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DeLaGarza-Pineda O, Mailo JA, Boylan G, Chau V, Glass HC, Mathur AM, Shellhaas RA, Soul JS, Wusthoff CJ, Chang T. Management of seizures in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101279. [PMID: 34563467 DOI: 10.1016/j.siny.2021.101279] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Neonatal encephalopathy (NE) is the most common etiology of acute neonatal seizures - about half of neonates treated with therapeutic hypothermia for NE have EEG-confirmed seizures. These seizures are best identified with continuous EEG monitoring, as clinical diagnosis leads to under-diagnosis of subclinical seizures and over-treatment of events that are not seizures. High seizure burden, especially status epilepticus, is thought to augment brain injury. Treatment, therefore, is aimed at minimizing seizure burden. Phenobarbital remains the mainstay of treatment, as it is more effective than levetiracetam and easier to administer than fosphenytoin. Emerging evidence suggests that, for many neonates, it is safe to discontinue the phenobarbital after acute seizures resolve and prior to hospital discharge.
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Affiliation(s)
- Oscar DeLaGarza-Pineda
- Department of Neurology, University Hospital "Dr. Jose E. Gonzalez", Monterrey, Nuevo León, Mexico.
| | - Janette A Mailo
- Neurology & Pediatrics, Stollery Children's Hospital and Glenrose Rehabilitation Hospital University of Alberta, Alberta, Canada.
| | - Geraldine Boylan
- Department of Pediatrics & Child Health University College Cork, Cork, Ireland.
| | - Vann Chau
- Division of Neurology, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada.
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California San Francisco, San Francisco, CA, USA, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA, Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA.
| | - Amit M Mathur
- Division of Neonatal Perinatal Medicine, Saint Louis University School of Medicine, SSM-Health Cardinal Glennon Children's Hospital, Saint Louis, MO, USA.
| | - Renée A Shellhaas
- Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Janet S Soul
- Neurology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Courtney J Wusthoff
- Division of Child Neurology, Division of Pediatrics-Neonatal and Developmental Medicine Stanford Children's Health, Palo Alto, CA, USA.
| | - Taeun Chang
- Neurology & Pediatrics, George Washington University School of Medicine & Health Sciences, Children's National Hospital, Washington, DC, USA.
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Pisani F, Spagnoli C, Falsaperla R, Nagarajan L, Ramantani G. Seizures in the neonate: A review of etiologies and outcomes. Seizure 2021; 85:48-56. [PMID: 33418166 DOI: 10.1016/j.seizure.2020.12.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 12/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Neonatal seizures occur in their majority in close temporal relation to an acute brain injury or systemic insult, and are accordingly defined as acute symptomatic or provoked seizures. However less frequently, unprovoked seizures may also present in the neonatal period as secondary to structural brain abnormalities, thus corresponding to structural epilepsies, or to genetic conditions, thus corresponding to genetic epilepsies. Unprovoked neonatal seizures should be thus considered as the clinical manifestation of early onset structural or genetic epilepsies that often have the characteristics of early onset epileptic encephalopathies. In this review, we address the conundrum of neonatal seizures including acute symptomatic, remote symptomatic, provoked, and unprovoked seizures, evolving to post-neonatal epilepsies, and neonatal onset epilepsies. The different clinical scenarios involving neonatal seizures, each with their distinct post-neonatal evolution are presented. The structural and functional impact of neonatal seizures on brain development and the concept of secondary epileptogenesis, with or without a following latent period after the acute seizures, are addressed. Finally, we underline the need for an early differential diagnosis between an acute symptomatic seizure and an unprovoked seizure, since it is associated with fundamental differences in clinical evolution. These are crucial aspects for neonatal management, counselling and prognostication. In view of the above aspects, we provide an outlook on future strategies and potential lines of research in this field.
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Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatry Unit, Medicine and Surgery Department, University of Parma, Italy
| | - Carlotta Spagnoli
- Child Neurology Unit, Department of Pediatrics, Azienda USL-IRCCS, Reggio Emilia, Italy
| | - Raffaele Falsaperla
- Neonatal Intensive Care Unit, University-Hospital Policlinico Vittorio Emanuele, Catania, Italy
| | - Lakshmi Nagarajan
- Children's Neuroscience Service, Department of Neurology, Perth Children's Hospital, Australia
| | - Georgia Ramantani
- Department of Neuropediatrics, University Children's Hospital Zurich, Switzerland.
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Juvale IIA, Che Has AT. Possible interplay between the theories of pharmacoresistant epilepsy. Eur J Neurosci 2020; 53:1998-2026. [PMID: 33306252 DOI: 10.1111/ejn.15079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/22/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023]
Abstract
Epilepsy is one of the oldest known neurological disorders and is characterized by recurrent seizure activity. It has a high incidence rate, affecting a broad demographic in both developed and developing countries. Comorbid conditions are frequent in patients with epilepsy and have detrimental effects on their quality of life. Current management options for epilepsy include the use of anti-epileptic drugs, surgery, or a ketogenic diet. However, more than 30% of patients diagnosed with epilepsy exhibit drug resistance to anti-epileptic drugs. Further, surgery and ketogenic diets do little to alleviate the symptoms of patients with pharmacoresistant epilepsy. Thus, there is an urgent need to understand the underlying mechanisms of pharmacoresistant epilepsy to design newer and more effective anti-epileptic drugs. Several theories of pharmacoresistant epilepsy have been suggested over the years, the most common being the gene variant hypothesis, network hypothesis, multidrug transporter hypothesis, and target hypothesis. In our review, we discuss the main theories of pharmacoresistant epilepsy and highlight a possible interconnection between their mechanisms that could lead to the development of novel therapies for pharmacoresistant epilepsy.
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Affiliation(s)
- Iman Imtiyaz Ahmed Juvale
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Ahmad Tarmizi Che Has
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
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Ou S, Xia L, Li R, Wang L, Xia L, Zhou Q, Pan S. Long-term outcome of seizure-free patients and risk factors of relapse following antiepileptic drug withdrawal. Epilepsy Behav 2018; 88:295-300. [PMID: 30340125 DOI: 10.1016/j.yebeh.2018.09.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aimed to investigate the long-term outcome in seizure-free patients and to explore the risk factors of seizure relapse following antiepileptic drug (AED) withdrawal. METHODS This study included 161 patients who had been seizure-free for at least 2 years. These patients were monitored over a follow-up period of at least 3 years or until seizure relapse after AED withdrawal. Patients were grouped into a seizure-free group and a relapse group. Risk factors of seizure relapse were analyzed. RESULTS During the follow-up period, 72 patients (44.7%) relapsed while 89 patients (55.3%) did not. The average time of relapse was 19.12 ± 27.17 months after the initiation of AED withdrawal, and majority of cases occurred within the first 24 months of AED withdrawal (73.6%). Univariate analysis showed that the likelihood of relapse was higher in patients with uncontrolled seizures beyond the first 6 months of AED therapy initiation, patients with a history of perinatal injury, patients with multiple seizure types, and patients who had been treated with a combination of AEDs. Multiple logistic regression analysis revealed that uncontrolled seizures beyond the first 6 months of AED treatment and a history of perinatal injury were independent risk factors of seizure relapse. CONCLUSION In the majority of cases, epilepsy relapse occurred within the first two years after the initiation of AED withdrawal. The independent risk factors of seizure relapse were uncontrolled seizures beyond the first 6 months of AED therapy and cases with a history of perinatal injury.
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Affiliation(s)
- Shuchun Ou
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Lu Xia
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Rong Li
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Li Wang
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Li Xia
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qin Zhou
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Songqing Pan
- Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China.
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Medical Doctor Association MDA. [Expert consensus on neurorestorotherapy for infants/toddlers with brain injury]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2018; 20:785-792. [PMID: 30369350 PMCID: PMC7389048 DOI: 10.7499/j.issn.1008-8830.2018.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 08/27/2018] [Indexed: 06/08/2023]
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Glass HC, Numis AL, Gano D, Bali V, Rogers EE. Outcomes After Acute Symptomatic Seizures in Children Admitted to a Neonatal Neurocritical Care Service. Pediatr Neurol 2018; 84:39-45. [PMID: 29886041 DOI: 10.1016/j.pediatrneurol.2018.03.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Neonatal seizures due to acute brain injury are associated with high rates of death, disability, and epilepsy. Our objective was to examine incidence of and risk factors for epilepsy among survivors of acute symptomatic neonatal seizures who were cared for by a neonatal neurocritical care service. METHODS Neonates with acute symptomatic seizures who were admitted to UCSF Benioff Children's Hospital Neuro-Intensive Care Nursery from July 2008 to June 2014 were considered for inclusion. RESULTS A total of 144 children with acute symptomatic seizures met study criteria and 37 (26%) died before age one. Eighty-seven children (85% of eligible survivors) were followed up to one year or longer. Epilepsy was diagnosed in eight children at median age 4.9 (interquartile range 1.7, 6.1) years. The cumulative incidence risk of epilepsy at one year was 2% (95% confidence interval 0.6% to 9%) and at five years was 7% (95% confidence interval 3% to 20%). Cerebral palsy was diagnosed in 21%. Bayley-III cognitive subscale less than 85 was present in 13%. Children with epilepsy were more likely to be preterm, have brain injury, and be discharged home on antiseizure medication, although the results were not significant after adjusted analysis. CONCLUSIONS The risk of epilepsy was lower and age at onset was older than in previous reports, which may be related to multiple factors including a neurocritical care approach, treatment of hypoxic-ischemic encephalopathy with hypothermia, high rate of neonatal transition to palliative care, and the exclusion of neonatal onset epilepsies. Continuation of antiseizure medications in infancy did not decrease the risk of epilepsy. Long-term, multicenter studies are needed to understand whether neonatal seizure management can alter the risk of epilepsy.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California.
| | - Adam L Numis
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | - Dawn Gano
- Department of Neurology, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California; Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
| | | | - Elizabeth E Rogers
- Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California
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Glass HC, Grinspan ZM, Shellhaas RA. Outcomes after acute symptomatic seizures in neonates. Semin Fetal Neonatal Med 2018; 23:218-222. [PMID: 29454756 DOI: 10.1016/j.siny.2018.02.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute symptomatic seizures are a common sign of neurological dysfunction and brain injury in neonates and occur in approximately one to three per 1000 live births. Seizures in neonates are usually a sign of underlying brain injury and, as such, are commonly associated with adverse outcomes. Neurological morbidities in survivors often co-occur; epilepsy, cerebral palsy, and intellectual disability often occur together in the most severely affected children. Risk factors for adverse outcome include prematurity, low Apgar scores, low pH on the first day of life, seizure onset <24 or >72 h after birth, abnormal neonatal neurological examination, abnormal neonatal electroencephalographic background, status epilepticus, and presence and pattern of brain injury (particularly deep gray or brainstem injury). Despite this list of potential indicators, accurate prediction of outcome in a given child remains challenging. There is great need for long-term, multicenter studies to examine risk factors for, and pathogenesis of, adverse outcomes following acute symptomatic seizures in neonates.
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Affiliation(s)
- Hannah C Glass
- Department of Neurology, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA.
| | - Zachary M Grinspan
- Department of Healthcare Policy, Department of Research and Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Renée A Shellhaas
- Department of Pediatrics, Department of Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
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Lyon KA, Arrey EN, Haider AS, Jeevan DS, Benardete EA. Endovascular treatment of a large ruptured middle cerebral artery bifurcation aneurysm in a 5-week-old infant: case report. J Neurosurg Pediatr 2017; 20:357-363. [PMID: 28777036 DOI: 10.3171/2017.5.peds17116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ruptured intracranial aneurysms are extremely rare in infants. The optimal treatment strategy is not well established. Both microsurgical and endovascular techniques and strategies have been tried, and in the literature there is a significant variability in outcome. The authors report the presentation and successful endovascular treatment of a large, ruptured, middle cerebral artery bifurcation aneurysm in a 5-week-old girl, one of only a few reported in the literature. Clinical and radiological findings at follow-up are also presented. The authors then review the literature on aneurysmal subarachnoid hemorrhage in infants, with particular regard to outcome after either endovascular or open surgical management. They also provide recommendations for follow-up in pediatric patients whose intracranial aneurysms have been treated with coil embolization.
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Affiliation(s)
- Kristopher A Lyon
- Department of Neurosurgery, Scott and White Medical Center, Texas A&M University Health Science Center College of Medicine, Temple; and
| | - Eliel N Arrey
- University of Texas Health Science Center, McGovern Medical School, Houston, Texas
| | - Ali S Haider
- Department of Neurosurgery, Scott and White Medical Center, Texas A&M University Health Science Center College of Medicine, Temple; and
| | - Dhruve S Jeevan
- Department of Neurosurgery, Scott and White Medical Center, Texas A&M University Health Science Center College of Medicine, Temple; and
| | - Ethan A Benardete
- Department of Neurosurgery, Scott and White Medical Center, Texas A&M University Health Science Center College of Medicine, Temple; and
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