizure type and administration of a second antiepileptic drug. Only one infant (3%) who manifested neither predictor developed the disease.

A tissue equivalent phantom for simultaneous near-infrared optical tomography and EEG

We describe a phantom which enables EEG and near-infrared optical tomography to be performed simultaneously over the same volume. The phantom provides a surface electrical contact impedance comparable to that of the human scalp, whilst also possessing an optical scattering coefficient and electrical conductivity equivalent to that of brain tissue. The construction of the phantom is described, as is the resulting simultaneous EEG and near infrared optical tomography experiment, which, to our knowledge, is the first performed on a scale comparable to that of the infant human brain. This imaging experiment successfully shows the suitability of this phantom construction for the assessment of simultaneous EEG and near infrared optical tomography systems.

A scoring system for early prognostic assessment after neonatal seizures

OBJECTIVE

The aim of this study was to devise a scoring system that could aid in predicting neurologic outcome at the onset of neonatal seizures.

METHODS

A total of 106 newborns who had neonatal seizures and were consecutively admitted to the NICU of the University of Parma from January 1999 through December 2004 were prospectively followed-up, and neurologic outcome was assessed at 24 months' postconceptional age. We conducted a retrospective analysis on this cohort to identify variables that were significantly related to adverse outcome and to develop a scoring system that could provide early prognostic indications.

RESULTS

A total of 70 (66%) of 106 infants had an adverse neurologic outcome. Six variables were identified as the most important independent risk factors for adverse outcome and were used to construct a scoring system: birth weight, Apgar score at 1 minute, neurologic examination at seizure onset, cerebral ultrasound, efficacy of anticonvulsant therapy, and presence of neonatal status epilepticus. Each variable was scored from 0 to 3 to represent the range from "normal" to "severely abnormal." A total composite score was computed by addition of the raw scores of the 6 variables. This score ranged from 0 to 12. A cutoff score of > or =4 provided the greatest sensitivity and specificity.

CONCLUSIONS

This scoring system may offer an easy, rapid, and reliable prognostic indicator of neurologic outcome after the onset of neonatal seizures. A final assessment of the validity of this score in routine clinical practice will require independent validation in other centers.

Epileptogenesis is increased in rats with neonatal isolation and early-life seizure and ameliorated by MK-801: a long-term MRI and histological study

Early-life stress has been shown to destabilize the homeostatic synaptic plasticity and compromise the developing brain to the later encountered insults. This study would determine the long-term epileptogenic effect of neonatal isolation (NI) on early-life seizure. There were five groups: normal rearing (NR) rats; NI rats; NR rats suffering from status epilepticus (SE) at P12 (NR-SE); NI-SE rats; NI-SE-MK801 rats. All adult rats were video monitored to detect behavioral seizures, examined with brain magnetic resonance imaging, and assessed for hippocampal NeuN-immunoreactive (NeuN-IR) cells. Behavioral seizures were detected in one of six NR-SE rats, all the NI-SE rats (eight of eight), and none in the NR, NI, or NI-SE-MK801 rats. High hippocampal T2 signal were only found in three of five NR-SE rats, five of six NI-SE rats, and one of five NI-SE-MK801 rats. There was a significant decrease in the number of hippocampal NeuN-IR cells in the NR-SE and NI-SE groups, compared with the NR group, and MK-801 treatment ameliorated the neuronal loss. Our results demonstrated that NI led to an increase in epileptogenesis in rat pups with early-life SE, and treatment with MK-801 could ameliorate brain injuries, indicating a critical role of N-methyl-d-aspartic acid receptor in the epileptogenic process.

Brain development and susceptibility to damage; ion levels and movements

Responses of immature brains to physiological and pathological stimuli often differ from those in the adult. Because CNS function critically depends on ion movements, this chapter evaluates ion levels and gradients during ontogeny and their alterations in response to adverse conditions. Total brain Na(+) and Cl(-) content decreases during development, but K(+) content rises, reflecting shrinkage of the extracellular and increase in the intracellular water spaces and a reduction in total brain water volume. Unexpectedly, [K(+)](i) seems to fall during the first postnatal week, which should reduce [K(+)](i)/ [K(+)](e) and result in a lower V(m), consistent with experimental observations. Neuronal [Cl(-)](i) is high during early postnatal development, hence the opening of Cl(-) conduction pathways may lead to plasma membrane depolarization. Equivalent loss of K(+)(i) into a relatively large extracellular space leads to a smaller increase in [K(+)](e) in immature animals, while the larger reservoir of Ca(2+)(e) may result in a greater [Ca(2+)](i) rise. In vivo and in vitro studies show that compared with adult, developing brains are more resistant to hypoxic/ischemic ion leakage: increases in [K(+)](e) and decreases in [Ca(2+)](e) are slower and smaller, consistent with the known low level of energy utilization and better maintenance of [ATP]. Severe hypoxia/ischemia may, however, lead to large Ca(2+)(i) overload. Rises in [K(+)](e) during epileptogenesis in vivo are smaller and take longer to manifest themselves in immature brains, although the rate of K(+) clearance is slower. By contrast, in vitro studies suggest the existence of a period of enhanced vulnerability sometime during the developmental period. This chapter concludes that there is a great need for more information on ion changes during ontogeny and poses the question whether the rat is the most appropriate model for investigation of mechanisms of pathological changes in human neonates.

Nitric oxide alters GABAergic synaptic transmission in cultured hippocampal neurons

Nitric oxide (NO) production increases during hypoxia/ischemia-reperfusion in the immature brain and is associated with neurotoxicity. NO at physiologic concentrations has been shown to modulate GABAergic (gamma-aminobutyric acid) synaptic transmission in the adult brain. However, the effects of neurotoxic concentrations of NO (relevant to hypoxia-ischemia) on GABAergic synaptic transmission remain unknown. The present study tests the hypothesis that nNOS is expressed at GABAergic synapses and that exposure to neurotoxic concentrations of NO results in enhanced GABAergic synaptic transmission in cultured hippocampal neurons (days-in-vitro 10-14) prepared from fetal rats. Using double immunocytochemistry techniques, we were able to demonstrate that nNOS is co-localized to both presynaptic and postsynaptic markers of GABAergic synapses. The effects of NO on GABAergic synaptic transmission were then studied using whole cell patch-clamp electrophysiology. Spontaneous and miniature inhibitory postsynaptic currents (sIPSCS and mIPSCs) were recorded prior to and after exposure to 250 microM of the NO donor diethyleneamine/nitric oxide adduct (DETA-NO). Exposure to DETA-NO resulted in increased sIPSCs and mIPSCs frequency, indicating that neurotoxic concentrations of NO enhance GABAergic synaptic transmission in cultured hippocampal neurons. Because GABA synapses appear to be excitatory in the immature brain, this effect may contribute to overall enhanced synaptic transmission and hyperexcitability. We speculate that NO represents one of the mechanisms by which hypoxia-ischemia increases seizure susceptibility in the immature brain.

Timing of neonatal seizures and intrapartum obstetrical factors

One hundred ninety-three neonates with seizures were available on a neonatal seizure database, which included intrapartum and neonatal factors such as labor duration, fetal heart rate abnormalities, cord blood gas values, Apgar scores and clinical signs of encephalopathy. Regression analyses (analysis of variance) were performed on the entire cohort as well as specific subsets of neonates (eg, neonatal encephalopathy vs no encephalopathy) to assess the relationship between seizure timing and intrapartum/neonatal factors. Seizures were noted earlier for the encephalopathic group than for the nonencephalopathic group. No significant differences were noted for any intrapartum or neonatal factors. Timing of neonatal seizures, with or without an encephalopathy occurs within the first 2 days after birth and is independent of selected intrapartum and neonatal factors, underscoring recent task force recommendations concerning neonatal encephalopathy. Factors other than intrapartum events more likely contribute to the encephalopathic repertoire of the newborn, including seizures.

Neonatal seizures: dilemmas in workup and management

There is a pressing need for consistent, evidence-based guidelines in the management of neonatal seizures by pediatric neurologists and neonatologists. Israeli pediatric neurologists and neonatologists completed a 20-item, self-administered questionnaire on choices of antiepileptic drugs, treatment of intractable neonatal seizures (unremitting seizures after 3 medications), treatment duration, and recommended workup. The responding 36/55 (65%) neurologists and 66/112 (59%) neonatologists made similar antiepileptic drug choices (phenobarbital as first line, phenytoin as second line, and benzodiazepines as third line). Antiepileptic treatment duration was similar for both groups, but varied considerably within them (range, 1-52 weeks). Neurologists tended to recommend longer treatment for seizures secondary to asphyxia or hemorrhage. Neurologists and neonatologists recommended different antiepileptic drugs for intractable neonatal seizures: valproic acid and topiramate by neurologists, vs lidocaine and benzodiazepines by neonatologists (P = 0.0023). Fewer neurologists recommended continuous electroencephalography monitoring after asphyxia than neonatologists (40% vs 70.5%, P = 0.013). These responses reflect both similarities and inconsistencies of the two groups in diagnosing and treating neonatal seizures. Our findings call for controlled clinical trials to establish protocols for (1) diagnosing neonatal seizures, (2) studying the efficacy and safety of new-generation antiepileptic drugs, and (3) determining optimal duration of drug administration.

"One swallow does not make a summer" ... or does it?

A Single Episode of Neonatal Seizures Permanently Alters Glutamatergic Synapses. Cornejo BJ, Mesches MH, Coultrap S, Browning MD, Benke TA. Ann Neurol 2007;61(5):411–426. OBJECTIVE: The contribution of seizures to cognitive changes remains controversial. We tested the hypothesis that a single episode of neonatal seizures (sNS) on rat postnatal day (P) 7 permanently impairs hippocampal-dependent function in mature (P60) rats because of long-lasting changes at the synaptic level. METHODS: sNS was induced with subcutaneously injected kainate on P7. Learning, memory, mossy fiber sprouting, spine density, hippocampal synaptic plasticity, and glutamate receptor expression and subcellular distribution were measured at P60. RESULTS: sNS selectively impaired working memory in a hippocampal-dependent radial arm water-maze task without inducing mossy fiber sprouting or altering spine density. sNS impaired CA1 hippocampal long-term potentiation and enhanced long-term depression. Subcellular fractionation and cross-linking, used to determine whether glutamate receptor trafficking underlies the alterations of memory and synaptic plasticity, demonstrated that sNS induced a selective reduction in the membrane pool of glutamate receptor 1 subunits. sNS induced a decrease in the total amount of N-methyl-d-aspartate receptor 2A and an increase in the primary subsynaptic scaffold, PSD-95. INTERPRETATION: These molecular consequences are consistent with the alterations in plasticity and memory caused by sNS at the synaptic level. Our data demonstrate the cognitive impact of sNS and associate memory deficits with specific alterations in glutamatergic synaptic function.

Preterm infants with video-EEG confirmed seizures: outcome at 30 months of age

OBJECTIVE

Our aim was to identify early predictors of poor neurodevelopmental outcome and of subsequent epilepsy in very early preterm and late preterm newborns with neonatal seizures.

STUDY DESIGN

Fifty-one preterm infants with gestational age (GA) <or=36 weeks were identified among those admitted to the NICU of University Hospital of Parma between January 1999 and December 2003 and prospectively followed-up. They were subdivided in two Groups: early preterm newborns with a GA <or=29 weeks and those with GA between 30 and 36 weeks. Selection criteria included multiple digital-video-EEG confirmed neonatal seizures and a follow-up of at least 30 months. Independent variables considered for analysis included neonatal risk factors, etiology and type of seizures, EEG activity, and cerebral ultrasound scan examinations.

RESULTS

Ten infants had a favorable outcome, 17 died, and 23 had an adverse outcome. One infant was lost on follow-up. Apgar score at 1 min (O.R.=15.457, 95% CI: 2.236-106.850, p=0.006) and severely abnormal background EEG activity (O.R.=8.298, 95% CI: 1.316-52.301, p=0.024) were independent predictors of abnormal outcome. Nine infants presented post-neonatal epilepsy. Severely abnormal Cerebral Ultrasound scans were predictive of epilepsy (O.R.=13.72, 95% CI: 1.959-96.149, p=0.008).

CONCLUSIONS

Neonatal seizures in preterm infants are associated to a high rate of mortality and severe morbidity in survivors but no definitive differences between the two groups of preterm infants were found. Risk-factors for development of subsequent epilepsy are strongly related to the underlying brain damage.

Neuropathogical features of a rat model for perinatal hypoxic-ischemic encephalopathy with associated epilepsy

Hypoxic-ischemic (HI) encephalopathy is an important neurological problem of the perinatal period. Little is known of the long-term progression of HI insults or the maladaptive changes that lead to epilepsy. Using rats with unilateral carotid occlusion followed by hypoxia at postnatal day 7, this study provides an initial analysis of the epilepsy caused by a perinatal HI insult with chronic and continuous behavioral monitoring. The histopathology was investigated at postnatal day 30 and later at > or =6 months of age using cresyl violet, Timm, and rapid Golgi staining and immunocytochemistry. The resultant epilepsy showed an increase in seizure frequency over time, with a preponderance for seizure clusters and behavioral features of an ipsilateral cerebral syndrome. In addition to parasagittal infarcts and porencephalic cysts in severe lesions, columnar neuronal death was found with cytomegaly in isolated groups of dysmorphic cortical neurons. Cortical dysgenesis was seen in the form of deep laminar cell loss, microgyri, white matter hypercellularity, and blurring of the white and gray matter junction. Mossy fiber sprouting was not only detected in the atrophied ipsilateral dorsal hippocampus of HI rats with chronic epilepsy, but was also found in comparable grades in spared ipsi- and contralateral ventral hippocampi. The cortical lesions in this animal model show histological similarities with those found in humans after perinatal HI. The occurrence of cortical abnormalities that are associated with epilepsy in humans correlates with the consequent detection of spontaneous recurrent seizures.

A multistage knowledge-based system for EEG seizure detection in newborn infants

OBJECTIVE

Automatic seizure detection has attracted attention as a method to obtain valuable information concerning the duration, timing, and frequency of seizures. Methods currently used to detect EEG seizures in adults show high false detection rates in neonates because they lack information about specific age-dependent features of normal and pathological EEG and artifacts. This paper describes a novel multistage knowledge-based seizure detection system for newborn infants to identify and classify normal and pathological newborn EEGs as well as seizures with a reduced false detection rate.

METHODS

We developed the system in a way to make comprehensive use of spatial and temporal contextual information obtained from multichannel EEGs. The system development consists of six major stages: (i) EEG data collection and bandpass filtering; (ii) automatic artifact detection; (iii) feature extraction from segments of non-seizure and seizure activities; (iv) feature selection via the relevance and redundancy analysis; (v) EEG classification and pattern recognition using a trained multilayer back-propagation neural network; and (v) knowledge-based decision-making to examine each of possible EEG patterns from a multi-channel perspective. The system was developed and tested with the EEG recordings of 10 newborns aged between 39 and 42 weeks.

RESULTS

The overall sensitivity, selectivity, and average detection rate of the system were 74%, 70.1%, and 79.7%, respectively. The average false detection of 1.55/h was also achieved by the system with a feature reduction up to 80%.

CONCLUSIONS

The expert rule-based decision-making subsystem accompanying the classifier helped to reduce the false detection rate, reject a wide variety of artifacts, and discriminate various patterns of EEG.

SIGNIFICANCE

This paper may serve as a guide for the selection of discriminative features to improve the accuracy of conventional seizure detection systems for routine clinical EEG interpretation and brain activity monitoring in newborns especially those hospitalized in the neonatal intensive care units.

An algorithm for the automatic detection of seizures in neonatal amplitude-integrated EEG

AIM

To develop and evaluate an algorithm for the automatic screening of electrographic neonatal seizures (ENS) in amplitude-integrated electroencephalography (aEEG) signals.

METHODS

CFM recordings were recorded in asphyxiated (near)term newborns. ENS of at least 60 sec were detected based on their characteristic pattern in the aEEG signal, an increase of its lower boundary. The algorithm was trained using five CFM recordings (training set) annotated by a neurophysiologist, observer1. The evaluation of the algorithm was based on eight different CFM recordings annotated by observer1 (test set observer 1) and an independent neurophysiologist, observer2 (test set observer 2).

RESULTS

The interobserver agreement between observer1 and 2 in interpreting ENS from the CFM recordings was high (G coefficient: 0.82). After dividing the eight CFM recordings into 1-min segments and classification in ENS or non-ENS, the intraclass correlation coefficient showed high correlations of the algorithm with both test sets (respectively, 0.95 and 0.85 with observer1 and 2). The algorithm showed in five recordings a sensitivity > or = 90% and approximately 1 false positive ENS per hour. However, the algorithm showed in three recordings much lower sensitivities: one recording showed ENSs of extremely high amplitude that were incorrectly classified by the algorithm as artefacts and two recordings suffered from low interobserver agreement.

CONCLUSION

This study shows the feasibility of automatic ENS screening based on aEEG signals and may facilitate in the bed-side interpretation of aEEG signals in clinical practice.

Pediatric epilepsy evaluations from the prenatal perspective

Prenatal contributions to childhood epilepsy include malformations and acquired injuries, which can occur from conception and throughout gestation. Five case histories from the Pediatric Epilepsy Service are discussed that exemplify maternal, fetal, and placental conditions that contribute to childhood epilepsy. Two full-term neonates presented with neonatal seizures, with or without accompanying encephalopathy. Placental pathology suggested antepartum maternal-placental diseases that caused or contributed to their brain disorders. Two children presented as preterm infants with systemic organ system diseases that also implicated brain injury. One child had a complicated maternal history with both genetic and acquired illnesses. Two children required epilepsy surgery, with improved seizure control despite persistent neurocognitive and neurobehavioral deficits related to diffuse encephalopathies. Dual pathology should include prenatal contributions to childhood epilepsy on both a genetic and acquired basis. Epileptologists should consider an ontogenetic approach to study the epileptic condition from a fetal neurology perspective.

Neonatal seizure classification: a fetal perspective concerning childhood epilepsy

Neonatal seizures are markers for time-specific etiologies during antepartum, intrapartum and neonatal time periods. Seizures with or without encephalopathic signs can represent a continuum of maternal, placental, fetal and neonatal risk factors and disease states. A multi-dimensional classification scheme for neonatal seizures is suggested that will help strategize specific therapeutic interventions to optimize neurologic outcome and anticipate later neurological morbidities including epilepsy risk. This scheme combines "epileptic" and "non-epileptic" seizure descriptions which capture time-specific and brain region-specific mechanisms for seizures. Synchronized video electroencephalographic monitoring provides the most accurate start and endpoints for cortically generated seizures. However, subcortical sites of injury may also initiate abnormal clinical signs with or without the subsequent expression of electrographic seizures. Co-registration of digital neuroimaging techniques such as magnetic resonance imaging with computational electroencephalographic datasets will provide more precise structure-function correlates for neonatal seizures that address both cortical and subcortical sites of injury. Finally, more precise definitions of neonatal status epilepticus need to be established because of the long-term harmful effects on brain development by prolonged seizures expressed as epilepsy and cognitive-behavioral deficits. With this expanded classification scheme for neonatal seizures, novel pharmacologic and surgical strategies can be designed for disease-specific rescue, repair, and regeneration strategies of damaged brain tissue that occur during fetal and neonatal periods, and are later expressed during infancy and childhood. Clinical neuroscientists must strive to develop a classification scheme that bridges bench to bedside concepts of developmental neural plasticity research, recognizing both negative and positive consequences of brain remodeling and repair of the child and adolescent brain. Developmental neural plasticity also extends into adulthood when brain remodeling mechanisms further contribute to epileptogenesis and continues to impair quality of life.

Amplitude-integrated electroencephalography: a tool for monitoring silent seizures in neonates

The clinical use of amplitude-integrated electroencephalography in the diagnosis of seizures in high-risk newborn infants with suspected central nervous system insult is evaluated with emphasis on silent seizures. Recordings from 93 infants with suspected central nervous system insults over a period of 7 years were retrospectively analyzed for the presence of electrical seizures and for their correlation with clinical events. Thirty infants (32%) had overt clinical seizures; 29 (97%) of these manifested clear seizure patterns in their tracings, and the remaining one infant had a suspected tracing. Eleven infants (12%) had subtle clinical seizures; of these 7 (59%) had clear electrical seizures, 3 (31%) had suspected tracing, and one had a normal tracing. Fifty-two infants (56%) had no clinical events indicative of seizures; of these 8 (15%) had clear electrical seizures, 17 (33%) had suspected tracings, and 27 (52%) had normal tracings. Electroencephalographic seizures are common in sick newborn infants. Amplitude-integrated electroencephalography can provide important information concerning their neurologic status and help to confirm or refute the presence of seizures in clinically suspected cases and detect infants with silent seizures.

Comparative clinical study of preterm and full-term newborn neonatal seizures

OBJECTIVE: To compare the characteristics of neonatal seizures between preterm and full-term infants in intensive care unit. METHOD: A prospective study was developed with 104 high-risk newborn, 30 preterm and 74 full-term infants, with clinical seizures. The dependent variable was gestational age. Statistical analyses: Fisher's exact test, odds-ratio and Mann Witney U test. RESULTS: There were significant differences (p<0.05): i) premature neonates develop neonatal seizures later, probably related to the etiologies of the seizures; ii) etiologically, there is a predominance of peri-intraventricular hemorrhage in preterm and of asphyxia in full term neonates; iii) clonic seizures are most frequent in preterm and subtle seizures in full term neonates. CONCLUSION: Although the study had a clinical basis, it was possible to identify differences when the dependent variable was gestational age.

Effect of neonatal isolation on outcome following neonatal seizures in rats--the role of corticosterone

Emerging evidence indicates that early maternal care permanently modifies the activity of hypothalamic-pituitary-adrenal (HPA) axis and is a critical factor in determining the capacity of the brain to compensate for later encountered insults. The purpose of this study was to determine the role of corticosterone (CORT) in the detrimental effects of neonatal isolation (NI) on seizures. Rats were assigned randomly to the following five groups: (1) control (CONT) rats; (2) NI rats that underwent daily separation from their dams from postnatal day 2 (P2) to P9; (3) status epilepticus (SE) rats, induced by lithium-pilocarpine (Li-Pilo) model at P10; (4) NI plus SE (NIS) rats and (5) NISM rats, a subset of NIS rats receiving metyrapone (100 mg/kg), a CORT synthesis inhibitor, immediately after SE induction. At P10, plasma CORT levels were compared at baseline in CONT and NI rats and in response to Li-Pilo-induced SE among SE, NIS and NISM rats. We evaluated the spatial memory in the Morris water maze at P50 approximately 55, the expression of hippocampal cyclic adenosine monophosphate (cAMP)-responsive element-binding protein phosphorylation at serine-133 (pCREBSer-133) at P55, hippocampal neuronal damage at P80 and seizure threshold at P100. The isolated rats exhibited higher CORT release in response to SE than non-isolated rats, and the NIS rats had greater cognitive deficits and decreased seizure threshold compared to the CONT, NI and SE groups. By contrast, the NISM group, compared to the NIS group, showed a normal CORT response to SE and better spatial memory but no difference in seizure threshold. Compared to the CONT group, the hippocampal pCREBSer-133 level was significantly reduced in all experimental groups (NI, SE, NIS, NISM) with no differences between groups. All rats were free of spontaneous seizures later in life and had no discernible neuronal loss in the hippocampus. Results in this model demonstrate repetitive NI enhances response of plasma CORT to SE, and exacerbates the neurological consequences of neonatal SE. Amelioration of neurological sequelae following reduction of the SE-induced excessive rise in plasma CORT implicates CORT in the pathogenesis of NI increasing the vulnerability to seizures.

Benign neonatal sleep myoclonus: an under-recognized, non-epileptic condition

During a 3-y period 13 newborns were referred for investigation of jerks. The events were epileptic in six children. The diagnosis of benign neonatal sleep myoclonus was made in the remaining seven children.

CONCLUSION

Benign neonatal sleep myoclonus is an important neonatal entity that can be mistaken for epilepsy.

c-Fos, N-methyl-d-aspartate receptor 2C, GABA-A-alpha1 immonoreactivity, seizure latency and neuronal injury following single or recurrent neonatal seizures in hippocampus of Wistar rat

To evaluate the long-term effects of single or recurrent prolonged neonatal seizures on seizure threshold and neuronal activity in the brain, a novel "twist" seizure was induced by coupling early-life flurothyl-induced seizures with later exposure to pentylenetetrazol. The authors assigned six neonatal rats for each group: the single-seizure group (SS), the recurrent-seizure group (RS) and the control group. At postnatal day 46, seizure threshold was examined using pentylenetetrazol, and then the brain slices were evaluated with thionine staining, in situ end labeling and immunohistochemical studies. The Results showed that the rats in SS and RS groups all had reduced latencies to develop generalized tonic seizures induced by PTZ compared with controls (P<0.01). Morphologic changes, cell loss and apoptotic cells were observed only in those of RS group. Significant fos and NR2C-immunoreactive positive cells were seen in hippocampus of rats in both SS and RS groups compared with controls (P<0.01). A significant decrease in the number of GABA-A-alpha1 immunoreactive positive neurons was detected in hippocampus in rats of SS and RS groups compared with the controls (P<0.01). We conclude that neonatal rats subjected to prolonged seizures have pronounced long-term effects on seizure threshold and neuronal neurophysiological activity in the brain. Obvious neuronal injury, however, was only seen in rat with recurrent-seizures. Subtle brain damage might occur in rats experiencing single prolonged neonatal seizures.

Long-term effects of neonatal seizures on subsequent N-methyl-d-aspartate receptor-1 and gamma-aminobutyric acid receptor A-α1 receptor expression in hippocampus of the Wistar rat

To evaluate the pathophysiological mechanism of subsequent reduced seizure threshold following neonatal seizures, single or recurrent prolonged seizures were induced to neonatal rats by the inhalant flurothyl. The expression of N-methyl-d-aspartate receptor 1 (NR1) and gamma-aminobutyric acid receptor A-alpha 1 (GABA-A-alpha 1) immunoreactivity in hippocampus were examined by Western blotting analysis at the day 7 (P7) and day 75 (P75) after the last seizure. Whereas there were no significant changes in single seizure group and recurrent seizure group of P75, NR1 expression enhanced significantly in P7 rats of recurrent seizure group. Meanwhile, polypeptide levels of GABA-A-alpha 1 receptor subunit decreased significantly in both single and recurrent seizure-treated P7 and P75 rats. Our results suggest that recurrent or single prolonged seizures during the neonatal period may have long-term effects on the balance between excitatory NMDA system and inhibitory GABA system in hippocampus of rats.

Neonatal seizures: diagnosis, pharmacologic interventions, and outcomes

Neonatal seizures are difficult to detect, diagnose, and manage. Infants with a history of seizures often have long-term neurologic sequelae. Controversy exists as to whether neonatal seizures themselves cause damage to the developing brain, and thus, subsequent sequelae; or if these sequelae are due primarily to the underlying cause of the seizures. Treatment of seizures involves identifying and treating the underlying etiology of the seizure and appropriate use of pharmacologic interventions. To provide the context for pharmacological management of seizures in newborns, this article examines the pathophysiology and etiology of seizures and discusses pharmacological agents and issues, short- and long-term outcomes, clinical implications, and directions for future research. Understanding pharmacological issues within this context provides a comprehensive foundation for decision making and management of neonatal seizures.