Neonatal Seizures
Neonatal Seizures
Neonatal Seizures
neonatal seizures
Author: Renée Shellhaas, MD, MS
Section Editors: Douglas R Nordli, Jr, MD, Joseph A Garcia-Prats, MD
Deputy Editor: John F Dashe, MD, PhD
Contributor Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Jun 2020. | This topic last updated: Sep 19, 2018.
INTRODUCTION
The occurrence of neonatal seizures may be the first, and perhaps the only, clinical
sign of a central nervous system (CNS) disorder in the newborn infant. As such,
seizures may indicate the presence of a potentially treatable etiology and should
prompt an immediate evaluation to determine cause and to institute etiology-
specific therapy. In addition, seizures themselves may require emergent therapy,
since they may adversely affect the infant's homeostasis or they can contribute to
further brain injury.
EPIDEMIOLOGY
Seizures occur more often in the neonatal period than at any other time of life;
during this period, they most often occur within the first week of life [1,2]. Reported
incidence ranges from 1.5 to 5.5 per 1000 in newborns [2-4] and may be even
higher in premature infants [5,6]. Seizure incidence varies with some specific risk
factors. Occurrence increases with decreasing gestational age and birth weight,
and with increasing acuity of illness [2,7-9].
ETIOLOGY
The etiology and prognosis of neonatal seizures and neonatal epilepsy syndromes
are discussed in more detail separately. (See "Etiology and prognosis of neonatal
seizures" and "Neonatal epilepsy syndromes".)
CLINICAL FEATURES
Seizures in the neonate have unique clinical features when compared with those
of older infants and children. There are age-dependent properties of the immature
brain that enhance seizure initiation, maintenance of the seizure discharge, and
propagation of the seizure discharge [16]. The clinical events that are most
consistently due to neonatal seizures are focal-clonic, focal-tonic, some types of
myoclonic, and epileptic spasms. Non-seizure paroxysmal events are common in
this age group and can sometimes be difficult to distinguish from seizures. (See
'Differential diagnosis' below.)
While focal-clonic seizures may be the most easily recognized by observers, these
events do have features that may be unique to the neonatal period. Focal-clonic
seizures may be unifocal, confined to specific muscle groups including those of
the proximal or distal limbs, trunk or neck, or regions of the face. Focal seizures
may alternate between sites of involvement within the same seizure. Focal
seizures may be multifocal and may exhibit clonic activity simultaneously but
asynchronously. If all four limbs are involved, this may give the appearance of a
generalized seizure. However, more careful inspection reveals that the limbs are
not moving synchronously.
Focal seizures can migrate from one region to another. Migration may be
according to traditional Jacksonian features (ie, contiguous spread over the
cortical representation of the limbs, face and trunk) or may be more erratic in
spread. Focal seizures may also be hemiconvulsive. In this regard, a seizure may
be initially confined to the hand on one side of the body and then abruptly involve
the remainder of that side of body without an intervening Jacksonian march.
Focal tonic — Focal tonic seizures occur less often than focal clonic seizures.
Focal tonic seizures are characterized by sustained, but transient, asymmetrical
posturing of the trunk or extremities or tonic deviation of the eyes. Seizures
involving the limbs or trunk may appear as unilateral flexion of the trunk with the
body pulling down and to one side or sustained flexion or extension of a limb.
When the eyes are involved, there is sustained conjugate deviation of the eyes to
one side. Any of these events are typically associated with focal EEG seizure
activity.
Tonic seizures are the hallmark of several neonatal epilepsy syndromes (eg,
Ohtahara syndrome, KCNQ2 encephalopathy). Therefore, prominent focal tonic
semiology should trigger consideration of neonatal-onset epilepsy as the etiology.
(See "Neonatal epilepsy syndromes", section on 'Severe syndromes'.)
Myoclonic events are distinguished from clonic seizures by the regular rate of
repetition and persistence of clonic events. Myoclonic seizures can be classified
as focal, generalized, or fragmentary. Focal myoclonic seizures have features
similar to focal clonic seizures except that myoclonic events are nonrepetitive and
erratic. Generalized myoclonic seizures include bilateral, symmetric jerking of all
extremities and/or muscles of the trunk and neck. Fragmentary myoclonus is
characterized by rapid, simultaneous but asynchronous, twitching of various small
muscle groups that are typically distal. Fragmentary myoclonus is typically
nonepileptic in origin.
Some forms of myoclonic seizures may occur with a consistent EEG seizure
discharge, although some do not. This reflects the fact that some myoclonic
seizures are generated at a cortical level and others are generated at more caudal
levels such as subcortical structures, brainstem, spinal cord, or neuromuscular
junction. In addition, some myoclonic seizures may be provoked by stimulation
and suppressed by limb restraint or body repositioning.
The seizures may occur in clusters and are most often present upon arousal of the
infant from sleep. On EEG, the seizures may be associated with a generalized, high
voltage, slow wave transient or generalized voltage attenuation. Spasms are
considered electroclinical seizures and are epileptic in origin. (See "Clinical
features and diagnosis of infantile spasms".)
DIFFERENTIAL DIAGNOSIS
Other paroxysmal events in the neonate that can be confused with seizures
include hyperekplexia, jitteriness, tremulousness, and clonus. Such events can
occur in normal and abnormal infants and can be differentiated from other clinical
events, particularly focal-clonic seizures, by their suppression by restraint. The
clinical phenomenology of these nonepileptic paroxysmal events, especially in
relation to how they are distinguished from epileptic seizures, is discussed
separately. Importantly, clinicians have been shown to be inaccurate in
distinguishing non-seizure paroxysmal events from electroclinical seizures [35,36].
(See "Nonepileptic paroxysmal disorders in infancy".)
This was illustrated by a retrospective study of 324 continuous video EEG studies
performed for the evaluation of paroxysmal vital sign changes in children [28].
Most of the studies were performed in neonates and infants less than one year
old, and an index event was captured in 52 percent of the studies. The recorded
vital sign changes were rarely related to seizures when the change was
hypotension (0 out of 12), hypertension (1 out of 22, 4.5 percent), or bradycardia (2
out of 26, 7.7 percent), and all seizures were associated with additional clinical
signs. Vital sign changes were more likely to be ictal when the change included
oxygen desaturation (11 out of 82, 13 percent) or apnea (22 out of 83, 27 percent),
particularly when accompanied by abnormal eye movements or an abrupt
decrease in tone. Tachycardia with or without additional clinical signs was a
seizure manifestation in 2 out of 23 studies (9 percent).
DIAGNOSIS
Historically, the diagnosis of neonatal seizures was most often made based on
clinical signs. However, modern electroencephalography (EEG) studies have
demonstrated that not all clinically suspicious events are epileptic seizures (in
fact, most are not), and most neonatal seizures are subclinical.
Contemporary diagnosis of neonatal seizures therefore relies on confirmatory
electroencephalographic (EEG) characteristics. When at-risk infants undergo EEG
monitoring, high rates of both false positive and false negative clinical diagnoses
are demonstrated (27 and 81 percent, respectively) [35,36].
● An "electroclinical seizure" occurs when the clinical event overlaps in time with
an EEG-confirmed seizure.
● A "subclinical seizure" is an EEG-confirmed seizure without associated clinical
signs.
● Clinical events that have no EEG correlate are not seizures.
Importantly, neonates who have high risk clinical scenarios and clinical events
which are very suspicious for seizures (eg, focal clonic jerking in a newborn with
clinical concern for acute HIE) should be evaluated and treated urgently, even if
EEG is not immediately available.
Video EEG monitoring — The gold standard for neonatal seizure diagnosis is multi-
channel video EEG monitoring [39]. Since this testing is specialized and resource-
intensive, it should be reserved for newborns at highest risk for seizures. There are
many examples of high-risk clinical scenarios, but in general EEG monitoring
should be considered for newborns with proven or suspected acute brain injury
and comorbid encephalopathy.
If the interictal background is stable and no seizures are recorded after 24 hours,
then monitoring may be discontinued. An exception is often made for neonates
treated with therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE).
These infants are frequently monitored throughout cooling and rewarming due to
the high incidence of seizures in this patient population (about 50 percent will
have neonatal seizures) [39,40].
If seizures are identified, EEG monitoring should continue until the infant is
seizure-free for 24 hours, unless this duration of monitoring is not in the infant’s
best interests (eg, a newborn with seizures due to a severe brain malformation
might not be expected to gain complete seizure control). Similarly, the guidelines
specify that transfer to a different intensive care facility, solely for the purposes of
EEG monitoring, might not always be in the infant’s best interest and should be
considered on a case-by-case basis [39].
ETIOLOGIC EVALUATION
History — The history should attempt to identify risk factors for seizures and clues
to the underlying etiology:
● Gestational and birth history – A thorough birth history should identify risk
factors for anoxic injury such as nuchal cord or cord thrombosis, fetal heart
rate decelerations, meconium, low Apgar scores, and placental abnormalities.
The nature of the delivery is also important, as infants born by operative
vaginal delivery are more likely to have intracranial hemorrhage. Other risk
factors for birth injury include macrosomia, maternal obesity, and abnormal
fetal presentation. (See "Neonatal birth injuries", section on 'Intracranial
hemorrhage'.)
● Family history – A detailed family history should include queries about early
sibling death from unknown causes or consanguinity (inborn errors of
metabolism) and family history of epilepsy, particularly neonatal (benign
familial neonatal epilepsy).
Lumbar puncture is recommended in all neonates with a positive blood culture and
should also be considered whenever there is clinical suspicion for sepsis, since
clinical signs of CNS infection can be lacking in young infants and infection is
among the most common causes of neonatal seizures. (See "Clinical features,
evaluation, and diagnosis of sepsis in term and late preterm infants", section on
'Laboratory tests'.)
Genetic testing — The role of genetic testing in the clinical care of children with
epilepsy is evolving as the number of monogenetic causes of early epileptic
encephalopathy increases and specific treatments become available for some
syndromes. In a prospective cohort study of 611 consecutive newborns with
seizures, 13 percent had an epilepsy syndrome, including 35 infants (6 percent)
with epileptic encephalopathy and 32 with congenital brain malformations [15].
Among 29 neonates with epileptic encephalopathy who underwent genetic testing,
83 percent had a genetic etiology identified, most commonly KCNQ2
encephalopathy. Among 23 neonates with brain malformations, 7 had a putative
genetic etiology. (See "Neonatal epilepsy syndromes" and "Localization-related
(focal) epilepsy: Causes and clinical features", section on 'Genetic focal epilepsy
syndromes'.)
● Seizures in the neonate have unique clinical features when compared with
those of older infants and children. The most common clinical seizure types in
neonates are focal-clonic, focal-tonic, some types of myoclonic, and epileptic
spasms (table 3), but most neonatal seizures are subclinical. (See 'Clinical
features' above.)
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