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Romantseva L, Lin N. Acute Seizures-Work-Up and Management in Children. Semin Neurol 2020; 40:606-616. [PMID: 33155186 DOI: 10.1055/s-0040-1718718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Seizures are common in the pediatric population; however, most children do not go on to develop epilepsy later in life. Selecting appropriate diagnostic modalities to determine an accurate diagnosis and appropriate treatment as well as with counseling families regarding the etiology and prognosis of seizures, is essential. This article will review updated definitions of seizures, including provoked versus unprovoked, as well as the International League Against Epilepsy operational definition of epilepsy. A variety of specific acute symptomatic seizures requiring special consideration are discussed, along with neonatal seizures and seizure mimics, which are common in pediatric populations.
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Affiliation(s)
- Lubov Romantseva
- Section of Pediatric Neurology, Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
| | - Nan Lin
- Section of Pediatric Neurology, Department of Pediatrics, Rush University Medical Center, Chicago, Illinois
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Griffith JL, Tomko ST, Guerriero RM. Continuous Electroencephalography Monitoring in Critically Ill Infants and Children. Pediatr Neurol 2020; 108:40-46. [PMID: 32446643 DOI: 10.1016/j.pediatrneurol.2020.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022]
Abstract
Continuous video electroencephalography (CEEG) monitoring of critically ill infants and children has expanded rapidly in recent years. Indications for CEEG include evaluation of patients with altered mental status, characterization of paroxysmal events, and detection of electrographic seizures, including monitoring of patients with limited neurological examination or conditions that put them at high risk for electrographic seizures (e.g., cardiac arrest or extracorporeal membrane oxygenation cannulation). Depending on the inclusion criteria and clinical characteristics of the population studied, the percentage of pediatric patients with electrographic seizures varies from 7% to 46% and with electrographic status epilepticus from 1% to 23%. There is also evidence that epileptiform and background CEEG patterns may provide important information about prognosis in certain clinical populations. Quantitative EEG techniques are emerging as a tool to enhance the value of CEEG to provide real-time bedside data for management and prognosis. Continued research is needed to understand the clinical value of seizure detection and identification of other CEEG patterns on the outcomes of critically ill infants and children.
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Affiliation(s)
- Jennifer L Griffith
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri.
| | - Stuart T Tomko
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
| | - Réjean M Guerriero
- Department of Neurology, Washington University School of Medicine, St. Louis, Missouri
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Dennis EL, Babikian T, Giza CC, Thompson PM, Asarnow RF. Neuroimaging of the Injured Pediatric Brain: Methods and New Lessons. Neuroscientist 2018; 24:652-670. [PMID: 29488436 DOI: 10.1177/1073858418759489] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Traumatic brain injury (TBI) is a significant public health problem in the United States, especially for children and adolescents. Current epidemiological data estimate over 600,000 patients younger than 20 years are treated for TBI in emergency rooms annually. While many patients experience a full recovery, for others there can be long-lasting cognitive, neurological, psychological, and behavioral disruptions. TBI in youth can disrupt ongoing brain development and create added family stress during a formative period. The neuroimaging methods used to assess brain injury improve each year, providing researchers a more detailed characterization of the injury and recovery process. In this review, we cover current imaging methods used to quantify brain disruption post-injury, including structural magnetic resonance imaging (MRI), diffusion MRI, functional MRI, resting state fMRI, and magnetic resonance spectroscopy (MRS), with brief coverage of other methods, including electroencephalography (EEG), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). We include studies focusing on pediatric moderate-severe TBI from 2 months post-injury and beyond. While the morbidity of pediatric TBI is considerable, continuing advances in imaging methods have the potential to identify new treatment targets that can lead to significant improvements in outcome.
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Affiliation(s)
- Emily L Dennis
- 1 Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of University Southern California, Marina del Rey, CA, USA
| | - Talin Babikian
- 2 Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.,3 UCLA Brain Injury Research Center, Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children's Hospital, Los Angeles, CA, USA.,4 UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA
| | - Christopher C Giza
- 3 UCLA Brain Injury Research Center, Department of Neurosurgery and Division of Pediatric Neurology, Mattel Children's Hospital, Los Angeles, CA, USA.,4 UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA.,5 Brain Research Institute, University of California, Los Angeles, CA, USA
| | - Paul M Thompson
- 1 Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of University Southern California, Marina del Rey, CA, USA.,6 Departments of Neurology, Pediatrics, Psychiatry, Radiology, Engineering, and Ophthalmology, University of Southern California, Los Angeles, CA, USA
| | - Robert F Asarnow
- 2 Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA.,4 UCLA Steve Tisch BrainSPORT Program, Los Angeles, CA, USA.,5 Brain Research Institute, University of California, Los Angeles, CA, USA.,7 Department of Psychology, University of California, Los Angeles, CA, USA
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Vaewpanich J, Reuter-Rice K. Continuous electroencephalography in pediatric traumatic brain injury: Seizure characteristics and outcomes. Epilepsy Behav 2016; 62:225-30. [PMID: 27500827 PMCID: PMC5014598 DOI: 10.1016/j.yebeh.2016.07.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/05/2016] [Accepted: 07/06/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality. Secondary injury that occurs as a result of a direct impact plays a crucial role in patient prognosis. The guidelines for the management of severe TBI target treatment of secondary injury. Posttraumatic seizure, one of the secondary injury sequelae, contributes to further damage to the injured brain. Continuous electroencephalography (cEEG) helps detect both clinical and subclinical seizure, which aids early detection and prompt treatment. OBJECTIVE The aim of this study was to examine the relationship between cEEG findings in pediatric traumatic brain injury and neurocognitive/functional outcomes. METHODS This study focuses on a subgroup of a larger prospective parent study that examined children admitted to a level-1 trauma hospital. The subgroup included sixteen children admitted to the pediatric intensive care unit (PICU) who received cEEG monitoring. Characteristics included demographics, cEEG reports, and antiseizure medication. We also examined outcome scores at the time of discharge and 4-6weeks postdischarge using the Glasgow Outcome Scale - Extended Pediatrics and center-based speech pathology neurocognitive/functional evaluation scores. RESULTS Sixteen patients were included in this study. Patients with severe TBI made up the majority of those that received cEEG monitoring. Nonaccidental trauma was the most frequent TBI etiology (75%), and subdural hematoma was the most common lesion diagnosed by CT scan (75%). Fifteen patients received antiseizure medication, and levetiracetam was the medication of choice. Four patients (25%) developed seizures during PICU admission, and 3 patients had subclinical seizures that were detected by cEEG. One of these patients also had both a clinical and subclinical seizure. Nonaccidental trauma was an etiology of TBI in all patients with seizures. Characteristics of a nonreactive pattern, severe/burst suppression, and lack of sleep architecture, on cEEG, were associated with poor neurocognitive/functional outcome. CONCLUSION Continuous electroencephalography demonstrated a pattern that associated seizures and poor outcomes in patients with moderate to severe traumatic brain injury, particularly in a subgroup of patients with nonaccidental trauma. Best practice should include institution-based TBI cEEG protocols, which may detect seizure activity early and promote outcomes. Future studies should include examination of individual cEEG characteristics to help improve outcomes in pediatric TBI.
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Affiliation(s)
- Jarin Vaewpanich
- Department of Pediatrics, Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Thung Phaya Thai, Ratchathewi, Bangkok 10400, Thailand.
| | - Karin Reuter-Rice
- School of Nursing, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States; School of Medicine, Dept. of Pediatrics, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States; Duke University, Duke Institute for Brain Sciences, 307 Trent Drive, DUMC 3322, Durham, NC 27710, United States.
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Arndt DH, Goodkin HP, Giza CC. Early Posttraumatic Seizures in the Pediatric Population. J Child Neurol 2016; 31:46-56. [PMID: 25564481 DOI: 10.1177/0883073814562249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 10/14/2014] [Indexed: 11/15/2022]
Abstract
Early posttraumatic seizure is a paramount clinical issue in pediatric traumatic brain injury patients as it is a common occurrence, yet an understudied entity at present. Recent literature recognizes several posttraumatic seizure subtypes based on time of presentation and the underlying pathophysiology: impact, immediate, delayed early, and late/posttraumatic epilepsy. Appropriate classification of pediatric posttraumatic seizure subtypes can be helpful for appropriate management and prognosis. This review will focus on early posttraumatic seizures, and the subtypes of early posttraumatic seizure. Incidence, risk factors, diagnosis, seizure semiology, status epilepticus, management, risk of recurrence, and prognosis were reviewed. The integration of continuous electroencephalographic (EEG) monitoring into pediatric traumatic brain injury management may hold the key to better characterizing and understanding pediatric early posttraumatic seizures. Topics for future research pertaining to pediatric early posttraumatic seizure are identified.
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Affiliation(s)
- Daniel H Arndt
- Division of Pediatric Neurology, Departments of Pediatrics and Neurology, Beaumont Children's Hospital & Beaumont Health System Neurosciences, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Howard P Goodkin
- Division of Pediatric Neurology, Departments of Neurology and Pediatrics, UVA Health System, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Christopher C Giza
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosurgery, David Geffen School of Medicine at UCLA; Mattel Children's Hospital-UCLA, Los Angeles, CA, USA
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Rzewnicki I, Łebkowski W, Kordecki JK. Evaluation of vestibulo-ocular reflex in patients with damage to the central nervous system (GCS score 5-3). Adv Med Sci 2015; 60:107-11. [PMID: 25638706 DOI: 10.1016/j.advms.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Revised: 10/27/2014] [Accepted: 12/01/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of our study was to evaluate the vestibulo-ocular reflex (VOR) in patients with severe damage to the central nervous system (CNS) in the diagnosis of brain death and survival prognosis. MATERIAL AND METHODS The study was conducted in 20 patients with extensive primary central nervous system damage against spontaneous intracranial haemorrhage or craniocerebral trauma and secondary central nervous system damage as a result of cardiac arrest with Glasgow Coma Scale (GCS) score from 3 to 5 treated in the Intensive Care Unit, University Hospital in Bialystok. For labyrinth stimulation we used water at 30°C, recording the reactions with ENG appliance. Records were analyzed in Nathanson-Bergman four-level scale. The first assessment was performed on the second day after the trauma and subsequently the assessments were repeated at 2-day intervals. RESULTS Of the 20 patients studied, the reflex was recorded in nine, which accounted for 45%. In the remaining 11 (55%) patients the reflex was not reported in any test and all of them died. Among patients with recorded VOR, five died and four survived. CONCLUSIONS The results of our study show the usefulness of performing the vestibulo-ocular test in patients with severe brain injury to predict their survival.
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Affiliation(s)
- Ireneusz Rzewnicki
- Department of Otolaryngology, University Hospital, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Łebkowski
- Department of Neurosurgery, University Hospital, Medical University of Bialystok, Bialystok, Poland
| | - Justyn Ksawery Kordecki
- Department of Diagnostic Radiology, Ministry of Internal Affairs and Administration Hospital, Bialystok, Poland.
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Grinspan ZM, Pon S, Greenfield JP, Malhotra S, Kosofsky BE. Multimodal monitoring in the pediatric intensive care unit: new modalities and informatics challenges. Semin Pediatr Neurol 2014; 21:291-8. [PMID: 25727511 DOI: 10.1016/j.spen.2014.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We review several newer modalities to monitor the brain in children with acute neurologic disease in the pediatric intensive care unit, such as partial brain tissue oxygen tension (PbtO2), jugular venous oxygen saturation (SjvO2), near infrared spectroscopy (NIRS), thermal diffusion measurement of cerebral blood flow, cerebral microdialysis, and EEG. We then discuss the informatics challenges to acquire, consolidate, analyze, and display the data. Acquisition includes multiple data types: discrete, waveform, and continuous. Consolidation requires device interoperability and time synchronization. Analysis could include pressure reactivity index and quantitative EEG. Displays should communicate the patient's current status, longitudinal and trend information, and critical alarms.
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Affiliation(s)
- Zachary M Grinspan
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, NY; Department of Pediatrics, Weill Cornell Medical College, New York, NY; Center for Healthcare Informatics and Policy, Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital, New York, NY.
| | - Steven Pon
- Department of Pediatrics, Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Jeffrey P Greenfield
- New York Presbyterian Hospital, New York, NY; Department of Neurologic Surgery, Weill Cornell Medical College, New York, NY
| | - Sameer Malhotra
- Center for Healthcare Informatics and Policy, Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital, New York, NY; Physician Organization, Weill Cornell Medical College, New York, NY
| | - Barry E Kosofsky
- Department of Pediatrics, Weill Cornell Medical College, New York, NY; New York Presbyterian Hospital, New York, NY
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Abstract
PURPOSE OF REVIEW To discuss the use of continuous video-electroencephalographic (cEEG) monitoring among critically ill children at risk for electrographic seizures and status epilepticus. RECENT FINDINGS Recent reports have demonstrated the growing, but heterogeneous, use of cEEG monitoring among North American pediatric institutions, and provided evidence for the high prevalence of subclinical seizures, particularly among encephalopathic patients with acute brain injury. Increasing seizure burden and status epilepticus have been shown to be independently associated with worse short-term and long-term outcomes. SUMMARY Certain high-risk children frequently experience electrographic seizures and status epilepticus, often without clinical signs, necessitating the use of cEEG monitoring for their diagnosis and management. Although an increasing electrographic seizure burden and status epilepticus are independently associated with worse outcome, further studies are needed to determine whether aggressive use of antiepileptic drugs to reduce seizure burden can improve outcome.
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Abstract
OBJECTIVE To determine the prevalence of acute symptomatic seizures in infants with supratentorial intracranial hemorrhage, to identify potential risk factors, and to determine the effect of acute seizures on long-term morbidity and mortality. DESIGN Children less than 24 months with intracranial hemorrhage were identified from a neurocritical care database. All patients who received seizure prophylaxis beginning at admission were included in the study. Risk factors studied were gender, etiology, location of hemorrhage, seizure(s) on presentation, and the presence of parenchymal injury. Acute clinical and electrographic seizures were identified from hospital medical records. Subsequent development of late seizures was determined based on clinical information from patients' latest follow-up. SETTING AND PATIENTS Patients with idiopathic neonatal intracranial hemorrhage, premature infants, and those with prior history of seizures were excluded from analysis. Seventy-two infants met inclusion criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty percent of infants had acute symptomatic seizures. The prevalence was similar regardless of whether etiology of hemorrhage was traumatic or nontraumatic. Seizures on presentation and parenchymal injury were independent risk factors of acute seizures (p = 0.001 and p = 0.006, respectively). Younger children and women were also at higher risk (p < 0.05). Twenty percent had electrographic-only seizures, and those with parenchymal injury trended toward an increased risk (p < 0.1). Acute seizures were not predictive of mortality, but nearly twice as many patients with acute seizures developed late seizures when compared with those without. Electrographic seizures and parenchymal injury were also predictive of development of late seizures (p < 0.001 and p = 0.013, respectively). CONCLUSIONS Despite seizure prophylaxis, infants with supratentorial intracranial hemorrhage are at high risk for acute symptomatic seizures. This is regardless of the etiology of hemorrhage. Younger patients, women, patients with parenchymal injury, and patients presenting with seizure are most likely to develop acute seizures. Although the benefits of seizure prophylaxis have not been studied in this specific population, these results suggest that it is an important component of acute care following intracranial hemorrhage.
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Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr 2014; 3:195-207. [PMID: 26835337 PMCID: PMC4729847 DOI: 10.3978/j.issn.2224-4336.2014.06.01] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Non-accidental trauma (NAT) is a leading cause of childhood traumatic injury and death in the United States. It is estimated that 1,400 children died from maltreatment in the United States in 2002 and abusive head trauma (AHT) accounted for 80% of these deaths. This review examines the epidemiology and risk factors for NAT as well as the general presentation and required medical work up of abused children. In addition, potential algorithms for recognizing cases of abuse are reviewed as well as outcomes in children with NAT and potential neurosurgical interventions which may be required. Finally, the evidence for seizure prophylaxis in this population is addressed.
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Affiliation(s)
- Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, Mail Code 10, Albany, NY 12208, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, Mail Code 10, Albany, NY 12208, USA
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