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Dilena R, Molisso MT, De Carli A, Mauri E, Circiello A, Di Benedetto A, Pisoni S, Bassi L, Bana C, Cappellari AM, Consonni D, Mastrangelo M, Granata T, La Briola F, Peruzzi C, Raviglione F, Striano P, Barbieri S, Mosca F, Fumagalli M. Retrospective study on neonatal seizures in a tertiary center of northern Italy after ILAE classification: Incidence, seizure type, EEG and etiology. Epilepsy Behav 2024; 159:109971. [PMID: 39094245 DOI: 10.1016/j.yebeh.2024.109971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVE We aimed to evaluate epidemiology, seizure type, EEG, and etiology of neonatal seizures (NS) in a tertiary neonatal intensive care unit. METHODS Data on infants with a neurophysiological confirmation of NS were collected between 2009 and 2022. Seizure types and epileptic syndromes were classified by the ILAE classification and EEG by the Italian Neonatal Seizure Collaborative Network (INNESCO) score. RESULTS Out of 91,253 neonates, 145 presented with NS; 69.7 % were born at term and 30.3 % were preterm infants. The incidence of NS in neonates born at our center was 1.2 per 1,000 live newborns (96/80697 neonates) while in the entire neonatal population admitted to our center it was 1.6 per 1,000 live births, increasing with lower preterm age. Compared to previous studies, we found a lower proportion of hypoxic-ischemic encephalopathy (HIE) (23.4 %) and a higher rate of genetic contribution (26.2 %). The infection rate was higher in preterm (31.8 %) than in full term (9.9 %) infants. Electrographic seizures were associated with acute provoked seizures (35.9 %), preterm age (52.3 %), and HIE (52.9 %). Vascular etiology was associated with focal clonic seizures (56.8 %). Non-structural neonatal genetic epilepsy was associated with sequential seizures (68.2 %), particularly KCNQ2 and SCN2A epilepsy. Background EEG was abnormal in all HIE, infections (85.7 %) and metabolic NS (83.3 %). In genetic epilepsy, background EEG depended on the epileptic syndrome: normal in 80 % of self-limited neonatal epilepsy and abnormal in 77.8 % of developmental and epileptic encephalopathy. Electroclinical seizures were associated with focal onset, while electrographic seizures correlated with a multifocal onset. CONCLUSIONS A low incidence of HIE and a high incidence of genetic etiology were observed in our cohort of NS. Seizure type and EEG features are fundamental to address etiology.
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Affiliation(s)
- Robertino Dilena
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Maria T Molisso
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Agnese De Carli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Eleonora Mauri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Alberta Circiello
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Alessia Di Benedetto
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Silvia Pisoni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Laura Bassi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy.
| | - Cristina Bana
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Alberto M Cappellari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Dario Consonni
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Epidemiology Unit, Milan, Italy.
| | | | - Tiziana Granata
- Fondazione IRCCS Istituto Neurologico Carlo Besta, Dipartimento di Neuroscienze Pediatriche, Child Neuropsychiatry Unit - Epilepsy Center, Milan, Italy.
| | - Francesca La Briola
- University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy; A.S.S.T. Santi Paolo e Carlo, Epilepsy Center - Child Neuropsychiatry Unit, Milan, Italy.
| | - Cinzia Peruzzi
- Fondazione IRCCS San Gerardo dei Tintori, Unità di Neuropsichiatria Infantile, Monza, Italy; Università degli Studi di Milano Bicocca, Dipartimento di Medicina e Chirurgia, Milan, Italy.
| | | | - Pasquale Striano
- IRCCS G. Gaslini, Pediatric Neurology and Muscular Diseases Unit, Genova, Italy; University of Genova, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Genova, Italy.
| | - Sergio Barbieri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurophysiopathology Unit, Department of Neuroscience and Mental Health, Milan, Italy.
| | - Fabio Mosca
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, NICU, Milan, Italy; University of Milan, Department of Clinical Sciences and Community Health, Milan, Italy.
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Arntsen V, Jamali A, Sikiric A, Kristensen E, Tangeraas T, Kupliauskiene G, Stefansdottir S, Bindoff LA, Sand T, Brodtkorb E. Utility and limitations of EEG in the diagnosis and management of ALDH7A1-related pyridoxine-dependent epilepsy. A retrospective observational study. Front Neurol 2024; 15:1355861. [PMID: 38419708 PMCID: PMC10899485 DOI: 10.3389/fneur.2024.1355861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Purpose Pyridoxine-dependent epilepsy due to ALDH7A1 variants (PDE-ALDH7A1) is a rare disorder, presenting typically with severe neonatal, epileptic encephalopathy. Early diagnosis is imperative to prevent uncontrolled seizures. We have explored the role of EEG in the diagnosis and management of PDE. Methods A total of 13 Norwegian patients with PDE-ALDH7A1 were identified, of whom five had reached adult age. Altogether 163 EEG recordings were assessed, 101 from the 1st year of life. Results Median age at seizure onset was 9 h (IQR 41), range 1 h-6 days. Median delay from first seizure to first pyridoxine injection was 2 days (IQR 5.5). An EEG burst suppression pattern was seen in eight patients (62%) during the first 5 days of life. Eleven patients had recordings during pyridoxine injections: in three, immediate EEG improvement correlated with seizure control, whereas in six, no change of epileptiform activity occurred. Of these six, one had prompt clinical effect, one had delayed effect (< 1 day), one had no effect, one had uncertain effect, and another had more seizures. A patient without seizures at time of pyridoxine trial remained seizure free for 6 days. Two patients with prompt clinical effect had increased paroxysmal activity, one as a conversion to burst suppression. Autonomic seizures in the form of apnoea appeared to promote respiratory distress and were documented by EEG in one patient. EEG follow-up in adult age did not show signs of progressing encephalopathy. Conclusion A neonatal burst suppression EEG pattern should raise the suspicion of PDE-ALDH7A1. Respiratory distress is common; isolated apnoeic seizures may contribute. EEG responses during pyridoxine trials are diverse, often with poor correlation to immediate clinical effect. Reliance on single trials may lead to under-recognition of this treatable condition. Pyridoxine should be continued until results from biomarkers and genetic testing are available.
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Affiliation(s)
- Vibeke Arntsen
- Department of Neurology and Clinical Neurophysiology, St. Olav University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ahmed Jamali
- Kavli Institute for Systems Neuroscience, Center for Computational Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
| | - Alma Sikiric
- Department of Neurohabilitation, Oslo University Hospital, Oslo, Norway
| | - Erle Kristensen
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
| | - Trine Tangeraas
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Guste Kupliauskiene
- Department of Paediatric and Adolescent Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Sigurbjörg Stefansdottir
- Department of Neurology and Clinical Neurophysiology, Stavanger University Hospital, Stavanger, Norway
| | - Laurence A. Bindoff
- Department of Clinical Medicine (K1), University of Bergen, Bergen, Norway
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Trond Sand
- Department of Neurology and Clinical Neurophysiology, St. Olav University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Eylert Brodtkorb
- Department of Neurology and Clinical Neurophysiology, St. Olav University Hospital, Trondheim, Norway
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
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Carapancea E, Cilio MR. A novel approach to seizures in neonates. Eur J Paediatr Neurol 2023; 46:89-97. [PMID: 37544258 DOI: 10.1016/j.ejpn.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
THE CHALLENGE OF SEIZURE RECOGNITION Recognition of seizures in neonates remains the foremost challenge to overcome. All neonates at risk for seizures, especially the critically ill, should undergo video-EEG monitoring. The initial step toward an accurate diagnosis is the accurate description and interpretation of the electro-clinical phenotype. THE IMPORTANCE OF SEIZURE SEMIOLOGY AND ASSOCIATION WITH ETIOLOGY: The early distinction between acute provoked seizures and neonatal-onset epilepsies serves as the primary determinant for guiding management, treatment choices, and duration. Seizures in neonates should be seen as a symptom, not a disease, and their semiology may suggest the etiology. TREATMENT OF ACUTE PROVOKED SEIZURES Neonates with hypoxic-ischemic encephalopathy respond best to phenobarbital, while levetiracetam is a better choice for neonates with congenital heart diseases. Anti-seizure medication can be discontinued after 72 h of seizure freedom, before discharge from the hospital. TREATMENT OF NEONATAL EPILEPSIES Neonates with epilepsy usually require a personalized, etiology-based approach in terms of choice and duration of treatment. Neonates with channelopathies tend to respond to sodium channel blockers such as carbamazepine, oxcarbazepine, or phenytoin. The surgical option should be considered early in cases of large brain malformations, such as hemimegalencephaly.
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Affiliation(s)
- Evelina Carapancea
- Institute of Neuroscience (IoNS), Université Catholique de Louvain, Brussels, Belgium
| | - Maria Roberta Cilio
- Institute of Neuroscience (IoNS), Université Catholique de Louvain, Brussels, Belgium; Division of Pediatric Neurology, Department of Pediatrics, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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Optical Monitoring in Neonatal Seizures. Cells 2022; 11:cells11162602. [PMID: 36010678 PMCID: PMC9407001 DOI: 10.3390/cells11162602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/30/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neonatal seizures remain a significant cause of morbidity and mortality worldwide. The past decade has resulted in substantial progress in seizure detection and understanding the impact seizures have on the developing brain. Optical monitoring such as cerebral near-infrared spectroscopy (NIRS) and broadband NIRS can provide non-invasive continuous real-time monitoring of the changes in brain metabolism and haemodynamics. AIM To perform a systematic review of optical biomarkers to identify changes in cerebral haemodynamics and metabolism during the pre-ictal, ictal, and post-ictal phases of neonatal seizures. METHOD A systematic search was performed in eight databases. The search combined the three broad categories: (neonates) AND (NIRS) AND (seizures) using the stepwise approach following PRISMA guidance. RESULTS Fifteen papers described the haemodynamic and/or metabolic changes observed with NIRS during neonatal seizures. No randomised controlled trials were identified during the search. Studies reported various changes occurring in the pre-ictal, ictal, and post-ictal phases of seizures. CONCLUSION Clear changes in cerebral haemodynamics and metabolism were noted during the pre-ictal, ictal, and post-ictal phases of seizures in neonates. Further studies are necessary to determine whether NIRS-based methods can be used at the cot-side to provide clear pathophysiological data in real-time during neonatal seizures.
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Tapani KT, Nevalainen P, Vanhatalo S, Stevenson NJ. Validating an SVM-based neonatal seizure detection algorithm for generalizability, non-inferiority and clinical efficacy. Comput Biol Med 2022; 145:105399. [DOI: 10.1016/j.compbiomed.2022.105399] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/21/2022] [Accepted: 03/09/2022] [Indexed: 01/01/2023]
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Falsaperla R, Sciuto L, La Spina L, Sciuto S, Praticò AD, Ruggieri M. Neonatal seizures as onset of Inborn Errors of Metabolism (IEMs): from diagnosis to treatment. A systematic review. Metab Brain Dis 2021; 36:2195-2203. [PMID: 34403026 PMCID: PMC8580891 DOI: 10.1007/s11011-021-00798-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
Neonatal seizures (NS) occur in the first 28 days of life; they represent an important emergency that requires a rapid diagnostic work-up to start a prompt therapy. The most common causes of NS include: intraventricular haemorrhage, hypoxic-ischemic encephalopathy, hypoglycemia, electrolyte imbalance, neonatal stroke or central nervous system infection. Nevertheless, an Inborn Error of Metabolism (IEM) should be suspected in case of NS especially if these are resistant to common antiseizure drugs (ASDs) and with metabolic decompensation. Nowadays, Expanded Newborn Screening (ENS) has changed the natural history of some IEMs allowing a rapid diagnosis and a prompt onset of specific therapy; nevertheless, not all IEMs are detected by such screening (e.g. Molybdenum-Cofactor Deficiency, Hypophosphatasia, GLUT1-Deficiency Syndrome) and for this reason neonatologists have to screen for these diseases in the diagnostic work-up of NS. For IEMs, there are not specific semiology of seizures and EEG patterns. Herein, we report a systematic review on those IEMs that lead to NS and epilepsy in the neonatal period, studying only those IEMs not included in the ENS with tandem mass, suggesting clinical, biochemical features, and diagnostic work-up. Remarkably, we have observed a worse neurological outcome in infants undergoing only a treatment with common AED for their seizures, in comparison to those primarily treated with specific anti-convulsant treatment for the underlying metabolic disease (e.g.Ketogenic Diet, B6 vitamin). For this reason, we underline the importance of an early diagnosis in order to promptly intervene with a targeted treatment without waiting for drug resistance to arise.
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Affiliation(s)
- Raffaele Falsaperla
- Unit of Pediatrics and Pediatric Emergency, University Hospital Policlinico "Rodolico-San Marco", Catania, Italy
- Unit of Neonatal Intensive Care and Neonatology, University Hospital Policlinico "Rodolico-San Marco", Catania, Italy
| | - Laura Sciuto
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy.
| | - Luisa La Spina
- Regional Reference Center for the Treatment and Control of Congenital Metabolic Diseases of Childhood, University Hospital Policlinico "Rodolico-San Marco", Catania, Italy
| | - Sarah Sciuto
- Pediatrics Postgraduate Residency Program, Section of Pediatrics and Child Neuropsychiatry, Department of Clinical and Experimental Medicine, University of Catania, Via S. Sofia 78, 95123, Catania, Italy
| | - Andrea D Praticò
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
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Cornet MC, Morabito V, Lederer D, Glass HC, Ferrao Santos S, Numis AL, Ferriero DM, Sands TT, Cilio MR. Neonatal presentation of genetic epilepsies: Early differentiation from acute provoked seizures. Epilepsia 2021; 62:1907-1920. [PMID: 34153113 DOI: 10.1111/epi.16957] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Although most seizures in neonates are due to acute brain injury, some represent the first sign of neonatal onset genetic epilepsies. Delay in recognition and lack of expert assessment of neonates with epilepsy may result in worse developmental outcomes. As in older children and adults, seizure semiology in neonates is an essential determinant in diagnosis. We aimed to establish whether seizure type at presentation in neonates can suggest a genetic etiology. METHODS We retrospectively analyzed the clinical and electroencephalographic (EEG) characteristics of seizures in neonates admitted in two Level IV neonatal intensive care units, diagnosed with genetic epilepsy, for whom a video-EEG recording at presentation was available for review, and compared them on a 1:2 ratio with neonates with seizures due to stroke or hypoxic-ischemic encephalopathy. RESULTS Twenty neonates with genetic epilepsy were identified and compared to 40 neonates with acute provoked seizures. Genetic epilepsies were associated with pathogenic variants in KCNQ2 (n = 12), KCNQ3 (n = 2), SCN2A (n = 2), KCNT1 (n = 1), PRRT2 (n = 1), and BRAT1 (n = 2). All neonates with genetic epilepsy had seizures with clinical correlates that were either tonic (18/20) or myoclonic (2/20). In contrast, 17 of 40 (42%) neonates with acute provoked seizures had electrographic only seizures, and the majority of the remainder had clonic seizures. Time to first seizure was longer in neonates with genetic epilepsies (median = 60 h of life) compared to neonates with acute provoked seizures (median = 15 h of life, p < .001). Sodium channel-blocking antiseizure medications were effective in 13 of 14 (92%) neonates with tonic seizures who were trialed at onset or during the course of the epilepsy. SIGNIFICANCE Seizure semiology is an easily accessible sign of genetic epilepsies in neonates. Early identification of the seizure type can prompt appropriate workup and treatment. Tonic seizures are associated with channelopathies and are often controlled by sodium channel-blocking antiseizure medications.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA
| | - Valeria Morabito
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | | | - Hannah C Glass
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.,Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Susana Ferrao Santos
- Department of Neurology, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Adam L Numis
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Donna M Ferriero
- Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.,Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Tristan T Sands
- Department of Neurology, Columbia University, New York, New York, USA
| | - Maria Roberta Cilio
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
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