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Epilepsy
A paroxysmal brain disorder of various etiologies characterized by recurrent seizures due to excessive electrical discharge of cerebral neurons associated with a variety of clinical and laboratory manifestations two or more seizures not directly provoked by intracranial infection, drug withdrawal, acute metabolic changes or fever
Neonatal Seizures
Tonic Seizuresfocal or generalized, may mimic decorticate or decerebrate posturing, primarily seen in preterms with intracranial hemorrhage & generally have poor prognosis Subtle seizures Consist of chewing motion, excessive salivation and alteration in respiratory rate including apnea, blinking, nystagmus, bicycling and pedaling movements, changes in color
ClonicClonic- focal (repetitive movements localized to a single limb) or multifocal (random migration of movements from limb to limb), consciousness may be preserved, primarily seen in term infants Myoclonic- sudden flexor movements (lightning-like jerks), may be focal, multifocal or generalized, may occuring singly or in clusters, if due to early myoclonic encephalopathy it carries a poor prognosis. Brief focal or generalized jerks of the extremities or body that tend to involve distal muscle groups
Why are seizure patterns in neonates more fragmentary than in older children? The cellular organization of the mature and immature brain is different. The neonatal brain has incomplete glial proliferation, w/ continuing migration of neurons, establishing complex axonal & dendritic contacts and myelin deposition.
The electrical discharges therefore spread incompletely and may remain localized to one hemisphere. The electrical discharges are slow to diffuse and bilateral synchronous discharges are rare.
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Major Causes of Neonatal Seizures In Relation to Time of Seizure Onset and Relative Frequency
TIME OF ONSET* ONSET* FREQUENCY Cause Full Term HypoxicHypoxic-Ischemic encephalopathy Intracranial hemorrhage Intracranial infection Developmental defects Hypoglycemia Hypocalcemia Other metabolic Epileptic syndromes 00-3 Days + + + + + + + + >3 Days +++ ++ ++ ++ + + RELATIVE Premature +++ + ++ ++ + + +
Rare
Common
+ + + + +
+ -
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Neonatal Seizures
(Epileptic Syndromes)
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Neonatal Seizures
Fifth-day fits
5th day of life normal appearing neonates with mulifocal seizures Present for less than 24 hours Good prognosis
Normal
50% 10% 90% 50% 100% 50% 50% 0%
Why should the infant with epileptic seizures be treated with AED
Potential adverse effects of seizure on: Ventilatory function Circulation Cerebral Metabolism Brain Development
disturbance in cerebral blood flow energy metabolism homeostasis of excitotoxic amino acids neurogenesis and synaptic reorganization
Phenytoin*: 20 mg/kg, IV (0.5-1.0 mg/kg/min) (0.5(Lorazepam: 0.05-0.10 mg/kg, IV) if available 0.05Midazolam: 0.2 mg/kg, IV;then,0.1-0.4 mg/kg/hr, IV IV;then,0.1-
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Clinical Scenario 1
F.M. a 36-37 month old baby boy is noted to have blinking of the eyelids with sucking movements of the mouth at 30 hours of life. The extremities are jittery when tactile stimuli is applied. Maternal history is unremarkable, NSD, G1P1 (1-00-1) no hypertension, no infection. Birth weight is 2.5kg. Apgar 8 and 10 at 1 and 5min. The blinking of the eyes and jittery movements of the extremities recur within the next hour.
Clinical Scenario 1
What is your impression? What work-ups will you request? Hgt, CBC, Serum Calcium, Electrolytes What will be your management? Na Luminal 20mg/g IV at 1mg/Kg/min infusion, maintain at 3.5 mg/g/day.
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Night terrors
1/3 will have somnambulism Emotional disorder should be explored in patient with prolonged and persistent night terrors Short course diazepam maybe considered while the family dynamics is investigated
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Febrile Seizures
3 mo 6 yrs (peak age of onset 14 18 mo) Normal Neurological Exam & development Occurs with fever (not due to CNS Infection) Most commonly due to viral URTI, otitis media, Roseola, UTI Normal EEG Mapped to Chromosomes 19p and 8q13-21 in some families- Autosomal Dominant pattern
Incidence Rate: 3-4% of young children
Age less than 12 mo A positive family history of febrile seizures Complex features Lower temperature before seizure onset Febrile seizures are not associated with decreased intellectual performance.
Positive family history of Epilepsy Onset of FS below 12 years Delayed milestones / Pre Existing Neurologic Disorder
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Reassurance and Education of the Parents Advise the parents regarding the use of oral diazepam at the onset of febrile illness
Oral Diazepam 0.3 mg/kg every 8 hours on the first day of illness
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