Crisis neonatales: evaluacion, diagnostico y tratamiento / Neonatal seizures: evaluation, diagnosis, and treatment

Resumen Las crisis convulsivas tienen una alta incidencia en la etapa neonatal, representando la principal manifes tación de disfunción neurológica. Ciertas condiciones fisiológicas del cerebro neonatal facilitan su aparición. Su diagnóstico puede ser un reto debido a que su semio logía no es tan clara comparado con niños mayores, y además, es necesario la confirmación por medio de EEG continuo o aEEG. Su reconocimiento oportuno es muy importante para un adecuado tratamiento y así evitar un impacto negative en el pronóstico a largo plazo. En la siguiente revisión, recapitulamos la fisiopatología, las causas y la clasificación de las crisis convulsivas neo natales, además de su correcto abordaje y las mejores opciones terapéuticas para su tratamiento dependiendo de la causa.

Abstract Seizures have a high incidence in the neonatal stage, being the main manifestation of neurological dysfunc tion. Certain physiological conditions of the neonatal brain facilitate its appearance. Its diagnosis can be a challenging because its semiology is not as clear as in older children, furthermore, confirmation by either EEG or aEEG is necessary. Its timely recognition is very im portant for adequate treatment and thus avoid a nega tive impact on the long-term outcome. In the following review, we recapitulate the pathophysiology, causes, and classification of neonatal seizures, as well as their correct approach and the best therapeutic options for their treatment depending on the cause.

Optimizing seizure detection by quantitative EEG in paediatric refractory status epilepticus

@#Background & Objective: Continuous electroencephalography (cEEG) is valuable in the diagnosis and management of refractory status epilepticus (RSE) but requires intensive skilled interpretation. Density spectral array (DSA) is a quantitative analytic tool used to screen cEEG recordings for seizures. This study aims to determine the optimal amplitude setting and to compare the use of single-averagetrendgraph display and eight-trendgraph display in seizure detection with DSA. Methods: Five excerpts from pediatric cEEG recordings with RSE were identified. In Phase 1 of the study, each of 4 readers determined the DSA amplitude setting one most preferred for each excerpt, and marked all seizures in one excerpt using one’s preferred setting. Inter-rater agreement in seizure detection was measured. In Phase 2, readers marked all seizures in all excerpts, first using single-average-trendgraph display, and then using eight-trendgraph display after a wash-out period. Intra-rater agreement in seizure detection between the two display methods was calculated. Results: In Phase 1, DSA readers’ choice of preferred amplitude settings varied widely but inter-rater agreement in seizure detection was high. In Phase 2, seizure detection using single- and eight-trendgraph displays showed high agreement with each other and, where they disagreed, single-average-trendgraph was more sensitive. Additionally, low seizure-to-background amplitude ratio in EEG recordings was associated with worse detection sensitivity/specificity. Conclusions: DSA amplitude settings do not affect seizure detection. Single-trendgraph display is comparable to eight-trendgraph display in screening cEEG for seizures. Seizure detection with DSA performs better in cEEG recordings with high seizure-to-background amplitude ratio.

Actualización en manejo del status convulsivo en niños / Status epilepticus in childhood. An Update

El estatus epiléptico (SE) en pediatría es una emergencia neurológica ya que presenta morbimortalidad. Existen diferencias con los adultos y su reconocimiento puede ser más difícil especialmente a edades tempranas. Se han precisado distintas etapas en el SE y se ha acortado el tiempo en su definición, lo anterior con el objetivo de dar opciones terapéuticas más precoces. Existen diversos protocolos terapéuticos y en todos ellos las benzodiazepinas constituyen la primera etapa, incluyendo la terapia pre-hospitalaria que si es bien realizada puede evitar la progresión al SE en un paciente con una crisis epiléptica. En estatus refractario y super refractario la evidencia es menor y el rol de los anestésicos es protagónico con la necesidad de un manejo integral en una unidad de cuidados intensivos pediátricos (UCIP) y con un monitoreo electroencefalográfico continuo (cEEG), este último resulta ser un recurso limitado especialmente en el sistema público. Palabras Claves: estado epiléptico, monitoreo EEG continuo, pacientes pediátricos, anticonvulsivantes.

Status epilepticus (SE) in pediatric patients is a neurological emergency because it is associated to morbidity and mortality. There are differences between children and adults, making its recognition harder, especially in early ages. Different stages have been defined in SE and the time has been shortened in its definition, with the aim to give earlier therapeutic options. There are several protocols and in all of them benzodiazepines are the first option, even in the pre-hospital scenario, which, if managed well, can avoid progression to SE in a patient with an epileptic seizure. In refractory SE the evidence is poor and the role of anesthetics is more important with the need for an comprehensive management in a pediatric intensive care unit (PICU) and with continuous electroencephalographic monitoring (eEEG), the latter being a limited resource especially in our public health system. Key words: Status epilepticus, pediatric patients, continuous EEG monitoring, antiepileptic drugs.

Papel de la monitorización electroencefalográfica continua en el diagnóstico de la epilepsia pediátrica / Role of continuous EEG monitoring in the diagnosis of pediatric epilepsy

El diagnóstico de la epilepsia es fundamentalmente clínico, pero frecuentemente se plantea el diagnóstico diferencial con fenómenos no epilépticos. El desarrollo de la monitorización EEG continua (MEEGC) en las últimas dos décadas ha permitido mejorar el diagnóstico de pacientes epilépticos de todas las edades. En este trabajo se revisan los datos de la literatura sobre la eficacia de los distintos tipos de MEEGC en el diagnóstico de la epilepsia pediátrica, resaltando especialmente nuestra experiencia personal. En nuestros estudios, la MEEGC ambulatoria suplementada con video permitió contestar la pregunta que determinó su petición en el 80% de pacientes diagnosticados de epilepsia y en el 83% de aquéllos con sospecha diagnóstica de epilepsia. Con la MEEGC ambulatoria asistida por ordenador, dichas cifras fueron 88% y 89%, respectivamente y con la MEEGC intrahospitalaria con video fueron 82% y 51%, respectivamente. La MEEGC intrahospitalaria con video es crucial en la evaluación de pacientes con epilepsia, candidatos al tratamiento quirúrgico. La MEEGC es también importante en pacientes con encefalopatías agudas ingresados en las unidades de cuidados intensivos. La MEEGC, tanto ambulatoria como intrahospitalaria, es muy útil en el diagnóstico diferencial de fenómenos clínicos epilépticos y no epilépticos y en la confirmación del tipo de epilepsia o síndrome epiléptico. Los avances tecnológicos y el desarrollo de nuevas modalidades de EEG en el futuro, harán que la electroencefalografía siga siendo una técnica muy importante en el estudio de la función cerebral en pacientes con enfermedades neurológicas agudas o crónicas.

The diagnosis of epilepsy is basically clinical, but it frequently raises the differential diagnosis with non-epileptic events. The development of continuous EEG monitoring (CEEGM) in the past decades has allowed a better diagnosis of epileptic patients of all ages. In this paper we review the data available in the literature about the efficacy of the different modalities of CEEGM in the diagnosis of pediatric epilepsy, emphasizing our personal experience. In our studies the ambulatory CEEGM supplemented with video allowed to answer the question that prompted its request in 80% of patients diagnosed with epilepsy and in 83% of those with the suspected diagnosis of epilepsy. With ambulatory computer-assisted CEEGM those figures were 88% and 89%, respectively, and with inpatient video-CEEGM they were 82% and 51%, respectively. The latter is crucial in the evaluation of epilepsy patients who are candidates for surgical treatment. Inpatient video-CEEGM is also very important in the management of patients with acute encephalopathies admitted to the Intensive Care Units. Both, ambulatory or inpatient CEEGM, are very useful in the differential diagnosis of clinical epileptic versus non-epileptic events, as well as in the confirmation of the type of epilepsy or epileptic syndrome. The development of technological advances and new EEG modalities in the future will help to continue to consider electroencephalography as a very important technique in the study of brain function in patients with acute or chronic encephalopathies.

Estado de mal epiléptico / Status epilepticus

INTRODUÇÃO: O estado de mal epiléptico (EME) é subdiagnosticado, especialmente as formas clínicas com sinais motores sutis ou apenas com alteração da consciência. É uma emergência neurológica que necessita diagnóstico imediato e a tratamento agressivo e para prevenir lesão neuronal. OBJETIVOS: Revisar, discutir e propor protocolo para o tratamento desta condição. METODOLOGIA: A literatura foi selecionada a partir de pesquisa nas bases de dados MEDLINE e PUBMED. RESULTADOS: Propomos um protocolo utilizando diazepam, fenitoína, fenobarbital, midazolam, thiopental e pentobarbital ainda nos casos refratários topiramato ou levetiracetam. CONCLUSÕES: Um protocolo estruturado para a investigação da etiologia e tratamento do EME é necessário e possibilita melhores chances de evolução dos casos.

INTRODUCTION: Status epilepticus (SE) is an under recognized medical emergency, especially subtle SE or clinical presentation mostly with conscience disturbance (nonconvulsive SE). It is a medical emergency that requires immediate and aggressive diagnoses and treatment. OBJECTIVES: Review, discuss and a protocol suggestion for treatment. METHODOLOGY: Literature publication was selected from MEDLINE and PUBMED. RESULTS: A protocol with diazepam, phenytoin, phenobarbital, midazolam, thiopental and pentobarbital, including topiramate and levetiracetam for refractory cases was proposed. CONCLUSIONS: A standardized protocol for SE work-up and treatment is useful and probably improves outcome.