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1. NEONATAL SEIZURES
Dr Laxman S Sirur
MD (Org. of Medicine)
www.similima.com 1
2. Definition
Neonatal period limited to :
- first 28 days for term infants
- 44 weeks gestational age for
pre-term
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3. The Definition of a Seizure
“paroxysmal discharge of cerebral neurons, sufficient to cause clinically detectable events that are apparent, either to the subject or to an observer” www.similima.com 3
4. Why do neonatal seizures have such unusual presentations?
Immature CNS cannot sustain a synchronized, well orchestrated generalized seizure www.similima.com 4
5.
Probable Mechanisms of Some Neonatal Seizures
PROBABLE MECHANISM DISORDER
Failure of Na + -K + pump secondary to Hypoxemia, ischemia,
? adenosine triphosphate and hypoglycemia
Excess of excitatory neurotransmitter
(eg.glutamic acid—excessive excitation) Hypoxemia, ischemia
and hypoglycemia
Deficit of inhibitory neurotransmitter Pyridoxine dependency
(i.e., relative excess of excitatory
neurotransmitter)
Membrane alteration— ? Na + Hypocalcemia and
Permeability hypomagnesemia
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Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4th ed. www.similima.com 5
6. Classification of Neonatal Seizures
Clinical
Electroencephalographic www.similima.com 6
7. Classification I. Clinical Seizure
Subtle
Tonic
Clonic
Myoclonic www.similima.com 7
8. Classification II. Electroencephalographic seizure
Epileptic
Non-epileptic
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9. Clinical Classification 1. Subtle
More in preterm than in term
Eye deviation (term)
Blinking, fixed stare (preterm)
Repetitive mouth and tongue movements
Apnea
Pedaling and tonic posturing of limbs www.similima.com 9
10. Clinical Classification 2. Tonic
Primarily in Preterm
May be focal or generalized
Sustained extension of the upper and
lower limbs (mimics decerebrate posturing)
Sustained flexion of upper with extension of
lower limbs (mimics decorticate posturing)
Signals severe ICH in preterm infants www.similima.com 10
11. Clinical Classification 3. Clonic
Primarily in term
Focal or multifocal
Clonic limb movements(synchronous or
asynchronous, localized or often with no anatomic order of progression)
Consciousness may be preserved
Signals focal cerebral injury
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12. Clinical Classification 4. Myoclonic
Rare
Focal, multifocal or generalized
Lightning-like jerks of extremities
(upper > lower) www.similima.com 12
13. Electroencephalographic seizure I. Epileptic
Consistently associated with electro-cortical seizure activity on the EEG
Cannot be provoked by tactile stimulation
Cannot be suppressed by restraint of involved limb or repositioning of the infant
Related to hyper synchronous discharges of a critical mass of neuron www.similima.com 13
14. Electroencephalographic seizures II. Non-epileptic
No electro-cortical signature
Provoked by stimulation
Suppressed by restraint or repositioning
Brainstem release phenomena (reflex) www.similima.com 14
15.
Jitteriness Versus Seizure
CLINICAL FEATURE JITTERINESS SEIZURE
Abnormality of gaze or eye O +
movement
Movements are stimulus + O
sensitive
Predominant movement Tremor Clonic jerking
Movements cease with passive + O
flexion
Autonomic changes O +
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16. NEONATAL SEIZURES Aetiology:
Hypoxia. HIE.
Metabolic disturbances: (hypoglycemia, hypocalcemia , hypomagnesmia , hypo & hypernatremia).
Inborn errors of Metabolism.
Infections: congenital & acquired.
Traumatic.
cont. www.similima.com 16
17. NEONATAL SEIZURES Aetiology:
Structural abnormalities.
Hemorrahge.
Maternal drugs.
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18. NEONATAL SEIZURES Investigation:
Glucose,Ca ,Mg .
Urea&Electrolytes :Na+, K+, Ca+
Lumber puncture : CSF
wbc?(viral,bacterial) Rbc’s ? Hmg.
Ammonia level. www.similima.com 18
19. NEONATAL SEIZURES Investigation:
ABG-acidosis.
Lactate/ Pyruvate ratio.
Drug screen.
Imaging: USG, CT, MRI.
Karyotyping.
EEG.
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20.
Drug Therapy For Neonatal Seizures
Standard Therapy
AED Initial Dose Maintenance Dose Route
Phenobarbital 20mg/kg 3 to 4 mg/kg per day lV, lM, PO
Phenytoin 20 mg/kg 3 to 4 mg/kg per day lV, POª
Fosphenytoin 20 mg/kg phenytoin 3 to 4 mg/kg per day lV, lM
equivalents
Lorazepam² 0.05 to 0.1 mg/kg Every 8 to 12 hours lV
Diazepam²´ 0.25 mg/kg Every 6 to 8 hours lV
AED= andtiepileptic drug; lV= intravenous; lM= intramuscular; PO= oral
ªOral phenytoin is not well absorbed.
²Benzodiazepines typically not used for maintenance therapy.
³Lorazepam preferred over diazepam. www.similima.com 20
21. Complications Cerebral palsy
Hydrocephalus
Epilepsy
Spasticity
Feeding difficulties
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22. MIASMATIC BACKGROUND OF SEIZURE Seizures comes in a mixed miasmatic state, it does not fall in a single group of miasmatic background.
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24. ABSINTHIUM www.similima.com 24
25. CUPRUM MET www.similima.com 25
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