Acute symptomatic seizures

Definition

Seizures that occur:

• ≤ 7 days of an acute neurological or systemic insult, drug or alcohol intoxication/withdrawal, or exposure to epileptogenic drugs.

                       or

• ≤ 24 h of a severe metabolic derangement

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Incidence

•~ 55% of all seizures

•~ 30% of all afebrile seizures                   

•Majority of neonatal seizures

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Pediatric Status epilepticus (SE)

 

Classic definition: Clinical event of 30 minutes duration or multiple events without return to baseline over 30 minutes. 

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Neurocritical Care Society (NCS) Definition 2012: ≥5 min of

• continuous clinical and/or electrographic seizure activity      

              or

• recurrent seizure activity without recovery (returning to baseline) between seizures.

 

 

** guideline intended for adults and children, not neonates**

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Neonatal Status Epilepticus

 

—Clinical seizure definition of “Multiple seizures over 30 minutes between which baseline brain function has not been restored” is difficult to determine in neonates

—

—Recurrent seizures: ≥ 50% of total summed duration of seizures in a 1 hour epoch (majority of neonatal SE)

 

—Electrographic seizure> 30 minutes (rare)

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American Epilepsy Society (AES) guideline for SE

Timeline-based algorithm for the treatment of convulsive seizures >5 minutes

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* Stabilization phase (0-5min)

* 1st  line therapy with BZDs (5-20min)

* 2nd line therapy with a non-BZD AED (20-40min)

* 3rd line therapy with a different 2nd line medication or general anesthetic drug phase (40-60min)

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Neonatal Seizures

Caution with clinical seizures - Clinical assessment of seizure is frequently inaccurate.

EEG confirmation recommended prior to treatment

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High rate of subclinical seizures, including uncoupling after seizure medication administration

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Recurrent seizures – when is treatment successful?

• Phenobarbital decreased EEG seizures (> 37 GA) within 1 h of administration but seizures were likely to return within 4 h of treatment.     

• Many clinicians use 24 hours seizure free as marker of successful treatment

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Phenobarbital and fosphenytoin are traditionally used.

• WHO guideline recommends phenobarbital 1st line (limited evidence)

• Limited efficacy (~ 50%)

• Medication interactions

• Neurodevelopmental concerns

• Variable metabolism, requiring blood draws for levels (PhT>>PB)

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Risk for post neonatal epilepsy in the first several years of life is < 25%

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​Hypothermia may reduce seizure burden for moderate but not severe neonatal HIE