NEONATAL SEIZURES: NARRATIVE REVIEW

Neonatal seizures are often complex and difcult to recognize, but can be identied through electroencephalogram (EEG) monitoring. The Brighton Collaboration has developed a scheme with ve levels of diagnostic certainty to guide treatment decisions when EEG is not available. Different seizure types are usually associated with specic underlying causes, which may require specic diagnostic and treatment approaches. Neonatal seizures require prompt management, including the stabilization of cardiovascular and respiratory function and the identication of the underlying cause. EEG monitoring is considered essential for the detection of seizures and should be performed until the neonate has been seizure-free for 12 to 24 hours. Treatment involves the use of antiseizure medication and may include pyridoxine challenge or other treatment options such as the ketogenic diet, intravenous immunoglobulin, or corticosteroids if seizures are refractory to conventional antiseizure medication. It is important to differentiate between seizures and nonepileptic motor phenomena, which can occur without obvious cause or as symptoms of drug withdrawal, electrolyte abnormalities, hypoglycemia, or infection. Neuroimaging is also considered essential for the detection of possible structural abnormalities in neonates with seizures.

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.

Application of root cause analysis on long-range video EEG monitoring quality on epilepsy patients / 现代临床护理

Objective To study the quality and effect of root cause analysis (RCA) on long-range video EEG monitoring on epilepsy patients.Methods The process of RCA long-range video EEG monitoring on patients with epilepsy was investigated to find out the root causes for quality of epilepsy capturing from pseudo differential of EEG and video effects.Then the measures were taken to improve the quality of monitoring.Result After the intervention,except canmera not clear enough,the incidences were significantly decreased compared with pre-intervention (all P ＜ 0.001).Conclusions Root cause analysis is effective in improving the quality of long-range video EEG monitoring on epilepsy patients.It is worth clinically promoting.

Recurrent Syncope Triggered by Ictal Asystole

No abstract available.

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.

Usefulness of video-EEG monitoring in paroxysmal nonepileptic events of children and adolescents / 소아과

PURPOSE: In addition to epileptic seizures (ES), a variety of physiologic, organic and psychogenic disorders can manifest as paroxysmal behavioral events. Paroxysmal nonepileptic events (PNEs) are quite encountered in infants, young children, and adolescents. In a substantial proportion of cases, a careful history and examination will elucidate their nature. However, in other cases, it is necessary to differentiate PNEs from ES by video-electroencephalographic (EEG) monitoring. We report our experiences with PNEs in a group of children and adolescents who underwent video-EEG monitoring. METHODS: From September, 2004 to June, 2006, one hundred thirty patients were monitored in the Pediatric Epilepsy Monitoring Units of Korea University Guro and Ansan hospitals. Their hospital charts were reviewed and video records of these events were analyzed. We observed all patients after video- EEG monitoring for more than 3 months. RESULTS: Typical spells occurred during monitoring in 33 patients, not associated with a seizure pattern on EEG recordings. Two patients were diagnosed as frontal lobe epilepsy on basis of typical semiology and clinical characteristics, so 31 patients were documented to have PNEs finally. The mean age of patients was 7.2+/-5.8 years. The male to female ratio was 15 (48.4%) to 16 (51.6%). Among 31 patients, fifteen patients had associated disorders such as epilepsy, developmental delay, cerebral palsy, gastric ulcer, attention deficit hyperactivity disorder or depressive disorder. Somatoform disorder and factitious disorder was frequently seen in children more than 5 years old (P0.05). CONCLUSION: Our study suggests that video-EEG monitoring is an important diagnostic tool in the evaluation of paroxysmal behavioral events. With correct diagnosis of the PNEs, several unnecessary treatment could be avoided.

Postoperative Electroclinical Features in Epilepsy Patients With Seizures After Anteromesial Temporal Resection

BACKGROUND: Anteromesial temporal resection (AMTR) is well established as effective in patients with intractable mesial temporal epilepsy. However, little electroclinical information is available relevant to poor surgical outcome after AMTR. We examined the postoperative electroclinical features based on postoperative MRI and video-EEG monitoring (VEM) in patients with poor surgical outcome. METHODS: We reviewed clinical features and postoperative VEM results in 20 patients with failure in AMTR. According to the postoperative electroclinical features, we classified them into mesial temporal (MT), bitemporal (BT), extramesial temporal (XMT), combined (C), and unclassified groups. The postoperative VEM results were compared among the groups. Surgical outcome was assessed in five patients who underwent reoperation. RESULTS: Patients comprised 6 MT, 2 BT, 6 XMT, 1 C, and 6 unclassified. Aura and automatism were more frequent in MT (50.0%, 83.3%) than in XMT (16.7%, 33.3%). Theta to delta rhythm, during the ictal onset and build-up period, was more frequent in MT (83.3%, 66.7%) than in XMT (33.3%, 33.3%). The ictal onset and build-up pattern of ictal EEG were most frequently localized to the frontotemporal region in MT (66.7%, 100.0%), while there was no predominantly localized region in XMT. The surgical outcome after reoperation was better in MT group than in XMT and C groups. CONCLUSIONS: Postoperative MRI and VEM are useful to assess the postoperative electroclinical features in failed AMTR. Reoperation of the residual mesiotemporal structures after confirming epileptogenic foci may have good surgical outcome.

The Role of Video-EEG Monitoring: Purpose and outcome / 대한간질학회지

BACKGROUND AND PURPOSE: We performed this study to explore the various diagnostic roles of video-EEG monitoring (VEM) and to assess the outcome after VEM. METHODS: 1749 patients who underwent VEM in the adult epilepsy section were included. We classified purposes of VEM and assessed outcome after VEM or epilepsy surgery guided by VEM. The outcome was assessed according to seizure frequency during the previous 12 months from the day of follow-up evaluation. RESULTS: The purposes of VEM were presurgical evaluation (68.5%), confirmation of epilepsy (15%), classification of seizures (9.4%), diagnosis of pseudoseizures (5.5%), and detection of nonconvulsive status epilepticus (1.7%). The efficiency of VEM was 89.2%, highest for presurgical evaluation (97.1%) and lowest for confirmation of seizures (66.0%). The number of events detected and the number of days needed differed according to the purposes of VEM. Epilepsy surgery was performed in 629 patients. The outcome of patients with epilepsy surgery was significantly better compared with patients without surgery despite presurgical evaluation (p<0.0001). Various other illnesses with transient symptoms as well as various epileptic syndromes were diagnosed by VEM. Better outcomes were observed in patients in whom VEM was used for classification and confirmation of seizures compared with patients in whom VEM was used for presurgical evaluation. CONCLUSIONS: VEM is a useful tool for various purposes. The efficiency, number of events and days of VEM differed according to the purposes. Patient outcome was also dependent on the purpose of the VEM as well as on treatment modalities.

The Clinical and Electroencephalographic Characteristics of Hypomotor Seizures in Children / 대한소아신경학회지

PURPOSE: A hypomotor seizure is a useful descriptive terminology, but its clinical and ictal characteristics are not fully understood. We investigated the clinical and electrophysiological characteristics of hypomotor seizures in children. METHODS: We reviewed 394 video-taped recordings, performed between Dec. 1994 and Feb. 2003., to select patients of hypomotor seizures. Exclusion criteria were as follows; i) hypomotor seizures accompanied with other types of seizures in a single event, ii) patients without neurocognitive dysfunctions who were older than 3 years old, iii) non-convulsive status epilepticus, iv) poor video quality. A total of 329 hypomotor seizures from 42 patients (M:F=27:15) were included. The mean age of onset was 1.9 years old, the mean age at the monitoring 4.5 years old, and the mean duration of follow-ups 3.9 years. RESULTS: Thirteen patients (31%) showed generalized onset, hypomotor seizures while 29 patients (69%) showed partial onset hypomotor seizures. 35 patients (83.3%) had neurocognitive deficits. Significant abnormalities in the on brain MRIs were revealed in 23 patients (54.8 %). The concordance rates of interictal epileptiform discharges were 29.0%. In 8 patients, (hypomotor seizures were separately accompanied by other types of seizures (19.0%)). Comparing generalized seizures (group 1) with partial seizures (group 2), there were no significant differences in the clinical parameters between the two groups. In brain MRIs, group 2 tended to have focal lesions. On the analysis of ictal rhythms in group 1, diffuse spike and wave discharges were noted in 8 patients, rhythmic beta in 2 patients, semirhythmic theta in 1 patient, diffuse attenuation of the background in 1 patient, and bilateral beta in 1 patient. Among 5 patients with ictal rhythms other than diffuse spike and wave discharges, 4 patients were younger than 3 years old. On the analysis in group 2, rhythmic ictal patterns were noted in 24 patients (82.8%), seimirhythmic in 2 patients (6.9%), and irregular in 3 patients (10.3%). The distribution of ictal frequencies was as follows:alpha in 3 (10.3%), beta in 4 (13.8%), theta in 10 (34.5%), delta in 4 (13.8%), repetitive spikes or sharp waves in 5 (17.3%), and spikes and waves in 3 (10.3%). Rhythmic beta patterns tended to be localized into the posterior quadrant. CONCLUSION: Hypomotor seizures consist of generalized-onset (31%) and partial-onset (69 %). No clinical parameters can predict the ictal patterns. Various patterns in patients with generalized onset hypomotor seizures under 3 years old may suggest different mechanisms of generalized hypomotor seizures from absence seizures. Rhythmic beta patterns from the posterior quadrant may suggest the localization-specific ictal patterns.

A Case of Abdominal Epilepsy Diagnosed by 24-hour Electroencephalogram Monitoring / 대한소아신경학회지

Abdominal epilepsy is an infrequent syndrome which occurrs with gastrointestinal complaints caused by a seizure activity. It is characterized by paroxysmal onset of abdominal pain without visceral disorders, but comes along with the alteration of awareness during the attack and abnormal electroencephalogram(EEG) findings. Like other epilepsies, this abdominal epilepsy is improved with anticonvulsant medication. We present a 14 year-old boy who had recurrent episodes of abdominal pain for 2 months, accompanied by hyperventilation and alteration of awareness. His interictal EEG findings were normal, but 24 hour EEG monitoring showed multifocal spikes and generalized epileptiform discharges when abdominal pain developed. After the medication with valproate, he became free of symptoms and signs.

Orientações ao paciente epiléptico submetido ao vídeo-eletrencefalograma: comparação dos níveis de ansiedade com o uso de diferentes estratégias / Orientations to epileptic patient undergoing a video-EEG monitoring: comparison of anxiety levels using different strategies

Trata-se de um estudo experimental, correlacional, com abordagem quantitativa que compara os níveis de ansiedade de dois grupos de pacientes epilépticos submetidos ao vídeo-eletrencefalograma (vídeo-EEG) que tiveram diferentes estratégias de orientação para o exame; o controle teve apenas orientações verbais e o experimental, além das orientações verbais, também, recebeu um manual de orientações, variável independente do estudo. A amostra foi, aleatoriamente, composta por dois grupos de 30 pacientes. Para avaliar o uso de diferentes estratégias de orientação, foi comparada a ansiedade dos grupos, por meio da aplicação do Inventário de Ansiedade Traço-Estado (IDATE), sendo o estado de ansiedade, avaliado pré e pós-exame. Os resultados mostraram que o grupo experimental apresentou perfil de ansiedade superior, porém, estado de ansiedade inferior, antes do exame, em relação ao controle. A ansiedade do grupo experimental foi mais baixa, antes do exame do que seu perfil, entretanto, o mesmo não ocorreu com o grupo controle. Após o exame, a grande maioria de ambos os grupos apresentou ansiedade baixa e menor que seu perfil. A estratégia de orientação com o manual parece ter beneficiado os pacientes que o receberam, promovendo a redução da ansiedade antes do exame ser realizado.

This exploratory, correlated and quantitative study had the objective to identify and compare the anxiety level between two groups of epileptic patients undergoing a video-EEG monitoring using different patients guidelines strategies. The random sample was composed by two groups of 30 patients each one. The control group only had verbal orientations and the experimental group, beyond the same orientations received a written guide (a booklet) with all the procedures too. The anxiety was assessed using State-Trait Anxiety Inventory (STAI-T and STAI-S) with the STAI-S being applied for both groups before and after examination as described above. The results demonstrated that, before video-EEG, the anxiety-trait score of the experimental group was higher and the anxiety-state was lower than the control group. After video-EEG, the majority of both groups demonstrated low anxiety-state score and lower than their anxiety-trait score. The strategy used with the written guide associated to verbal orientations seems to help to reduce the anxiety level before the video-EEG.

Cryptogenic Gelastic Seizures from Medial Frontal Area: 2 Cases

Little has been known about what pathways subserve mirth and its expression laughter. We report two patients with cryptogenic gelastic seizures who provide some insight into the mechanisms of laughter. Invasive video-EEG monitoring showed ictal onset zone to be either in the left or right medial frontal cortex. After resection of the medial frontal area, including the epileptogenic focus, patients have been in gelastic seizure-free state. This suggests the possibility that medial frontal cortex is involved in the motor act of laughter.

A Case of Suspected Autosomal Dominant Nocturnal Frontal Lobe Epilepsy / 대한소아신경학회지

Autosomal dominant nocturnal frontal lobe epilepsy(ADNFLE) is a recently identified partial epilepsy. This disorder is characterized by a variable age of onset(mostly in childhood), autosomal dominant inheritance, clusters of brief frontal nocturnal seizures, negative findings on neuroimaging, and fairly good prognosis. Carbamazepine is known to be the most useful drug in this type of epilepsy. We experienced a case of 5-year-old boy who had unusual arousal and irritability every night for 3 years and had sharp & wave discharges from frontal lobe region in long-term video-EEG monitoring, who was suspected as an autosomal dominant nocturnal frontal lobe epilepsy. We report a case with a brief review of literatures.

Intractable Epilepsy associated with Neurocysticercosis: Perilesional Epileptogenic Features

BACKGROUND: Neurocysticercosis (NCC) is the most common parasitic disease of the CNS and seizures are the most frequent clinical manifestations of it. Although the medical treatment of NCC is effective, epilepsy surgery is still needed to treat refractory seizures. We investigated five cases with refractory seizures due to NCC to verify perilesional epileptogenic changes in NCC. METHOD: We included 5 intractable epilepsy patients who had epilepsy surgery and pathologically proven cysticercosis although serological tests were negative. A routine EEG and brain MRI were performed in all patients. Video scalp-EEG monitorings were done in 5 patients, including an invasive-EEG monitoring in one. We analyzed the relationships between semiology, brain MRI, interictal, and ictal EEG findings, pathologic features and surgical outcomes. RESULTS: All patients had abdominal or psychic aura, evolving into automotor seizure and then secondarily generalized tonic clonic seizures. Two patients often had only the aura. In brain MRI, four patients had showed NCC lesions in the mesial temporal area, and one had it in the basal occipital area. Hippocampal atrophy was also detected in 3 patients. Irritative and ictal onset zones on an EEG were located around the lesions. Pathologic findings confirmed hippocampal sclerosis in 3 patients and coritcal dyslamination and many single heterotopic neurons in the temporal lobe in 1 patient. Surgical outcomes showed 3 patients in class IA, 1 in class IC, and 1 in class IIB by Engel classification. CONCLUSIONS: Epileptic foci could be formed focally around the NCC lesion and hippocampal sclerosis frequently accompanied when the lesion was located near the mesial temporal structures. After verifying epileptic foci and lesion, epilepsy surgery had good surgical outcome.