Effect of neonatal seizure burden and etiology on the long-term outcome: data from a randomized, controlled trial

Incidence and Predictors of Later Epilepsy in Neonates with Encephalopathy: The Impact of Electrographic Seizures

OBJECTIVES

To determine the incidence of later epilepsy in full-term infants with neonatal encephalopathy (NE) who undergo continuous electroencephalography (cEEG) monitoring in the neonatal period and to identify potential predictors of later epilepsy both in infants with and without electrographic neonatal seizures (ENS).

METHODS

This was a retrospective observational study performed at Cork University Maternity Hospital, Cork, Ireland, between 2003 and 2019. All term infants with NE had a minimum of 2 h of cEEG monitoring in the neonatal period. ENS were identified via cEEG monitoring. Pediatric medical charts were reviewed to determine if epilepsy developed after the neonatal period and to determine potential predictors of epilepsy in infants both with and without ENS.

RESULTS

Two hundred and eighty infants were included. The overall incidence rate of epilepsy was 17.55 per 1000 person-years (95% CI: 10.91 to 28.23). In infants with ENS (n = 82), the incidence rate was 39.27 per 1000 person-years (95% CI: 22.30 to 69.16). In infants without ENS (n = 198), the incidence rate was 7.54 per 1000 person-years (95% CI: 3.14 to 18.12). The incidence rate was significantly higher in the ENS group compared to the non-ENS group (p-value = 0.002). Several potential predictors for the development of later epilepsy were identified including infants delivered vaginally, low Apgar scores at 1 and 5 min, severe HIE diagnosis, presence of ENS, a severely abnormal EEG background and an abnormal brain MRI.

SIGNIFICANCE

Following NE, term infants are at risk of epilepsy with a significantly higher incidence rate in infants who experience ENS compared to those who did not. Close follow-up is required in both groups well into the childhood period.

PLAIN LANGUAGE SUMMARY

This study aimed to determine the occurrence of epilepsy in children who were monitored for seizures in the newborn period. The occurrence of epilepsy was higher in infants who experienced seizures in the newborn period compared to those who did not. Several potential predictors of later epilepsy were identified in both groups of infants (those with and without seizures in the newborn period). Both groups of infants require close follow-up in childhood.

Effectiveness of sodium channel blockers in treating neonatal seizures due to arterial ischemic stroke

OBJECTIVE

Few studies have evaluated the efficacy of antiseizure medications (ASMs) according to the etiology of neonatal acute provoked seizures. We aimed to investigate the response to ASMs in term/near term neonates with acute arterial ischemic stroke (AIS), as well as the type of seizure at presentation and the monitoring approach.

METHODS

We retrospectively evaluated neonates from 15 European level IV neonatal intensive care units who presented with seizures due to AIS and were monitored by continuous electroencephalography (cEEG) and/or amplitude-integrated EEG (aEEG) in whom actual recordings, timing, doses, and response to ASMs were available for review.

RESULTS

One hundred seven neonates were referred, and 88 were included. Of those, 56 met the criteria for evaluating the treatment response. The mean time to treatment was 7.9 h (SD = 16.4), and the most frequently administered first-line ASM was phenobarbital (PB; 74/88, 84.1%). Seizures were controlled within 24 h from onset of symptoms in 64.3% (36/56) of neonates. Phenytoin (PHT) was effective in almost all neonates in whom it was trialed (24/25, 96.0%), whereas PB was effective in only 22.0% of patients (11/50). Infants treated with PB or PHT as first-line treatment (53/56, 94.6%) showed a higher response rate with PHT (6/6, 100.0%) than with PB (11/47, 23.4%). Monitoring approach and seizure types were evaluated in 88 infants. Forty-six of 88 (52.3%) were monitored with cEEG and 47.7% (42/88) with aEEG, with or without intermittent cEEG. The mean monitoring duration was 65.8 h (SD = 39.21). In 83 of 88 (94.3%) infants, the type of seizure suspected clinically prior to monitoring was confirmed afterward. Unilateral focal clonic seizures were seen in 71 of 88 infants (80.7%), whereas 11 of 88 (12.5%) presented with ictal apneas.

SIGNIFICANCE

Our findings provide evidence in a large, homogenous cohort that PHT is more effective than PB in treating neonatal acute symptomatic seizures due to AIS.

Treating Seizures and Improving Newborn Outcomes for Infants with Hypoxic-Ischemic Encephalopathy

Hypoxic-ischemic encephalopathy is the most common cause of neonatal seizures. Continuous electroencephalographic monitoring is recommended given high rates of subclinical seizures. Prompt diagnosis and treatment of seizures may improve neurodevelopmental outcomes. International League Against Epilepsy guidelines indicate that (1) phenobarbital remains the first-line treatment of neonatal seizures and (2) early discontinuation of antiseizure medications following resolution of acute provoked seizures, and prior to discharge home, is recommended. Long-term follow-up of these infants is necessary to screen for postneonatal epilepsy and support neurodevelopment.

Advances in Electroencephalographic Biomarkers of Neonatal Hypoxic Ischemic Encephalopathy

Electroencephalography (EEG) is a key objective biomarker of newborn brain function, delivering critical, cotside insights to aid the management of encephalopathy. Access to continuous EEG is limited, forcing reliance on subjective clinical assessments. In hypoxia ischaemia, the primary cause of encephalopathy, alterations in EEG patterns correlate with. injury severity and evolution. As HIE evolves, causing secondary neuronal death, EEG can track injury progression, informing neuroprotective strategies, seizure management and prognosis. Despite its value, challenges with interpretation and lack of on site expertise has limited its broader adoption. Technological advances, particularly in digital EEG and machine learning, are enhancing real-time analysis. This will allow EEG to expand its role in HIE diagnosis, management and outcome prediction.

Neonatal Seizures

Neonatal seizures are common among patients with acute brain injury or critical illness and can be difficult to diagnose and treat. The most common etiology of neonatal seizures is hypoxic-ischemic encephalopathy, with other common causes including ischemic stroke and intracranial hemorrhage. Neonatal clinicians can use a standardized approach to patients with suspected or confirmed neonatal seizures that entails laboratory testing, neuromonitoring, and brain imaging. The primary goals of management of neonatal seizures are to identify the underlying cause, correct it if possible, and prevent further brain injury. This article reviews recent evidence-based guidelines for the treatment of neonatal seizures and discusses the long-term outcomes of patients with neonatal seizures.

Acute symptomatic seizures in newborns: a narrative review

Acute symptomatic seizures are the main sign of neurological dysfunction in newborns. This is linked to the unique characteristics of the neonatal brain, making it hyperexcitable compared to older ages, and to the common occurrence of some forms of acquired brain injury, namely hypoxic-ischemic encephalopathy. In this narrative review we will provide an overview of neonatal seizures definition, their main underlying etiologies, diagnostic work-up and differential diagnoses, and will discuss about therapeutic options and prognostic outlook. The latest publications from the ILAE Task Force on Neonatal Seizures will be presented and discussed. Of note, they highlight the current lack of robust evidence in this field of clinical neurology. We will also report on specificities pertaining to low-and-middle income countries in terms of incidence, main etiologies and diagnosis. The possibilities offered by telemedicine and automated seizures detection will also be summarized in order to provide a framework for future directions in seizures diagnosis and management with a global perspective. Many challenges and opportunities for improving identification, monitoring and treatment of acute symptomatic seizures in newborns exist. All current caveats potentially represent different lines of research with the aim to provide better care and reach a deeper understanding of this important topic of neonatal neurology.

Neonatal Seizures in Low- and Middle-Income Countries: A Review of the Literature and Recommendations for the Management

Neonatal seizures are a common cause of neonatal intensive care unit (NICU) admission and a significant source of morbidity and mortality worldwide. Over the recent decades, there have been significant improvements in perinatal and neonatal medicine and electroencephalograp hic monitoring that have enhanced the diagnosis and treatment of neonatal seizures in highincome countries. However, the management of neonatal seizures remains a major challenge in low- to middle-income countries, where the availabilityof resources is limited. The purpose of this article is to present a comprehensive review of the current evidence on the etiology, pathophysiology, diagnosis, and treatment of neonatal seizures and to offer practical management recommendations that could be implemented in resource-limited settings. Cite this article as: Spenard S, Ivan Salazar Cerda C, Cizmeci MN. Neonatal seizures in low and middleincome countries: Review of the literature and recommendations for the management. Turk Arch Pediatr. 2024;59(1):13-22.

Investigating the Impact on Long-Term Outcomes and the Necessity of Hereditary Thrombophilia Screening in Presumed or Perinatal Arterial Ischemic Stroke

This study aimed to investigate the influence of prothrombotic risk factors on long-term outcomes of patients with perinatal arterial ischemic stroke. The study was conducted through an analysis of monitoring results that were regularly maintained for approximately 20 years at a tertiary stroke-monitoring center. The study assessed prothrombotic risk factors, radiological area of involvement, clinical presentation, treatments, clinical outcomes, and long-term outcomes of the 48 patients included in the study, with a mean monitoring time of 77.6 ± 45.7 months (range: 6-204). Our results showed that the presence of prothrombotic risk factors did not affect long-term outcomes. However, patients with middle cerebral artery infarction had the highest risk of developing cerebral palsy, whereas those with presumed stroke had the highest risk of developing epilepsy. This study suggests that prothrombotic risk factors should not be evaluated during the acute stage unless there is a strong suspicion of the patient's history, and prevention or early diagnosis of presumed stroke patients will positively impact their long-term prognosis.