1
|
Lin R, Du N, Ning S, Zhang M, Feng J, Chen X, Ma L, Li J. Distinct profiles of cerebral oxygenation in focal vs. secondarily generalized EEG seizures in children undergoing cardiac surgery. Front Neurol 2024; 15:1353366. [PMID: 38784902 PMCID: PMC11111896 DOI: 10.3389/fneur.2024.1353366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 04/25/2024] [Indexed: 05/25/2024] Open
Abstract
Objectives Seizures are common in children undergoing cardiopulmonary bypass (CPB). Cerebral oxygen saturation (ScO2) by near-infrared spectroscopy is routinely monitored in many centers, but the relations between the levels and changes of ScO2 and brain injuries remain incompletely understood. We aimed to analyze the postoperative profiles of ScO2 and cerebral blood flow velocity in different types of EEG seizures in relation to brain injuries on MRI. Methods We monitored continuous EEG and ScO2 in 337 children during the first 48 h after CPB, which were analyzed in 3 h periods. Cerebral blood flow peak systolic velocity (PSV) in the middle cerebral artery was measured daily by transcranial Doppler. Postoperative cerebral MRI was performed before hospital discharge. Results Based on the occurrence and spreading types of seizures, patients were divided into three groups as patients without seizures (Group N; n = 309), those with focal seizures (Group F; n = 13), or with secondarily generalized seizures (Group G; n = 15). There were no significant differences in the onset time and duration of seizures and incidence of status epilepticus between the two seizures groups (Ps ≥ 0.27). ScO2 increased significantly faster across Group N, Group G, and Group F during the 48 h (p < 0.0001) but its overall levels were not significantly different among the three groups (p = 0.30). PSV was significantly lower (p = 0.003) but increased significantly faster (p = 0.0003) across Group N, Group G, and Group F. Group F had the most severe brain injuries and the highest incidence of white matter injuries on MRI among the three groups (Ps ≤ 0.002). Conclusion Postoperative cerebral oxygenation showed distinct profiles in secondarily generalized and particularly focal types of EEG seizures in children after CPB. A state of 'overshooting' ScO2 with persistently low PSV was more frequently seen in those with focal seizures and more severe brain injury. Information from this study may have important clinical implications in detecting brain injuries when monitoring cerebral oxygenation in this vulnerable group of children after CPB.
Collapse
Affiliation(s)
- Rouyi Lin
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Na Du
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Heart Center, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Shuyao Ning
- Department of Electroneurophysiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University Guangdong Province, Guangzhou, China
| | - Mingjie Zhang
- Department of Radiology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University Guangdong Province, Guangzhou, China
| | - Jinqing Feng
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Xinxin Chen
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Heart Center, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Ma
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Heart Center, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Jia Li
- Guangdong Provincial Key Laboratory of Research in Structural Birth Defect Disease, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
2
|
Li J, Zhang G, Wang X, Qiangba C, Song X, Lin R, Huang C, Yang X, Ning S, Zhang J, Liao H, Xie S, Suo Z, Qi H, Yu Z, Shi R, Yao Y. Characteristics of neonatal hypoxic-ischemic encephalopathy at high altitude and early results of therapeutic hypothermia. BMC Pediatr 2023; 23:609. [PMID: 38037071 PMCID: PMC10691051 DOI: 10.1186/s12887-023-04421-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Altitude hypoxia and limited socioeconomic conditions may result in distinctive features of neonatal hypoxic-ischemic encephalopathy (HIE). Therapeutic hypothermia (TH) has not been used at altitude. We examined characteristics of HIE and early outcomes of TH in 3 centers at two high altitudes, 2 at 2,261 m and 1 at 3,650 m. METHODS The incidence of HIE at NICUs was noted. TH was conducted when personnel and devices were available in 2019~2020. Standard inclusion criteria were used, with the addition of admission age >6 hours and mild HIE. Demographic and clinical data included gestational age, gender, weight, Apgar score, ethnics, age on admission, age at TH and clinical degree of HIE. EEG was monitored for 96 hours during hypothermia and rewarming. MRI was performed before discharge. RESULTS There was significant difference in ethnics, HIE degree, age at TH across 3 centers. The overall NICU incidence of HIE was 4.0%. Among 566 HIE patients, 114 (20.1%) received TH. 63 (55.3%) patients had moderate/severe HIE. Age at TH >6 hours occurred in 34 (29.8%) patients. EEG discharges showed seizures in 7~11% of patients, whereas spikes/sharp waves in 94~100%, delta brushes in 50~100%. After TH, MRI showed moderate to severe brain injury in 77% of patients, and correlated with center, demographic and clinical variables (Ps≤0.0003). Mortality was 5% during hospitalization and 11% after discharge until 1 year. CONCLUSIONS At altitude, the incidence of HIE was high and brain injury was severe. TH was limited and often late >6 hours. EEG showed distinct patterns attributable to altitude hypoxia. TH was relatively safe. TRIAL REGISTRATION The study was registered on February 23, 2019 in Chinese Clinical Trial Register (ChiCTR1900021481).
Collapse
Affiliation(s)
- Jia Li
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China.
- Clinical Physiology Laboratory, Capital Institute of Pediatrics, Beijing, China.
| | - Guofei Zhang
- NICU, Qinghai Red Cross Hospital, Xining, Qinghai, China
| | - Xiaorong Wang
- NICU, Qinghai Women's and Children's Hospital, Xining, Qinghai, China
| | | | - Xiaoyan Song
- NICU, Nanfang Hospital, Guangzhou, Guangdong, China
| | - Rouyi Lin
- Clinical Physiology Laboratory, Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Chantao Huang
- Department of Radiology, Nanfang Hospital, Guangzhou, Guangdong, China
| | - Xiaoying Yang
- NICU, Qinghai Women's and Children's Hospital, Xining, Qinghai, China
| | - Shuyao Ning
- Department of Electroneurophysiology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangdong, China
| | - Jian Zhang
- Clinical Physiology Laboratory, Capital Institute of Pediatrics, Beijing, China
| | - Haiyan Liao
- Clinical Physiology Laboratory, Capital Institute of Pediatrics, Beijing, China
| | - Siyuan Xie
- Clinical Physiology Laboratory, Capital Institute of Pediatrics, Beijing, China
| | - Zhen Suo
- Department of Echocardiography, Lhasa People's Hospital, Lhasa, Tibet, China
| | - Haiying Qi
- Department of Echocardiography, Qinghai Women's and Children' Hospital, Xining, Qinghai, China
| | - Zhen Yu
- NICU, Lhasa People's Hospital, Lhasa, Tibet, China
| | - Runling Shi
- NICU, Qinghai Women's and Children's Hospital, Xining, Qinghai, China
| | - Yanli Yao
- Clinical Physiology Laboratory, Capital Institute of Pediatrics, Beijing, China
| |
Collapse
|
3
|
Cho KHT, Hounsell N, McClendon E, Riddle A, Basappa, Dhillon SK, Bennet L, Back S, Sherman LS, Gunn AJ, Dean JM. Postischemic Infusion of Apigenin Reduces Seizure Burden in Preterm Fetal Sheep. Int J Mol Sci 2023; 24:16926. [PMID: 38069249 PMCID: PMC10706648 DOI: 10.3390/ijms242316926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/23/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
Seizures are common in preterm newborns and are associated with poor neurodevelopmental outcomes. Current anticonvulsants have poor efficacy, and many have been associated with upregulation of apoptosis in the developing brain. Apigenin, a natural bioactive flavonoid, is a potent inhibitor of hyaluronidase and reduces seizures in adult animal models. However, its impact on perinatal seizures is unclear. In the present study, we examined the effect of apigenin and S3, a synthetic, selective hyaluronidase inhibitor, on seizures after cerebral ischemia in preterm fetal sheep at 0.7 gestation (98-99 days, term ~147 days). Fetuses received sham ischemia (n = 9) or ischemia induced by bilateral carotid occlusion for 25 min. Immediately after ischemia, fetuses received either a continuous infusion of vehicle (0.036% dimethyl sulfoxide, n = 8) or apigenin (50 µM, n = 6). In a pilot study, we also tested infusion of S3 (2 µM, n = 3). Fetuses were monitored continuously for 72 h after ischemia. Infusion of apigenin or S3 were both associated with reduced numbers of animals with seizures, total seizure time, and mean seizure burden. S3 was also associated with a reduction in the total number of seizures over the 72 h recovery period. In animals that developed seizures, apigenin was associated with earlier cessation of seizures. However, apigenin or S3 treatment did not alter recovery of electroencephalographic power or spectral edge frequency. These data support that targeting brain hyaluronidase activity with apigenin or S3 may be an effective strategy to reduce perinatal seizures following ischemia. Further studies are required to determine their effects on neurohistological outcomes.
Collapse
Affiliation(s)
- Kenta H. T. Cho
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| | - Natalya Hounsell
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| | - Evelyn McClendon
- Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; (E.M.); (A.R.); (S.B.)
| | - Art Riddle
- Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; (E.M.); (A.R.); (S.B.)
| | - Basappa
- Laboratory of Chemical Biology, Department of Studies in Organic Chemistry, University of Mysore, Manasagangotri, Mysore 570006, India;
| | - Simerdeep K. Dhillon
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| | - Stephen Back
- Department of Pediatrics, Oregon Health & Science University, Portland, OR 97239, USA; (E.M.); (A.R.); (S.B.)
- Department of Neurology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Larry S. Sherman
- Division of Neuroscience, Oregon National Primate Research Center, Beaverton, OR 97006, USA;
- Department of Cell, Developmental and Cancer Biology, Oregon Health & Science University, Portland, OR 97239, USA
| | - Alistair J. Gunn
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| | - Justin M. Dean
- Department of Physiology, University of Auckland, Auckland 1142, New Zealand; (K.H.T.C.); (N.H.); (S.K.D.); (L.B.); (A.J.G.)
| |
Collapse
|
4
|
Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Anti-seizure medications for neonates with seizures. Cochrane Database Syst Rev 2023; 10:CD014967. [PMID: 37873971 PMCID: PMC10594593 DOI: 10.1002/14651858.cd014967.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Newborn infants are more prone to seizures than older children and adults. The neuronal injury caused by seizures in neonates often results in long-term neurodevelopmental sequelae. There are several options for anti-seizure medications (ASMs) in neonates. However, the ideal choice of first-, second- and third-line ASM is still unclear. Further, many other aspects of seizure management such as whether ASMs should be initiated for only-electrographic seizures and how long to continue the ASM once seizure control is achieved are elusive. OBJECTIVES 1. To assess whether any ASM is more or less effective than an alternative ASM (both ASMs used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 2. To assess maintenance therapy with ASM versus no maintenance therapy after achieving seizure control. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 3. To assess treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, Epistemonikos and three databases in May 2022 and June 2023. These searches were not limited other than by study design to trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that included neonates with EEG-confirmed or clinically diagnosed seizures and compared (1) any ASM versus an alternative ASM, (2) maintenance therapy with ASM versus no maintenance therapy, and (3) treatment of clinical or EEG seizures versus treatment of clinical seizures alone. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility, risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence interval (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 18 trials (1342 infants) in this review. Phenobarbital versus levetiracetam as first-line ASM in EEG-confirmed neonatal seizures (one trial) Phenobarbital is probably more effective than levetiracetam in achieving seizure control after first loading dose (RR 2.32, 95% CI 1.63 to 3.30; 106 participants; moderate-certainty evidence), and after maximal loading dose (RR 2.83, 95% CI 1.78 to 4.50; 106 participants; moderate-certainty evidence). However, we are uncertain about the effect of phenobarbital when compared to levetiracetam on mortality before discharge (RR 0.30, 95% CI 0.04 to 2.52; 106 participants; very low-certainty evidence), requirement of mechanical ventilation (RR 1.21, 95% CI 0.76 to 1.91; 106 participants; very low-certainty evidence), sedation/drowsiness (RR 1.74, 95% CI 0.68 to 4.44; 106 participants; very low-certainty evidence) and epilepsy post-discharge (RR 0.92, 95% CI 0.48 to 1.76; 106 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Phenobarbital versus phenytoin as first-line ASM in EEG-confirmed neonatal seizures (one trial) We are uncertain about the effect of phenobarbital versus phenytoin on achieving seizure control after maximal loading dose of ASM (RR 0.97, 95% CI 0.54 to 1.72; 59 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Maintenance therapy with ASM versus no maintenance therapy in clinically diagnosed neonatal seizures (two trials) We are uncertain about the effect of short-term maintenance therapy with ASM versus no maintenance therapy during the hospital stay (but discontinued before discharge) on the risk of repeat seizures before hospital discharge (RR 0.76, 95% CI 0.56 to 1.01; 373 participants; very low-certainty evidence). Maintenance therapy with ASM compared to no maintenance therapy may have little or no effect on mortality before discharge (RR 0.69, 95% CI 0.39 to 1.22; 373 participants; low-certainty evidence), mortality at 18 to 24 months (RR 0.94, 95% CI 0.34 to 2.61; 111 participants; low-certainty evidence), neurodevelopmental disability at 18 to 24 months (RR 0.89, 95% CI 0.13 to 6.12; 108 participants; low-certainty evidence) and epilepsy post-discharge (RR 3.18, 95% CI 0.69 to 14.72; 126 participants; low-certainty evidence). Treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates (two trials) Treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation (MD -1871.16, 95% CI -4525.05 to 782.73; 68 participants; low-certainty evidence), mortality before discharge (RR 0.59, 95% CI 0.28 to 1.27; 68 participants; low-certainty evidence) and epilepsy post-discharge (RR 0.75, 95% CI 0.12 to 4.73; 35 participants; low-certainty evidence). The trials did not report on mortality or neurodevelopmental disability at 18 to 24 months. We report data from the most important comparisons here; readers are directed to Results and Summary of Findings tables for all comparisons. AUTHORS' CONCLUSIONS Phenobarbital as a first-line ASM is probably more effective than levetiracetam in achieving seizure control after the first loading dose and after the maximal loading dose of ASM (moderate-certainty evidence). Phenobarbital + bumetanide may have little or no difference in achieving seizure control when compared to phenobarbital alone (low-certainty evidence). Limited data and very low-certainty evidence preclude us from drawing any reasonable conclusion on the effect of using one ASM versus another on other short- and long-term outcomes. In neonates who achieve seizure control after the first loading dose of phenobarbital, maintenance therapy compared to no maintenance ASM may have little or no effect on all-cause mortality before discharge, mortality by 18 to 24 months, neurodevelopmental disability by 18 to 24 months and epilepsy post-discharge (low-certainty evidence). In neonates with hypoxic-ischaemic encephalopathy, treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation, all-cause mortality before discharge and epilepsy post-discharge (low-certainty evidence). All findings of this review apply only to term and late preterm neonates. We need well-designed RCTs for each of the three objectives of this review to improve the precision of the results. These RCTs should use EEG to diagnose seizures and should be adequately powered to assess long-term neurodevelopmental outcomes. We need separate RCTs evaluating the choice of ASM in preterm infants.
Collapse
Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, KMCH Institute of Health Sciences and Research (KMCHIHSR), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Ronit Pressler
- Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
- Clinical Neurophysiology and Neonatology, Cambridge University Hospital, Cambridge, UK
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Francesco Brigo
- Neurology, Hospital of Merano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Merano-Meran, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano-Bozen, Italy
| | - Hans Hartmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| |
Collapse
|
5
|
Koster LK, Zamyadi R, Yan L, Payne ET, McBain KL, Dunkley BT, Hahn CD. Brain network properties of clinical versus subclinical seizures among critically ill children. Clin Neurophysiol 2023; 149:33-41. [PMID: 36878028 DOI: 10.1016/j.clinph.2023.02.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/16/2023] [Accepted: 02/05/2023] [Indexed: 02/17/2023]
Abstract
OBJECTIVE Electrographic seizures are common among critically ill children, and have been associated with worse outcomes. Despite their often-widespread cortical representation, most of these seizures remain subclinical, a phenomenon which remains poorly understood. We compared the brain network properties of clinical versus subclinical seizures to gain insight into their relative potential deleterious effects. METHODS Functional connectivity (phase lag index) and graph measures (global efficiency and clustering coefficients) were computed for 2178 electrographic seizures recorded during 48-hours of 19-channel continuous EEG monitoring obtained in 20 comatose children. Frequency-specific group differences in clinical versus subclinical seizures were analyzed using a non-parametric ANCOVA, adjusting for age, sex, medication exposure, treatment intensity and seizures per subject. RESULTS Clinical seizures demonstrated greater functional connectivity than subclinical seizures at alpha frequencies, but less connectivity than subclinical seizures at delta frequencies. Clinical seizures also demonstrated significantly higher median global efficiency than subclinical seizures (p < 0.01), and significantly higher median clustering coefficients across all electrodes at alpha frequencies. CONCLUSIONS Clinical expression of seizures correlates with greater alpha synchronization of distributed brain networks. SIGNIFICANCE The stronger global and local alpha-mediated functional connectivity observed during clinical seizures may indicate greater pathological network recruitment. These observations motivate further studies to investigate whether the clinical expression of seizures may influence their potential to cause secondary brain injury.
Collapse
Affiliation(s)
- Laura K Koster
- Division of Neurology, The Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Canada; Neurosciences & Mental Health Program, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Rouzbeh Zamyadi
- Neurosciences & Mental Health Program, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Luowei Yan
- Neurosciences & Mental Health Program, The Hospital for Sick Children Research Institute, Toronto, Canada
| | - Eric T Payne
- Department of Pediatrics, Section of Neurology, Alberta Children's Hospital and University of Calgary, Calgary, Canada
| | - Kristin L McBain
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Benjamin T Dunkley
- Neurosciences & Mental Health Program, The Hospital for Sick Children Research Institute, Toronto, Canada; Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Canada; Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Cecil D Hahn
- Division of Neurology, The Hospital for Sick Children and Department of Paediatrics, University of Toronto, Toronto, Canada; Neurosciences & Mental Health Program, The Hospital for Sick Children Research Institute, Toronto, Canada.
| |
Collapse
|
6
|
Pediatric Intensive Care Unit Patients: Sedation, Monitoring, and Neurodevelopmental Outcomes. J Neurosurg Anesthesiol 2023; 35:147-152. [PMID: 36745180 DOI: 10.1097/ana.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 12/12/2022]
Abstract
The design and conduct of pediatric sedation studies in critically ill patients have historically been challenging due to the complexity of the pediatric intensive care unit (PICU) environment and the difficulty of establishing equipoise. Clinical trials, for instance, represent 1 important means of advancing our knowledge in this field, but there is a paucity of such studies in the literature. Accounting for ground-level factors in planning for each trial phase (eg, enrollment, intervention, assessment, and follow-up) and the presence of broader system limitations is of key importance. In addition, there is a need for early planning, coordination, and obtaining buy-in from individual study sites and staff to ensure success, particularly for multicenter studies. This review synthesizes the current state of pediatric sedation research and the myriad of challenges in designing and conducting successful trials in this particular area. The review poses consideration for future research directions, including novel study designs, and discusses electroencephalography monitoring and neurodevelopmental outcomes of PICU survivors.
Collapse
|
7
|
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.
Collapse
|
8
|
Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Antiseizure medications for neonates with seizures. Hippokratia 2022. [DOI: 10.1002/14651858.cd014967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology; Kovai Medical Center and Hospital (KMCH); KMCH Institute of Health Sciences and Research; Coimbatore India
| | | | | | | | - Francesco Brigo
- Department of Neurological and Movement Sciences. Section of Clinical Neurology; University of Verona; Verona Italy
| | | |
Collapse
|
9
|
Verma V, Lange F, Bainbridge A, Harvey-Jones K, Robertson NJ, Tachtsidis I, Mitra S. Brain temperature monitoring in newborn infants: Current methodologies and prospects. Front Pediatr 2022; 10:1008539. [PMID: 36268041 PMCID: PMC9577084 DOI: 10.3389/fped.2022.1008539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/15/2022] [Indexed: 02/02/2023] Open
Abstract
Brain tissue temperature is a dynamic balance between heat generation from metabolism, passive loss of energy to the environment, and thermoregulatory processes such as perfusion. Perinatal brain injuries, particularly neonatal encephalopathy, and seizures, have a significant impact on the metabolic and haemodynamic state of the developing brain, and thereby likely induce changes in brain temperature. In healthy newborn brains, brain temperature is higher than the core temperature. Magnetic resonance spectroscopy (MRS) has been used as a viable, non-invasive tool to measure temperature in the newborn brain with a reported accuracy of up to 0.2 degrees Celcius and a precision of 0.3 degrees Celcius. This measurement is based on the separation of chemical shifts between the temperature-sensitive water peaks and temperature-insensitive singlet metabolite peaks. MRS thermometry requires transport to an MRI scanner and a lengthy single-point measurement. Optical monitoring, using near infrared spectroscopy (NIRS), offers an alternative which overcomes this limitation in its ability to monitor newborn brain tissue temperature continuously at the cot side in real-time. Near infrared spectroscopy uses linear temperature-dependent changes in water absorption spectra in the near infrared range to estimate the tissue temperature. This review focuses on the currently available methodologies and their viability for accurate measurement, the potential benefits of monitoring newborn brain temperature in the neonatal intensive care unit, and the important challenges that still need to be addressed.
Collapse
Affiliation(s)
- Vinita Verma
- Institute for Women's Health, University College London, London, United Kingdom
| | - Frederic Lange
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Alan Bainbridge
- Medical Physics and Engineering, University College London Hospital, London, United Kingdom
| | - Kelly Harvey-Jones
- Institute for Women's Health, University College London, London, United Kingdom
| | - Nicola J Robertson
- Institute for Women's Health, University College London, London, United Kingdom
| | - Ilias Tachtsidis
- Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, United Kingdom
| |
Collapse
|
10
|
Fung FW, Wang Z, Parikh DS, Jacobwitz M, Vala L, Donnelly M, Topjian AA, Xiao R, Abend NS. Electrographic Seizures and Outcome in Critically Ill Children. Neurology 2021; 96:e2749-e2760. [PMID: 33893203 PMCID: PMC8205469 DOI: 10.1212/wnl.0000000000012032] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 03/04/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the association between electroencephalographic seizure (ES) and electroencephalographic status epilepticus (ESE) exposure and unfavorable neurobehavioral outcomes in critically ill children with acute encephalopathy. METHODS This was a prospective cohort study of acutely encephalopathic critically ill children undergoing continuous EEG monitoring (CEEG). ES exposure was assessed as (1) no ES/ESE, (2) ES, or (3) ESE. Outcomes assessed at discharge included the Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds), Pediatric Cerebral Performance Category (PCPC), and mortality. Unfavorable outcome was defined as a reduction in GOS-E-Peds or PCPC score from preadmission to discharge. Stepwise selection was used to generate multivariate logistic regression models that assessed associations between ES exposure and outcomes while adjusting for multiple other variables. RESULTS Among 719 consecutive critically ill patients, there was no evidence of ES in 535 patients (74.4%), ES occurred in 140 patients (19.5%), and ESE in 44 patients (6.1%). The final multivariable logistic regression analyses included ES exposure, age dichotomized at 1 year, acute encephalopathy category, initial EEG background category, comatose at CEEG initiation, and Pediatric Index of Mortality 2 score. There was an association between ESE and unfavorable GOS-E-Peds (odds ratio 2.21, 95% confidence interval 1.07-4.54) and PCPC (odds ratio 2.17, 95% confidence interval 1.05-4.51) but not mortality. There was no association between ES and unfavorable outcome or mortality. CONCLUSIONS Among acutely encephalopathic critically ill children, there was an association between ESE and unfavorable neurobehavioral outcomes, but no association between ESE and mortality. ES exposure was not associated with unfavorable neurobehavioral outcomes or mortality.
Collapse
Affiliation(s)
- France W Fung
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA.
| | - Zi Wang
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Darshana S Parikh
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Marin Jacobwitz
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Lisa Vala
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Maureen Donnelly
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Alexis A Topjian
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Rui Xiao
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| | - Nicholas S Abend
- From the Departments of Neurology (F.F.W., N.S.A.), Pediatrics (F.F.W., N.S.A.), Biostatistics, Epidemiology and Informatics (Z.W., R.X.), and Anesthesia & Critical Care (A.A.T., N.S.A.) and Center for Clinical Epidemiology and Biostatistics (R.X., N.S.A.), Perelman School of Medicine at the University of Pennsylvania; and Departments of Pediatrics (Division of Neurology) (F.F.W., D.S.P., M.J., N.S.A.), Neurodiagnostics (L.V., M.D., N.S.A.), and Anesthesia and Critical Care Medicine (A.A.T.), Children's Hospital of Philadelphia, PA
| |
Collapse
|
11
|
Sandoval Karamian AG, Wusthoff CJ. Current and Future Uses of Continuous EEG in the NICU. Front Pediatr 2021; 9:768670. [PMID: 34805053 PMCID: PMC8595393 DOI: 10.3389/fped.2021.768670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/12/2021] [Indexed: 11/28/2022] Open
Abstract
Continuous EEG (cEEG) is a fundamental neurodiagnostic tool in the care of critically ill neonates and is increasingly recommended. cEEG enhances prognostication via assessment of the background brain activity, plays a role in predicting which neonates are at risk for seizures when combined with clinical factors, and allows for accurate diagnosis and management of neonatal seizures. Continuous EEG is the gold standard method for diagnosis of neonatal seizures and should be used for detection of seizures in high-risk clinical conditions, differential diagnosis of paroxysmal events, and assessment of response to treatment. High costs associated with cEEG are a limiting factor in its widespread implementation. Centralized remote cEEG interpretation, automated seizure detection, and pre-natal EEG are potential future applications of this neurodiagnostic tool.
Collapse
Affiliation(s)
| | - Courtney J Wusthoff
- Division of Child Neurology, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, United States
| |
Collapse
|
12
|
Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav 2019; 101:106409. [PMID: 31420288 DOI: 10.1016/j.yebeh.2019.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Pediatric status epilepticus carries a substantial risk for morbidity and mortality, but the relationship between seizure burden, treatment, and outcome remains incompletely understood. This review summarizes the evidence linking seizure burden and outcomes among critically ill children in the intensive care unit (ICU), a population in whom accurate quantification of seizure burden is possible using continuous electroencephalographic monitoring. Several high-quality observational studies among critically ill children have reported an association between higher seizure burden and worse outcome, even after adjusting for potential confounders such as age, etiology, and illness severity. Although these studies support the hypothesis that seizures contribute to brain injury and worsen outcome, a causal link between seizures and outcome remains to be proven. The relationship between seizures and outcome is likely complex, and dependent on factors such as etiology, preexisting neurological disability, medication exposure, and possibly individual genetic factors. Studies attempting to define this complex relationship will need to measure and account for these factors in their analyses. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
Collapse
|
13
|
Kline-Fath BM, Horn PS, Yuan W, Merhar S, Venkatesan C, Thomas CW, Schapiro MB. Conventional MRI scan and DTI imaging show more severe brain injury in neonates with hypoxic-ischemic encephalopathy and seizures. Early Hum Dev 2018; 122:8-14. [PMID: 29803998 DOI: 10.1016/j.earlhumdev.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/09/2018] [Accepted: 05/17/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neonates with hypoxic-ischemic encephalopathy (HIE) and seizures have poorer outcome for undetermined reasons. AIMS Our aim was to determine if brain imaging was more abnormal in neonates with HIE and electrographically confirmed seizures and whether this was impacted by seizure burden. STUDY DESIGN Single center retrospective review. SUBJECTS Forty-eight term neonates with HIE (with and without seizures) underwent MRI brain scans before age 14 days between the years 2008 and 2013. OUTCOME MEASURES Images were rated using a MRI injury score and fractional anisotropy (FA) values were extracted from diffusion tensor imaging (DTI). RESULTS The seizure group (n = 25) had significantly more injury within white matter, basal ganglia, posterior limb of internal capsule, and watershed areas compared to the group without seizures (n = 23). The severity of injury in all measured areas increased with increasing seizure severity. The seizure group also had lower FA values in posterior limb of the internal capsule and the splenium of corpus callosum. CONCLUSIONS Neonates with HIE and seizures had more brain injury that occurred in areas typically affected by HIE and was greater with higher seizure burden. Seizures may be a marker of more severe brain injury or seizures themselves may amplify brain damage from HIE.
Collapse
Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, USA
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Weihong Yuan
- Neuroimaging Research Consortium, Cincinnati Children's Hospital Medical Center, USA
| | - Stephanie Merhar
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Charu Venkatesan
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Cameron W Thomas
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA
| | - Mark B Schapiro
- Division of Neurology, Cincinnati Children's Hospital Medical Center, USA.
| |
Collapse
|
14
|
Outcomes following electrographic seizures and electrographic status epilepticus in the pediatric and neonatal ICUs. Curr Opin Neurol 2018; 30:156-164. [PMID: 28118303 DOI: 10.1097/wco.0000000000000425] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Increasing recognition of electrographic seizures and electrographic status epilepticus in critically ill neonates and children has highlighted the importance of identifying their potential contributions to neurological outcomes to guide optimal management. RECENT FINDINGS Recent studies in children and neonates have found an independent association between increasing seizure burden and worse short-term and long-term outcomes, even after adjusting for other important contributors to outcome such as seizure cause and illness severity. The risk of worse neurological outcome has been shown to increase above a seizure burden threshold of 12-13 min/h, which is considerably lower than the conventional definition of status epilepticus of 30 min/h. Randomized controlled trials in neonates have demonstrated that electroencephalography-targeted therapy can successfully reduce seizure burden, but due to their small size these trials have not been able to demonstrate that more aggressive electroencephalography-targeted treatment of both subclinical and clinical seizures results in improved outcome. SUMMARY Despite mounting evidence for an independent association between increasing seizure burden and worse outcome, further study is needed to determine whether early seizure identification and aggressive antiseizure treatment can improve neurodevelopmental outcomes.
Collapse
|
15
|
Young L, Berg M, Soll R. Prophylactic barbiturate use for the prevention of morbidity and mortality following perinatal asphyxia. Cochrane Database Syst Rev 2016; 2016:CD001240. [PMID: 27149645 PMCID: PMC8520740 DOI: 10.1002/14651858.cd001240.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Seizures are common following perinatal asphyxia and may exacerbate secondary neuronal injury. Barbiturate therapy has been used for infants with perinatal asphyxia in order to prevent seizures. However, barbiturate therapy may adversely affect neurodevelopment leading to concern regarding aggressive use in neonates. OBJECTIVES To determine the effect of administering prophylactic barbiturate therapy on death or neurodevelopmental disability in term and late preterm infants following perinatal asphyxia. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 11), MEDLINE via PubMed (1966 to 30 November 2015), EMBASE (1980 to 30 November 2015), and CINAHL (1982 to 30 November 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials (RCT) and quasi-RCTs. SELECTION CRITERIA We included all RCTs or quasi-RCTs of prophylactic barbiturate therapy in term and late preterm infants without clinical or electroencephalographic evidence of seizures compared to controls following perinatal asphyxia. DATA COLLECTION AND ANALYSIS Three review authors independently selected, assessed the quality of, and extracted data from the included studies. We assessed methodologic quality and validity of studies without consideration of the results. The review authors independently extracted data and performed meta-analyses using risk ratios (RR) and risk differences (RD) for dichotomous data and mean difference for continuous data with 95% confidence intervals (CI). For significant results, we calculated the number needed to treat for an additional beneficial outcome (NNTB) or for an additional harmful outcome (NNTH). MAIN RESULTS In this updated review, we identified nine RCTs of any barbiturate therapy in term and late preterm infants aged less than three days old with perinatal asphyxia without evidence of seizures. Eight of these studies compared prophylactic barbiturate therapy to conventional treatment (enrolling 439 infants) and one study compared barbiturate therapy to treatment with phenytoin (enrolling 17 infants). Prophylactic barbiturate therapy versus conventional treatment: one small trial reported a decreased risk of death or severe neurodevelopmental disability for barbiturate therapy (phenobarbital) versus conventional treatment (RR 0.33, 95% CI 0.14 to 0.78; RD -0.55, 95% CI -0.84 to -0.25; NNTB 2, 95% CI 1 to 4; 1 study, 31 infants) (very low quality evidence).Eight trials comparing prophylactic barbiturate therapy with conventional treatment following perinatal asphyxia demonstrated no significant impact on the risk of death (typical RR 0.88, 95% CI 0.55 to 1.42; typical RD -0.02, 95% CI -0.08 to 0.05; 8 trials, 429 infants) (low quality evidence) and the one small trial noted above reported a significant decrease in the risk of severe neurodevelopmental disability (RR 0.24, 95% CI 0.06 to 0.92; RD -0.43, 95% CI -0.73 to -0.13; NNTB 2, 95% CI 1 to 8; 1 study, 31 infants) (very low quality evidence).A meta-analysis of the six trials reporting on seizures in the neonatal period demonstrated a statistically significant reduction in seizures in the prophylactic barbiturate group versus conventional treatment (typical RR 0.62, 95% CI 0.48 to 0.81; typical RD -0.18, 95% CI -0.27 to -0.09; NNTB 5, 95% CI 4 to 11; 6 studies, 319 infants) (low quality evidence). There were similar results in subgroup analyses based on type of barbiturate and Sarnat score. Prophylactic barbiturate therapy versus other prophylactic anticonvulsant therapy: one study reported on prophylactic barbiturate versus prophylactic phenytoin. There was no significant difference in seizure activity in the neonatal period between the two study groups (RR 0.89, 95% CI 0.07 to 12.00; 1 trial, 17 infants). AUTHORS' CONCLUSIONS We found only low or very low quality evidence addressing the use of prophylactic barbiturates in infants with perinatal asphyxia. Although the administration of prophylactic barbiturate therapy to infants following perinatal asphyxia did reduce the risk of seizures, there was no reduction seen in mortality and there were few data addressing long-term outcomes. The administration of prophylactic barbiturate therapy for late preterm and term infants in the immediate period following perinatal asphyxia cannot be recommended for routine clinical practice. If used at all, barbiturates should be reserved for the treatment of seizures. The results of the current review support the use of prophylactic barbiturate therapy as a promising area of research. Future studies should be of sufficient size and duration to detect clinically important reductions in mortality and severe neurodevelopmental disability and should be conducted in the context of the current standard of care, including the use of therapeutic hypothermia.
Collapse
Affiliation(s)
- Leslie Young
- University of Vermont Medical CenterDivision of Neonatal‐Perinatal Medicine111 Colchester AvenueSmith 5BurlingtonVermontUSA05401
| | - Marie Berg
- University of Vermont Medical CenterDivision of Neonatal‐Perinatal Medicine111 Colchester AvenueSmith 5BurlingtonVermontUSA05401
| | - Roger Soll
- University of Vermont Medical CenterDivision of Neonatal‐Perinatal Medicine111 Colchester AvenueSmith 5BurlingtonVermontUSA05401
| | | |
Collapse
|
16
|
Park EJ, Otaduy MCG, Lyra KPD, Andrade CS, Castro LHM, Passarelli V, Valerio RMF, Jorge CL, Tsunemi MH, Leite CDC. Extratemporal abnormalities in phosphorus magnetic resonance spectroscopy of patients with mesial temporal sclerosis. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:93-8. [DOI: 10.1590/0004-282x20160005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/26/2015] [Indexed: 11/22/2022]
Abstract
ABSTRACT Objective We evaluated extratemporal metabolic changes with phosphorus magnetic resonance spectroscopy (31P-MRS) in patients with unilateral mesial temporal sclerosis (MTS). Method 31P-MRS of 33 patients with unilateral MTS was compared with 31 controls. The voxels were selected in the anterior, posterior insula-basal ganglia (AIBG, PIBG) and frontal lobes (FL). Relative values of phosphodiesters- PDE, phosphomonoesters-PME, inorganic phosphate - Pi, phosphocreatine- PCr, total adenosine triphosphate [ATPt = γ- + a- + b-ATP] and the ratios PCr/ATPt, PCr/γ-ATP, PCr/Pi and PME/PDE were obtained. Results We found energetic abnormalities in the MTS patients compared to the controls with Pi reduction bilaterally in the AIBG and ipsilaterally in the PIBG and the contralateral FL; there was also decreased PCr/γ-ATP in the ipsilateral AIBG and PIBG. Increased ATPT in the contralateral AIBG and increased γ-ATP in the ipsilateral PIBG were detected. Conclusion Widespread energy dysfunction was detected in patients with unilateral MTS.
Collapse
|
17
|
Mitra S, Bale G, Mathieson S, Uria-Avellanal C, Meek J, Tachtsidis I, Robertson NJ. Changes in Cerebral Oxidative Metabolism during Neonatal Seizures Following Hypoxic-Ischemic Brain Injury. Front Pediatr 2016; 4:83. [PMID: 27559538 PMCID: PMC4978952 DOI: 10.3389/fped.2016.00083] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/27/2016] [Indexed: 01/01/2023] Open
Abstract
Seizures are common following hypoxic-ischemic brain injury in newborn infants. Prolonged or recurrent seizures have been shown to exacerbate neuronal damage in the developing brain; however, the precise mechanism is not fully understood. Cytochrome-c-oxidase is responsible for more than 90% of ATP production inside mitochondria. Using a novel broadband near-infrared spectroscopy system, we measured the concentration changes in the oxidation state of cerebral cytochrome-c-oxidase (Δ[oxCCO]) and hemodynamics during recurrent neonatal seizures following hypoxic-ischemic encephalopathy in a newborn infant. A rapid increase in Δ[oxCCO] was noted at the onset of seizures along with a rise in the baseline of amplitude-integrated electroencephalogram. Cerebral oxygenation and cerebral blood volume fell just prior to the seizure onset but recovered rapidly during seizures. Δ[oxCCO] during seizures correlated with changes in mean electroencephalogram voltage indicating an increase in neuronal activation and energy demand. The progressive decline in the Δ[oxCCO] baseline during seizures suggests a progressive decrease of mitochondrial oxidative metabolism.
Collapse
Affiliation(s)
- Subhabrata Mitra
- Department of Neonatology, Institute for Women's Health, University College London , London , UK
| | - Gemma Bale
- Department of Medical Physics and Biomedical Engineering, University College London , London , UK
| | - Sean Mathieson
- Department of Neonatology, Institute for Women's Health, University College London , London , UK
| | - Cristina Uria-Avellanal
- Department of Neonatology, Institute for Women's Health, University College London , London , UK
| | - Judith Meek
- Department of Neonatology, Institute for Women's Health, University College London , London , UK
| | - Ilias Tachtsidis
- Department of Medical Physics and Biomedical Engineering, University College London , London , UK
| | - Nicola J Robertson
- Department of Neonatology, Institute for Women's Health, University College London , London , UK
| |
Collapse
|
18
|
Thordstein M. Potentials with potential. Acta Paediatr 2015; 104:112-3. [PMID: 25610993 DOI: 10.1111/apa.12912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Magnus Thordstein
- Clinical Neurophysiology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|
19
|
Kang SK, Kadam SD. Neonatal Seizures: Impact on Neurodevelopmental Outcomes. Front Pediatr 2015; 3:101. [PMID: 26636052 PMCID: PMC4655485 DOI: 10.3389/fped.2015.00101] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/05/2015] [Indexed: 11/24/2022] Open
Abstract
Neonatal period is the most vulnerable time for the occurrence of seizures, and neonatal seizures often pose a clinical challenge both for their acute management and frequency of associated long-term co-morbidities. Etiologies of neonatal seizures are known to play a primary role in the anti-epileptic drug responsiveness and the long-term sequelae. Recent studies have suggested that burden of acute recurrent seizures in neonates may also impact chronic outcomes independent of the etiology. However, not many studies, either clinical or pre-clinical, have addressed the long-term outcomes of neonatal seizures in an etiology-specific manner. In this review, we briefly review the available clinical and pre-clinical research for long-term outcomes following neonatal seizures. As the most frequent cause of acquired neonatal seizures, we focus on the studies evaluating long-term effects of HIE-seizures with the goal to evaluate (1) what parameters evaluated during acute stages of neonatal seizures can reliably be used to predict long-term outcomes? and (2) what available clinical and pre-clinical data are available help determine importance of etiology vs. seizure burdens in long-term sequelae.
Collapse
Affiliation(s)
- Seok Kyu Kang
- Neuroscience Laboratory, Hugo Moser Research Institute at Kennedy Krieger , Baltimore, MD , USA
| | - Shilpa D Kadam
- Neuroscience Laboratory, Hugo Moser Research Institute at Kennedy Krieger , Baltimore, MD , USA ; Department of Neurology, Johns Hopkins University School of Medicine , Baltimore, MD , USA
| |
Collapse
|
20
|
Inoue T, Shimizu M, Hamano SI, Murakami N, Nagai T, Sakuta R. Epilepsy and West syndrome in neonates with hypoxic-ischemic encephalopathy. Pediatr Int 2014; 56:369-72. [PMID: 24274080 DOI: 10.1111/ped.12257] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 09/30/2013] [Accepted: 10/25/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Perinatal hypoxic-ischemic encephalopathy (HIE) has been linked to the development of late-onset seizures. The aim of the present study was to determine the incidence of epilepsy and West syndrome in children with perinatal HIE and identify factors associated with the development of postnatal seizure disorders. METHODS We retrospectively enrolled 208 term and late-preterm infants diagnosed with perinatal HIE from April 2000 to March 2009 at Saitama Children's Medical Center. Children with obvious multiple anomalies and known chromosomal abnormalities were excluded. A questionnaire was distributed to parents to determine seizure-related outcomes. Medical records were retrospectively reviewed and relevant clinical parameters were analyzed. RESULTS In total, 162 questionnaires were answered (77.9%). Of the 162 subjects, 26 (16.0%) developed epilepsy, and eight subjects (4.9%) were diagnosed with West syndrome. Neonatal seizures occurred in 72 subjects (44.4%). The incidence of epilepsy and West syndrome was significantly higher in infants who experienced neonatal seizures than in those without seizure history. A total of 82 subjects were diagnosed with moderate (n = 52) or severe HIE (n = 30), of whom 57 subjects (69.5%) received therapeutic hypothermia. The incidence of epilepsy was significantly lower in these treated subjects. In addition, subjects with moderate or severe HIE were significantly more likely to develop late-onset epilepsy and West syndrome than those with mild HIE. CONCLUSIONS The severity of perinatal HIE and neonatal seizures is a potential risk factor for the development of late-onset seizures. Therapeutic hypothermia may reduce the risk of the development of epilepsy in such cases.
Collapse
Affiliation(s)
- Takeshi Inoue
- Department of Pediatrics, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Japan; Division of Neonatology, Saitama Children's Medical Center, Saitama, Japan
| | | | | | | | | | | |
Collapse
|
21
|
Abend NS, Wusthoff CJ, Goldberg EM, Dlugos DJ. Electrographic seizures and status epilepticus in critically ill children and neonates with encephalopathy. Lancet Neurol 2014; 12:1170-9. [PMID: 24229615 DOI: 10.1016/s1474-4422(13)70246-1] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Electrographic seizures are seizures that are evident on EEG monitoring. They are common in critically ill children and neonates with acute encephalopathy. Most electrographic seizures have no associated clinical changes, and continuous EEG monitoring is necessary for identification. The effect of electrographic seizures on outcome is the focus of active investigation. Studies have shown that a high burden of electrographic seizures is associated with worsened clinical outcome after adjustment for cause and severity of brain injury, suggesting that a high burden of such seizures might independently contribute to secondary brain injury. Further research is needed to determine whether identification and management of electrographic seizures reduces secondary brain injury and improves outcome in critically ill children and neonates.
Collapse
Affiliation(s)
- Nicholas S Abend
- Departments of Neurology and Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | |
Collapse
|
22
|
Srinivasakumar P, Zempel J, Wallendorf M, Lawrence R, Inder T, Mathur A. Therapeutic hypothermia in neonatal hypoxic ischemic encephalopathy: electrographic seizures and magnetic resonance imaging evidence of injury. J Pediatr 2013; 163:465-70. [PMID: 23452588 DOI: 10.1016/j.jpeds.2013.01.041] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 12/20/2012] [Accepted: 01/22/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the electrographic seizure burden in neonates with hypoxic ischemic encephalopathy (HIE) treated with or without therapeutic hypothermia and stratified results by severity of HIE and severity of injury as assessed by magnetic resonance imaging (MRI). STUDY DESIGN Between 2007 and 2011, video-electroencephalography (EEG) monitoring was initiated in neonates with moderate to severe HIE. Seizure burden (in seconds) was calculated, and brain MRI scans were quantitatively scored. Data were analyzed by ANOVA, the Student t test, and the χ(2) test. RESULTS Sixty-nine neonates with moderate or severe HIE were prospectively enrolled, including 51 who received therapeutic hypothermia and 18 who did not. The mean duration of video-EEG monitoring was longer in the therapeutic hypothermia group (72 ± 34 hours vs 48 ± 34 hours; P = .01). The therapeutic hypothermia group had a lower electrographic seizure burden (log units) after controlling for injury, as assessed by MRI (2.9 ± 0.6 vs 6.2 ± 0.9; P = .003). A reduction in seizure burden was seen in neonates with moderate HIE (P = .0001), but not in those with severe HIE (P = .80). Among neonates with injury assessed by MRI, seizure burden was lower in those with mild (P = .0004) and moderate (P = .02) injury, but not in those with severe injury (P = .90). CONCLUSION Therapeutic hypothermia was associated with reduced electrographic seizure burden in neonatal HIE. This effect was detected on video-EEG in infants with moderate HIE, but not in those with severe HIE. When stratified by injury as assessed by MRI, therapeutic hypothermia was associated with a reduced seizure burden in infants with mild and moderate injury, but not in those with severe injury.
Collapse
|
23
|
Regulation of ClC-2 gating by intracellular ATP. Pflugers Arch 2013; 465:1423-37. [PMID: 23632988 PMCID: PMC3778897 DOI: 10.1007/s00424-013-1286-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/18/2013] [Accepted: 04/18/2013] [Indexed: 12/27/2022]
Abstract
ClC-2 is a voltage-dependent chloride channel that activates slowly at voltages negative to the chloride reversal potential. Adenosine triphosphate (ATP) and other nucleotides have been shown to bind to carboxy-terminal cystathionine-ß-synthase (CBS) domains of ClC-2, but the functional consequences of binding are not sufficiently understood. We here studied the effect of nucleotides on channel gating using single-channel and whole-cell patch clamp recordings on transfected mammalian cells. ATP slowed down macroscopic activation and deactivation time courses in a dose-dependent manner. Removal of the complete carboxy-terminus abolishes the effect of ATP, suggesting that CBS domains are necessary for ATP regulation of ClC-2 gating. Single-channel recordings identified long-lasting closed states of ATP-bound channels as basis of this gating deceleration. ClC-2 channel dimers exhibit two largely independent protopores that are opened and closed individually as well as by a common gating process. A seven-state model of common gating with altered voltage dependencies of opening and closing transitions for ATP-bound states correctly describes the effects of ATP on macroscopic and microscopic ClC-2 currents. To test for a potential pathophysiological impact of ClC-2 regulation by ATP, we studied ClC-2 channels carrying naturally occurring sequence variants found in patients with idiopathic generalized epilepsy, G715E, R577Q, and R653T. All naturally occurring sequence variants accelerate common gating in the presence but not in the absence of ATP. We propose that ClC-2 uses ATP as a co-factor to slow down common gating for sufficient electrical stability of neurons under physiological conditions.
Collapse
|
24
|
Abstract
Neonatal seizures can be difficult to recognize given the variation in their presentation. Hence, diagnosis and appropriate treatment may be delayed. Morphology of seizures in this age group is discussed, followed by common etiological entities. Special emphasis is laid on treatable disease states such as vitamin responsive seizure disorders and benign conditions that may not warrant aggressive treatment. Conditions that may have devastating neurological consequences are discussed in some detail so that the treating pediatrician can provide realistic information to the parents of such newborns. Imaging and laboratory workup is outlined, followed by guidelines for ordering and interpreting an electroencephalogram in this age group. Finally, treatment options in the form of antiepileptics are discussed with mention of new avenues for diagnosis and treatment that may become commonly employed in the future.
Collapse
Affiliation(s)
- Lalitha Sivaswamy
- Department of Neurology, Children’s Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201, USA.
| |
Collapse
|
25
|
Abstract
Identifying the specific etiology of epilepsy is often difficult. The search for the cause often leads the clinician to suspect inborn errors of intermediary metabolism and other degenerative metabolic diseases. Although these uncommon diseases are often difficult to determine, a correct diagnosis is critical for treatment and genetic counseling. A review of the relevant biochemistry will aid in understanding the pathophysiology of seizures in these conditions. The stream-lined approach to the initial laboratory evaluation that is offered will enable the clinician to screen for most metabolic and degenerative diseases that are associated with epilepsy.
Collapse
Affiliation(s)
- B H Cohen
- Section of Pediatric Neurology, Cleveland Clinic Foundation, Ohio 44195
| |
Collapse
|
26
|
Abstract
Seizures are more prevalent during the neonatal period than at any other time in the human lifespan. During early development, neonates are developmentally predisposed to excitatory neuronal activity increasing their susceptibility to seizures. Status epilepticus is poorly defined in this subpopulation with a lack of a consensus definition. In this review, we discuss the common etiologies of recurrent seizures in the newborn in addition to current trends on monitoring and treatment. Finally, we discuss the current evidence in both animal and human studies that indicate that neonatal seizures may be harmful to the immature brain with adverse long-term neurodevelopment outcomes.
Collapse
|
27
|
Glass HC, Glidden D, Jeremy RJ, Barkovich AJ, Ferriero DM, Miller SP. Clinical Neonatal Seizures are Independently Associated with Outcome in Infants at Risk for Hypoxic-Ischemic Brain Injury. J Pediatr 2009; 155:318-23. [PMID: 19540512 PMCID: PMC3014109 DOI: 10.1016/j.jpeds.2009.03.040] [Citation(s) in RCA: 280] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 02/02/2009] [Accepted: 03/19/2009] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To examine whether neonatal seizures are associated with neurodevelopmental outcomes in infants with hypoxia-ischemia independent of the presence and severity of brain injury seen on magnetic resonance imaging (MRI). STUDY DESIGN We used multivariate regression to examine the independent effect of clinical neonatal seizures and their treatment on neurodevelopment in 77 term newborns at risk for hypoxic-ischemic brain injury. Clinical seizures were recorded prospectively, and high-resolution newborn MRI measured the severity of brain injury. The outcome measure was the Full-Scale Intelligence Quotient (FSIQ) of the Wechsler Preschool and Primary Scale of Intelligence-Revised and neuromotor score at age 4 years. RESULTS After controlling for severity of injury on MRI, the children with neonatal seizures had worse motor and cognitive outcomes compared with those without seizures. The magnitude of effect varied with seizure severity; children with severe seizures had a lower FSIQ than those with mild/moderate seizures (P < .0001). CONCLUSIONS Clinical neonatal seizures in the setting of birth asphyxia are associated with worse neurodevelopmental outcome, independent of the severity of hypoxic-ischemic brain injury. Randomized controlled trials are needed to determine whether differences in seizure treatment can improve outcome.
Collapse
Affiliation(s)
- Hannah C Glass
- Department of Neurology, University of California San Francisco, San Francisco, CA 94143-0663, USA.
| | | | | | | | | | | |
Collapse
|
28
|
Lawrence R, Mathur A, Nguyen The Tich S, Zempel J, Inder T. A pilot study of continuous limited-channel aEEG in term infants with encephalopathy. J Pediatr 2009; 154:835-41.e1. [PMID: 19230897 DOI: 10.1016/j.jpeds.2009.01.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Revised: 12/30/2008] [Accepted: 01/05/2009] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the accuracy, feasibility, and impact of limited-channel amplitude integrated electroencephalogram (aEEG) monitoring in encephalopathic infants. STUDY DESIGN Encephalopathic infants were placed on limited-channel aEEG with a software-based seizure event detector for 72 hours. A 12-hour epoch of conventional EEG-video (cEEG) was simultaneously collected. Infants were randomly assigned to monitoring that was blinded or visible to the clinical team. If a seizure detection event occurred in the visible group, the clinical team interpreted whether the event was a seizure, based on review of the limited-channel aEEG. EEG data were reviewed independently offline. RESULTS In more than 68 hours per infant of limited-channel aEEG monitoring, 1116 seizures occurred (>90% clinically silent), with 615 detected by the seizure event detector (55%). Detection improved with increasing duration of seizures (73% >30 seconds, 87% >60 seconds). Bedside physicians were able to accurately use this algorithm to differentiate true seizures from false-positives. The visible group had a 52% reduction in seizure burden (P = .114) compared with the blinded group. CONCLUSIONS Monitoring for seizures with limited-channel aEEG can be accurately interpreted, compares favorably with cEEG, and is associated with a trend toward reduced seizure burden.
Collapse
Affiliation(s)
- Russell Lawrence
- Department of Pediatrics, St Louis Children's Hospital, Washington University, St Louis, MO 63110, USA.
| | | | | | | | | |
Collapse
|
29
|
Pisani F, Orsini M, Braibanti S, Copioli C, Sisti L, Turco EC. Development of epilepsy in newborns with moderate hypoxic-ischemic encephalopathy and neonatal seizures. Brain Dev 2009; 31:64-8. [PMID: 18490125 DOI: 10.1016/j.braindev.2008.04.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2008] [Revised: 03/30/2008] [Accepted: 04/04/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Hypoxic-ischemic encephalopathy (HIE) is one of the most frequent causes of neonatal death or neurological handicaps such as cerebral palsy, mental delay, and epilepsy. Moreover, an acute consequence of HIE are neonatal seizures which can cause an additional brain damage. The neurodevelopmental outcome is known in the mild or severe cases of HIE, but in the moderate conditions the predictivity results, to date, unsatisfying. OBJECTIVE The purpose of this prospective study was to appraise the development of post-neonatal epilepsy in a cohort of term infants with moderate HIE and neonatal seizures. METHODS This study considered all newborns admitted to Neonatal Intensive Care Unit of the University of Parma between January 2000 and December 2002 for perinatal asphyxia, then followed by Neonatal Neurology Service. In all patients, neonatal variables such as type of delivery, birth weight, gestational age, Apgar scores, the need for resuscitation and assisted ventilation soon after birth, and arterial-blood pH were analyzed. RESULTS Ninety-two newborns were enrolled in the study because of perinatal asphyxia. Of these, 27 subjects developed mild HIE, 25 moderate, and five severe HIE. Neonatal seizures were present in 13 subjects with moderate HIE and in all newborns with severe HIE. At the last follow-up, only three infants belonging to patients with severe HIE developed epilepsy. CONCLUSION Moderate HIE seems not to be related to post-neonatal epilepsy either if associated or not with neonatal seizures.
Collapse
Affiliation(s)
- Francesco Pisani
- Child Neuropsychiatric Unit, Department of Neonatology, University of Parma, Via Gramsci, 14, 43100 Parma, Italy.
| | | | | | | | | | | |
Collapse
|
30
|
Sirsi D, Nangia S, LaMothe J, Kosofsky BE, Solomon GE. Successful management of refractory neonatal seizures with midazolam. J Child Neurol 2008; 23:706-9. [PMID: 18539997 DOI: 10.1177/0883073807313041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Seizures are indicative of underlying neurologic dysfunction in neonates. Repeated seizures may be deleterious to the brain even without disturbances of ventilation or perfusion. First-line antiepileptic drugs such as phenobarbital and phenytoin are not very effective in controlling seizures in neonates. Rapid control of status epilepticus with midazolam has been demonstrated in 2 previous studies with complete clinical and electrographic response in neonates who did not respond to phenobarbital and phenytoin. We report our experience with 3 neonates with status epilepticus. Seizures in all 3 neonates did not respond to phenobarbital and phenytoin but responded to midazolam infusion. Midazolam may be considered a safe and effective antiepileptic drug in refractory neonatal seizures of diverse etiologies.
Collapse
Affiliation(s)
- Deepa Sirsi
- Division of Pediatric Neurology, Department of Pediatrics, New York Presbyterian Hospital-Weill Cornell Medical College, New York, NY 10021, USA
| | | | | | | | | |
Collapse
|
31
|
van Rooij LGM, de Vries LS, Handryastuti S, Hawani D, Groenendaal F, van Huffelen AC, Toet MC. Neurodevelopmental outcome in term infants with status epilepticus detected with amplitude-integrated electroencephalography. Pediatrics 2007; 120:e354-63. [PMID: 17671044 DOI: 10.1542/peds.2006-3007] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study evaluated seizure, patient characteristics, and neurodevelopmental outcome of term newborns with amplitude-integrated electroencephalography-detected status epilepticus. METHODS Fifty-six term infants with status epilepticus were identified during a 12.5-year period. The time of onset of status epilepticus, background pattern before and after status epilepticus, success of controlling status epilepticus with antiepileptic drugs, and neurodevelopmental outcome were studied. RESULTS The incidence of status epilepticus in our population was 18%. Forty-two infants (75%) had a poor outcome and 14 were normal at follow-up. When all infants were studied as a single group, we found that not the duration, but the background pattern was correlated with neurodevelopmental outcome. In 50% of the infants with a poor outcome, the background pattern was abnormal before the status epilepticus and in 71% after the status epilepticus. Among infants with a good outcome, background pattern was normal in 14% before and 7% after the status epilepticus. In a subgroup of 48 infants with hypoxic-ischemic encephalopathy, there was a significant difference in background pattern, as well as in duration of the status epilepticus between infants with a poor outcome, compared with those with a good outcome. In 48% of the infants with a poor outcome, the background pattern was abnormal before, and in 75% after the status epilepticus, compared with 25% and 13%, respectively, for those with a good outcome. In 57% of the infants with a hemorrhage or perinatal arterial stroke, the status epilepticus was not controlled with antiepileptic drugs, compared with 21% in infants with hypoxic-ischemic encephalopathy (not significant). CONCLUSIONS The background pattern at the onset of status epilepticus was the main predictor of neurodevelopmental outcome. The duration of the status epilepticus was only of predictive value in the infants with hypoxic-ischemic encephalopathy. No association was found between the ability to control status epilepticus and subsequent neurodevelopmental outcome.
Collapse
Affiliation(s)
- Linda G M van Rooij
- Department of Neonatology, Wilhelmina Children's Hospital, 3508 AB Utrecht, The Netherlands
| | | | | | | | | | | | | |
Collapse
|
32
|
Nguyen The Tich S, d'Allest AM, Touzery de Villepin A, de Belliscize J, Walls-Esquivel E, Salefranque F, Lamblin MD. [Pathological patterns in neonatal EEG before 30 weeks of gestational age]. Neurophysiol Clin 2007; 37:177-221. [PMID: 17889793 DOI: 10.1016/j.neucli.2007.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Accepted: 06/24/2007] [Indexed: 11/19/2022] Open
Abstract
Pathological features on very premature EEG concern background abnormalities and abnormal patterns. Positive rolandic sharp waves keep an important place regarding diagnosis and prognosis. Background abnormalities give essential complementary informations. Unusual patterns (abnormal localisation or morphological aspect, high amplitude) remain early markers of cerebral lesions. Analysis of these pathological features must always take into account treatment given to the baby, which can by itself modify the EEG.
Collapse
|
33
|
Evans DJ, Levene MI, Tsakmakis M. Anticonvulsants for preventing mortality and morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev 2007:CD001240. [PMID: 17636659 DOI: 10.1002/14651858.cd001240.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Seizures are common following perinatal asphyxia and may exacerbate secondary neuronal injury by increasing cerebral metabolic demand, causing fluctuations in oxygenation and perfusion, and triggering the release of excitatory neurotransmitters. Anticonvulsant therapy has been used in infants with perinatal asphyxia in order to prevent seizures. However, long term anticonvulsant therapy may lead to inhibition of brain development. Therefore, the routine use of anticonvulsant therapy to prevent seizures following perinatal asphyxia needs to be evaluated. OBJECTIVES To assess the effect of administering anticonvulsants to infants of 37 weeks gestation or more following perinatal asphyxia on death or subsequent severe neurodevelopmental disability and/or the prevention of seizures. SEARCH STRATEGY Relevant randomised controlled trials were identified using a combination of electronic database searches, hand searches and a search of the Cochrane Controlled Trials Registry. SELECTION CRITERIA All randomised or quasi-randomised controlled clinical trials that reported data comparing the following outcomes: mortality, neurodevelopmental disability, neonatal seizures and adverse events, following anticonvulsant therapy in term infants (37 weeks or more) compared to controls (with or without placebo) following perinatal asphyxia. DATA COLLECTION AND ANALYSIS Methodological quality and validity of studies were assessed without consideration of the results. Data relevant to the outcome were extracted and analysed. MAIN RESULTS Seven randomised or quasi-randomised controlled trials that met the selection criteria were included. No studies were of sufficient methodological quality and size to demonstrate a valid, clinically significant change in the risk of mortality or severe neurodevelopmental disability. A meta-analysis combining five studies comparing barbiturates with conventional therapy following perinatal asphyxia demonstrated no difference in risks of death, severe neurodevelopmental disability, or the combined outcome of death or severe neurodevelopmental disability. AUTHORS' CONCLUSIONS At the present time, anticonvulsant therapy to term infants in the immediate period following perinatal asphyxia cannot be recommended for routine clinical practice, other than in the treatment of prolonged or frequent clinical seizures. Any future studies should be of sufficient size to have the power to detect clinically important reductions in mortality and severe neurodevelopmental disability.
Collapse
Affiliation(s)
- D J Evans
- Southmead Hospital, Neonatal Intensive Care Unit, Southmead Hospital, Bristol, UK, BS10 5NB.
| | | | | |
Collapse
|
34
|
Abstract
OBJECTIVE To survey anti-epileptic drug (AED) treatment of early-onset neonatal seizures by neonatologists and paediatric neurologists. METHODS A self-administered questionnaire was posted to Australian and New Zealand neonatologists and paediatric neurologists. Participants were given the hypothetical case of a full-term infant with early-onset seizures following perinatal asphyxia and asked to nominate their preferred AED for treatment of three seizure episodes during the first 24 h. RESULTS One hundred and seven (57%) of 187 individuals answered the questionnaire: neonatologists responded more often than neurologists (chi(2) (1,187) = 7.18, P = 0.007). Phenobarbitone was used by 95% of the respondents to treat the first episode of seizures and 75% of them used an appropriate loading dose (20 mg/kg). Phenobarbitone was used by 84 and 40% of the respondents to treat the second- and third-seizure episodes, respectively. Neonatologists used phenobarbitone, phenytoin and a benzodiazepine with equal frequency to treat a third episode of seizures, whereas neurologists rarely used a benzodiazepine. Neonatologists used significantly larger total doses of phenobarbitone than neurologists. Very few respondents used pyridoxine to treat recurrent seizures that were historically linked to perinatal asphyxia and hypoxic-ischaemic encephalopathy. Neonatologists were more likely than neurologists to discontinue AED within a few days of seizure cessation (chi(2) (1,106) = 11.60, P = 0.0006). CONCLUSIONS Australian and New Zealand neonatologists and paediatric neurologists generally use phenobarbitone to treat neonatal seizures presumed to be owing to hypoxic-ischaemic encephalopathy, though they do not always use appropriate doses. Neonatologists use phenobarbitone, phenytoin or a benzodiazepine for second and third episodes of seizures, whereas neurologists tend not to use benzodiazepines. Neonatologists use larger total doses of phenobarbitone than neurologists in pursuit of seizure control. Neonatologists discontinue AED earlier than neurologists.
Collapse
Affiliation(s)
- Kathryn Browning Carmo
- Department of Neonatology, Royal Alexandra Hospital for Children, Sydney, New South Wales, Australia
| | | |
Collapse
|
35
|
Toet MC, Groenendaal F, Osredkar D, van Huffelen AC, de Vries LS. Postneonatal epilepsy following amplitude-integrated EEG-detected neonatal seizures. Pediatr Neurol 2005; 32:241-7. [PMID: 15797180 DOI: 10.1016/j.pediatrneurol.2004.11.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2004] [Accepted: 11/08/2004] [Indexed: 10/25/2022]
Abstract
To assess the incidence of postneonatal epilepsy in term infants treated with antiepileptic drugs for neonatal seizure discharges that were detected with amplitude-integrated electroencephalography (aEEG), 206 term infants were monitored using this modality. They received antiepileptic drugs for clinical as well as subclinical neonatal seizures. Follow-up data were analyzed for the development of postneonatal epilepsy and for their neurodevelopmental outcome, assessed at 3, 9, 18 months, and 3 and 5 years of age. A total of 169 (82%) neonates received two or more antiepileptic drugs. Overall mortality was 39% (n = 80). Forty-one of the 126 survivors (33%) were abnormal at follow-up, and 12 of them developed postneonatal epilepsy (9.4%). Eighty-four children survived after hypoxic-ischemic encephalopathy grade II (n = 92), and 6 (7%) developed postneonatal epilepsy. In this subgroup, no postneonatal epilepsy was observed if seizures were controlled within 48 hours after birth and when not more than two antiepileptic drugs were required. Twenty-four children survived after an intracranial hemorrhage (n = 28), and only 1 (4%) developed postneonatal epilepsy. Eleven children survived after perinatal arterial stroke (n = 13), and 2 (18%) developed postneonatal epilepsy. In conclusion, the incidence of postneonatal epilepsy after treatment of clinical and subclinical neonatal seizures detected with continuous amplitude-integrated electroencephalography was 9.4%; This figure is lower than previously reported in children who only received treatment for clinical seizures.
Collapse
Affiliation(s)
- Mona C Toet
- Department of Neonatology, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | | | | | | |
Collapse
|
36
|
Abstract
1H and 31P spectroscopy detects relevant metabolite changes in patients with TLE. Numerous studies confirm reduction in NAA and in the ratio of PCr/Pi. In his 1999 review, Kuzniecky concluded that proton MRS, using single-voxel or chemical shift imaging, lateralizes temporal lobe epilepsy in 65% to 96% of cases, with bilateral changes seen in 35% to 45% of cases, whereas phosphorus MRS shows a lateralizing PCr/Pi ratio in 65% to 75% of the TLE patients. There are indications that these changes are reversible with seizure treatment. Improvements in MRS technology, such as the ability to calculate absolute concentrations, to account for differences be-tween gray and white matter and to achieve better spectral resolution by use of a higher magnetic field strength, will now allow more extensive use of this technique for patients with epilepsy.
Collapse
Affiliation(s)
- Ruben Kuzniecky
- NYU Comprehensive Epilepsy Center, New York University School of Medicine, 403 East 34th Street, New York, NY 10016, USA.
| |
Collapse
|
37
|
Abstract
BACKGROUND Neonatal seizures are a common problem and most neonates with seizures are treated with anticonvulsants. There is wide variation in clinical practice in both diagnosis and treatment of such seizures and this reflects the lack of clear evidence of the relative benefit and harm of the anticonvulsants used. The routine use of anticonvulsants to treat seizures in neonates needs to be evaluated. OBJECTIVES To assess and compare (with respect to benefits and harm) different anticonvulsants administered to neonates for the treatment of established seizures. SEARCH STRATEGY Relevant randomised controlled trials were identified using a combination of electronic database searches (MEDLINE 1966 - March 2004, EMBASE 1980 - March 2004), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004) and hand searches. Identification of ongoing or unpublished trials was attempted by contacting prominent authors in the field and searching electronic registers of ongoing trials. SELECTION CRITERIA All randomised or quasi-randomised controlled clinical trials with reported data comparing the following outcomes: mortality, neurodevelopmental disability, need for additional anticonvulsants, need for maintenance anticonvulsants at discharge and adverse events (hypotension requiring volume or inotropic support, arrhythmia, respiratory depression, hepatotoxicity) in neonates treated for seizures with systemic anticonvulsants compared to placebo, no drug or alternative anticonvulsants. DATA COLLECTION AND ANALYSIS Methodological quality and validity were assessed without consideration of the results. The first reviewer screened the title and abstracts of studies identified by the above search strategy. Full text versions of studies of potential relevance were re-screened by both reviewers. Studies meeting the pre-specified inclusion criteria were included. Relevant data were extracted and analysed separately and any disagreements were resolved by discussion. MAIN RESULTS Only two randomised controlled trials published in full could be identified. Painter 1999 showed that both of the two most commonly used anticonvulsants (phenobarbital and phenytoin) were similarly effective (RR 1.03 95% CI 0.96 to 1.62), controlling seizures in less than fifty percent of infants. Painter 1999 did not report mortality or neurodevelopmental outcome. Boylan 2004 randomised infants who failed to respond to phenobarbital to receive either lidocaine or midazolam as second-line agents. There was a trend for lidocaine to be more effective in reducing seizure burden (RR 0.40 95% CI 0.14 to 1.17) but both groups had similarly poor long term outcomes assessed at one year. REVIEWERS' CONCLUSIONS At present there is little evidence from randomised controlled trials to support the use of any of the anticonvulsants currently used in the neonatal period. In the literature, there remains a body of opinion that seizures should be treated because of the concern that seizures in themselves may be harmful, although this is only supported by relatively low grade evidence (Levene 2002; Massingale 1993). Development of safe and effective treatment strategies relies on future studies of high quality (randomised controlled trials with methodology that assures validity) and of sufficient size to have the power to detect clinically important reductions in mortality and severe neurodevelopmental disability in addition to any short term reduction in seizure burden.
Collapse
Affiliation(s)
- D Booth
- Peter Congdon Neonatal Unit, Clarendon Wing, Leeds General Infirmary, Leeds, West Yorkshire, UK, LS2 9NS.
| | | |
Collapse
|
38
|
Rubaj A, Zgodziński W, Sieklucka-Dziuba M. The epileptogenic effect of seizures induced by hypoxia: the role of NMDA and AMPA/KA antagonists. Pharmacol Biochem Behav 2003; 74:303-11. [PMID: 12479949 DOI: 10.1016/s0091-3057(02)00998-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypoxia of the brain may alter further seizure susceptibility in a different way. In this study, we tried to answer the question how episode of convulsion induced by hypoxia (HS) changes further seizure susceptibility, and how N-methyl-D-aspartic acid (NMDA) and AMPA/KA receptor antagonists influence this process. Adult Albino Swiss mice exposed to hypoxia (5% O(2)) developed clonic/tonic convulsions after about 340 s. Mice which underwent 10 s but not 5 s seizures episode subsequently exhibited significantly increased seizure susceptibility to low doses (equal ED(16)) of bicuculline (BCC) and NMDA during a 3-week observation period. No morphological signs of brain tissue damage were seen in light microscope on the third day after a hypoxia-induced seizure (HS). Learning abilities assessed in passive avoidance test as well as spontaneous alternation were not disturbed after an HS episode. Pretreatment with AMPA/KA receptor antagonist NBQX effectively prolonged latency to HS and given immediately after seizure episode also attenuated subsequent convulsive susceptibility rise, however, NMDA receptor antagonist, MK-801, appeared to be ineffective. These results suggest that a seizure episode induced by hypoxia, depending on its duration, may play an epileptogenic role. The AMPA/KA receptor antagonist prolongs the latency to HS, and given after this episode, prevents the long-term epileptogenic effect.
Collapse
Affiliation(s)
- Andrzej Rubaj
- Department of Cardiology, Medical University of Lublin, Jaczewskiego 8, 20-090 Lublin, Poland.
| | | | | |
Collapse
|
39
|
Mizrahi EM, Clancy RR. Neonatal seizures: early-onset seizure syndromes and their consequences for development. MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES RESEARCH REVIEWS 2001; 6:229-41. [PMID: 11107188 DOI: 10.1002/1098-2779(2000)6:4<229::aid-mrdd2>3.0.co;2-y] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The determination of the developmental consequences of seizure syndromes in the neonate is based upon a number of factors which include: understanding of the clinical and electroencephalographic (EEG) features of neonatal seizures; current theories of the mechanisms by which neonatal seizures are generated; a current classification of neonatal seizures; potential etiologic and risk factors for seizures; and therapies. In addition, different seizure types, mechanisms of generation and etiologies of cerebral dysfunction may vary with conceptional age of the infant. There are a few distinct neonatal epileptic syndromes, which are rare, have been well described: benign neonatal convulsions; benign neonatal familial convulsions; early myoclonic encephalopathy and early infantile epileptic encephalopathy. The prognosis for the first two is relatively good while the outcome for the other two with encephalopathy is catastrophic. However, the majority of neonatal seizures occur as acute, reactive events in association with a wide range of etiologic factors. These etiologic factors, as well as those of the more traditionally defined syndromes, are the main determinants of eventual developmental outcome of neonates who experience seizures. Although experimental data suggests that some epileptic seizures eventually may have physiological, histological, metabolic, or behavioral consequences, there is yet direct evidence in humans to suggest that the occurrence of seizures themselves in the neonate is the main determinant of long-term outcome.
Collapse
Affiliation(s)
- E M Mizrahi
- Section of Neurophysiology, Department of Neurology, and Section of Pediatric Neurology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030, USA.
| | | |
Collapse
|
40
|
|
41
|
Evans DJ, Levene MI. Anticonvulsants for preventing mortality and morbidity in full term newborns with perinatal asphyxia. Cochrane Database Syst Rev 2000:CD001240. [PMID: 11686984 DOI: 10.1002/14651858.cd001240] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the benefits and harm of administering anticonvulsants to infants of 37 weeks gestation or more following perinatal asphyxia with the primary aims of prevention of death or subsequent severe neurodevelopmental disability and/or the prevention of seizures. SEARCH STRATEGY Relevant randomised controlled trials were identified using a combination of electronic database searches (MEDLINE), hand searches and a search of the Neonatal Review Group trials register. SELECTION CRITERIA All randomised, or quasi-randomised, controlled clinical trials with reported data comparing the following outcomes: mortality, neurodevelopmental disability, neonatal seizures and adverse events, following anticonvulsant therapy in term infants (37 weeks or more), compared to controls with or without placebo, following perinatal asphyxia. DATA COLLECTION AND ANALYSIS Methodological quality and validity of studies were assessed without consideration of the results. Data relevant to the outcome were extracted and analysed. MAIN RESULTS Five randomised or quasi-randomised controlled trials which met the selection criteria were identified. No studies were of sufficient methodological quality and size to demonstrate a valid, clinically significant change in the risk of mortality or severe neurodevelopmental disability. A meta-analysis combining three studies comparing barbiturates with conventional therapy following perinatal asphyxia demonstrated no difference in risks of death, severe neurodevelopmental disability, or death or severe neurodevelopmental disability. REVIEWER'S CONCLUSIONS At the present time, anticonvulsant therapy to term infants in the immediate period following perinatal asphyxia cannot be recommended for routine clinical practice, other than in the treatment of prolonged or frequent clinical seizures. Any future studies should be of high quality: randomised control trials with allocation concealment, performance and outcome assessment blinding. Such studies should be of sufficient size, with minimal attrition, to have the power to detect clinically important reductions in mortality and severe neurodevelopmental disability, as the primary outcome measures.
Collapse
Affiliation(s)
- D J Evans
- Neonatal Intensive Care Unit, Southmead Hospital, Neonatal Intensive Care Unit, Southmead Hospital, Bristol, UK, BS10 5NB.
| | | |
Collapse
|
42
|
Walton NY, Nagy AK, Treiman DM. Altered residual ATP content in rat brain cortex subcellular fractions following status epilepticus induced by lithium and pilocarpine. J Mol Neurosci 1998; 11:233-42. [PMID: 10344793 DOI: 10.1385/jmn:11:3:233] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Changes in residual ATP concentrations were investigated following subcellular fractionation of rat brain cortex after a prolonged period of status epilepticus induced by sequential administration of lithium and pilocarpine. After 2 h of continuous high-amplitude rapid spiking on EEG, we found significantly decreased levels of residual ATP in the homogenate and mitochondria fractions from status epilepticus rat brains compared to matched controls. No difference in residual ATP level was observed in the synaptosomal preparations of status epilepticus animals compared to controls. Inorganic phosphate concentration in the status animals was higher than controls in the cytosolic fraction only. F1-ATPase activity, an enzymatic indicator of mitochondrial ATP synthesis rate, was significantly higher in the status brains, whereas other mitochondrial enzymes were not different in the status and control rat groups. These findings, together with our earlier report of reduced synaptosomal ecto-ATPase activity, suggest that either the corresponding in vivo ATP concentrations were reduced as a result of status epilepticus or other biochemical changes had occurred that facilitated the hydrolysis of ATP following decapitation. Controls for and measurement of such other changes failed to provide an explanation for the observed changes in residual ATP.
Collapse
Affiliation(s)
- N Y Walton
- Neurology and Research Services, VA Medical Center, Los Angeles, CA 90073, USA
| | | | | |
Collapse
|
43
|
van der Grond J, Gerson JR, Laxer KD, Hugg JW, Matson GB, Weiner MW. Regional distribution of interictal 31P metabolic changes in patients with temporal lobe epilepsy. Epilepsia 1998; 39:527-36. [PMID: 9596206 PMCID: PMC2735262 DOI: 10.1111/j.1528-1157.1998.tb01416.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE We compared the 31P metabolites in different brain regions of patients with temporal lobe epilepsy (TLE) with those from controls. METHODS Ten control subjects and 11 patients with TLE were investigated with magnetic resonance imaging (MRI) and [31P]MR spectroscopic imaging (MRSI). [31P]MR spectra were selected from a variety of brain regions inside and outside the temporal lobe. RESULTS There were no asymmetries of inorganic phosphate (Pi), pH, or phosphomonoesters (PME) between regions in the left and right hemispheres of controls. In patients with TLE, Pi and pH were higher and PME was lower throughout the entire ipsilateral temporal lobe as compared with the contralateral side and there were no significant asymmetries outside the temporal lobe. The degree of ipsilateral/contralateral asymmetry for all three metabolites was substantially greater for the temporal lobe than for the frontal, occipital, and parietal lobes, and these asymmetries provided additional data for seizure localization. As compared with levels in controls, Pi and pH were increased and PME were decreased on the ipsilateral side in patients with TLE. There were changes in Pi, pH, and PME on the contralateral side in persons with epilepsy as compared with controls, contrary to changes on the ipsilateral side. CONCLUSIONS Our findings provide some insight into the metabolic changes that occur in TLE and may prove useful adjuncts for seizure focus lateralization or localization.
Collapse
Affiliation(s)
- J van der Grond
- Department of Radiology, University Hospital Utrecht, The Netherlands
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
Neuroimaging techniques have improved the understanding, diagnosis, and management of epilepsy. By providing excellent structural information, MRI is the technique of choice in evaluating patients with epilepsy. Functional imaging techniques, including MR spectroscopy, functional MRI, positron emission tomography, and single photon emission CT, permit noninvasive assessment of the epileptic substrate, its functional status, and neuroreceptors. The MRI-based techniques will potentially assume a greater role in the cost-effective workup of the patient. Currently, newer techniques such as magnetoencephalography, magnetic source imaging, and optical imaging are research tools.
Collapse
Affiliation(s)
- Y Y Sitoh
- Department of Diagnostic Imaging, Tan Tock Seng Hospital, Singapore
| | | |
Collapse
|
45
|
Thompson JE, Castillo M, Kwock L. MR SPECTROSCOPY IN THE EVALUATION OF EPILEPSY. Magn Reson Imaging Clin N Am 1998. [DOI: 10.1016/s1064-9689(21)00442-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
46
|
du plessis A, Volpe JJ. Prognosis for Development in the Newborn Requiring Neurosurgical Intervention. Neurosurg Clin N Am 1998. [DOI: 10.1016/s1042-3680(18)30289-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
47
|
Affiliation(s)
- D Evans
- Division of Paediatrics and Child Health, University of Leeds.
| | | |
Collapse
|
48
|
Abstract
The purpose of this study was to determine whether mild hypothermia after a moderate hypoxic-ischemic insult reduces the extent of brain damage. Hypoxia was achieved in newborn piglets (n = 24; age, 14-72 h) by abrupt reduction of the inspired oxygen concentration (FiO2) to the maximum concentration (approximately 6%) giving low amplitude (< 7.0 microV) EEG. FiO2 was temporarily increased if heart rate, blood pressure, or end expiratory partial pressure of alveolar CO2 (PAco2) were markedly reduced. This intermittently resulted in EEG amplitude greater than 7 microV, the EEG traces were therefore later examined to determine the duration of low amplitude EEG. After 45 min of hypoxia, the animals were randomized to normothermia (39 degrees C) or hypothermia (35 degrees C) for 3 h. Hypothermia was achieved by applying packs containing ice water. Neurologic assessments and EEG recordings were performed regularly until 3 d when the brains were perfusion fixed. Histologic damage in cortex/white matter, cerebellum, hippocampus, basal ganglia, and thalamus was graded by a pathologist blind to treatment allocation. We found that the severity of brain damage (by histopathologic and neurologic evaluation) was not significantly different when the piglets were normothermic after hypoxia compared with the group made hypothermic. Increased duration of low amplitude EEG and seizure activity were associated with increased damage. When controlling for duration of hypoxia and excluding seizures, piglets undergoing hypothermia had approximately 50% less severe histopathologic damage in cortex/white matter, cerebellum, and hippocampus than those kept normothermic. Thalamus and basal ganglia had no or minor damage. It was concluded that there was no general beneficial effect of postinsult hypothermia. However, when controlling for the duration of the insult and occurrence of seizures, hypothermia reduced the severity of brain damage. This indicates a significant neuroprotective effect of 3 h of mild hypothermia on moderate, but not severe, hypoxic-ischemic insults.
Collapse
MESH Headings
- Animals
- Animals, Newborn
- Brain Damage, Chronic/etiology
- Brain Damage, Chronic/pathology
- Brain Damage, Chronic/physiopathology
- Brain Damage, Chronic/prevention & control
- Electroencephalography
- Female
- Hypothermia, Induced
- Hypoxia, Brain/complications
- Hypoxia, Brain/pathology
- Hypoxia, Brain/physiopathology
- Hypoxia, Brain/therapy
- Male
- Regression Analysis
- Seizures/etiology
- Swine
Collapse
Affiliation(s)
- K Haaland
- Department of Surgical Research, National Hospital, Oslo, Norway
| | | | | | | |
Collapse
|
49
|
Abstract
Magnetic resonance spectroscopy (MRS) is a new tool for evaluation of patients with epilepsy, demonstrating abnormalities of energy and lipid metabolism ictally and, more recently, interictally. These metabolic abnormalities include increased inorganic phosphate, pH, and decreased phosphomonoesters as determined by 31P MRS, as well as decreased N-acetylaspartate determined by 1H MRS. Furthermore, increased lactic acid has been detected postictally. These metabolic changes appear to be confined to the region of seizure origination and can be detected interictally. Therefore, they can be used for lateralization of the epileptogenic focus. Ongoing research suggests that these abnormalities may also be useful in localization of the focus, demonstrating metabolic alterations in temporal lobe epilepsy (TLE) similar to those in neocortical epilepsy. However, further technical development will be required before the goal of using these techniques for localization of the epileptogenic focus can be realized. For TLE lobe epilepsy at least, the clinical utility of 1H MRS to lateralize the seizure focus has clearly been demonstrated by several centers. The consistent findings in TLE suggest that 1H MRS is ready to become part of the evaluation process of patients with medically refractory epilepsy being evaluated for seizure surgery.
Collapse
Affiliation(s)
- K D Laxer
- Department of Neurology, University of California, San Francisco, USA
| |
Collapse
|
50
|
Setzer N. Perioperative Presentation of Seizures in Neonates. Anesth Analg 1996. [DOI: 10.1213/00000539-199604000-00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|