Shavonne L. Massey

Treatment Duration After Acute Symptomatic Seizures in Neonates: A Multicenter Cohort Study

&NA; We aimed to define determinants of duration of treatment for acute symptomatic neonatal seizures in a contemporary multicenter observational cohort study. After adjustment for potential confounders, only study site and seizure etiology remained significantly associated with the chance of continuing antiseizure medication after discharge to home.

Impact of an ICU EEG monitoring pathway on timeliness of therapeutic intervention and electrographic seizure termination

We aimed to determine whether implementation of a structured multidisciplinary electroencephalography (EEG) monitoring pathway improved the timeliness of administration of antiseizure medication in response to electrographic seizures in encephalopathic critically ill children.

Acute VI nerve palsy in a 4 year-old girl with Chiari I malformation and pontomedullary extension of syringomyelia: Case report and review of the literature

We report the case of a previously healthy 4 year-old African American female who presented to the emergency department with acute onset of unilateral abducens nerve palsy and torticollis. Within 12 h of presentation, the patients symptoms progressed to include ipsilateral facial nerve palsy and gait ataxia. On exam, the patient demonstrated right cranial nerve VI and VII palsies, ataxic gait with left lateropulsion, spasticity of bilateral lower extremities with clonus, and the presence of bilateral Babinski sign. MRI of the brain and spinal cord revealed severe Chiari I malformation with associated extensive holochord syringomyelia and syringobulbia. The patient underwent successful surgical decompression 72 h after initial presentation. We review the literature on Chiari malformations and syringomyelia, including epidemiology, presentation and neurological manifestations, and treatment recommendations. As our patient had a very acute presentation, we additionally review the previously reported cases of acute and atypical presentation of patients with Chiari I malformation and syringomyelia. The aim of this report is to make practitioners aware of the acuteness with which children with Chiari malformation type I with syringomyelia and syringobulbia can present.

Electrographic Seizures in Children and Neonates Undergoing Extracorporeal Membrane Oxygenation.

Objective: We aimed to determine the prevalence and risk factors for electrographic seizures in neonates and children requiring extracorporeal membrane oxygenation support. Design: Prospective quality improvement project. Setting: Quaternary care pediatric institution. Patients: Consistent with American Clinical Neurophysiology Society electroencephalographic monitoring recommendations, neonates and children requiring extracorporeal membrane oxygenation support underwent clinically indicated electroencephalographic monitoring. Interventions: We performed a 2-year quality improvement study from July 2013 to June 2015 evaluating electrographic seizure prevalence and risk factors. Main Results: Ninety-nine of 112 patients (88%) requiring extracorporeal membrane oxygenation support underwent electroencephalographic monitoring. Electrographic seizures occurred in 18 patients (18%), of whom 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively electrographic-only seizures. Electrographic seizures were more common in patients with low cardiac output syndrome (p = 0.03). Patients with electrographic seizures were more likely to die prior to discharge (72% vs 30%; p = 0.01) and have unfavorable outcomes (54% vs 17%; p = 0.004) than those without electrographic seizures. Conclusions: Electrographic seizures occurred in 18% of neonates and children requiring extracorporeal membrane oxygenation support, often constituted electrographic status epilepticus, and were often electrographic-only thereby requiring electroencephalographic monitoring for identification. Low cardiac output syndrome was associated with an increased risk for electrographic seizures. Electrographic seizures were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether electrographic seizures identification and management improves outcomes.

Intracranial localisation of ictal urinary urge epileptogenic zone to the non-dominant temporal lobe

Ictal urinary urge is a rare symptom of focal epilepsy usually localising to the non-dominant hemisphere, specifically, the temporal lobe. Lateralisation in previously described cases has been established using scalp video-EEG monitoring or functional imaging. We report the case of a 19-year-old girl with refractory epilepsy and ictal urinary urge arising from the non-dominant temporal lobe, confirmed by invasive, subdural EEG monitoring. Since undergoing a temporal lobectomy two and a half years ago, the patient has not experienced ictal urinary urge. To our knowledge, this is the first report demonstrating localisation of ictal urinary urge epileptogenic zone to the non-dominant temporal lobe by invasive intracranial monitoring.

Electroencephalographic Response to Deep Hypothermic Circulatory Arrest in Neonatal Swine and Humans

BACKGROUND Piglets are used to study neurologic effects of deep hypothermic circulatory arrest (DHCA), but no studies have compared human and swine electroencephalogram (EEG) responses to DHCA. The importance of isoelectricity before circulatory arrest is not fully known in neonates. We compared the EEG response to DHCA in human neonates and piglets. METHODS We recorded 2 channel, left and right centroparietal, subdermal EEG in 10 neonatal patients undergoing operations involving DHCA and 10 neonatal piglets that were placed on cardiopulmonary bypass and underwent a simulated procedure using DHCA. EEG waveforms were analyzed for the presence and extent of burst suppression and isoelectricity by automated moving window analysis. The patients were monitored with 16-channel array EEG for 48 hours postoperatively and underwent postoperative brain magnetic resonance imaging. RESULTS After induction of anesthesia, humans and piglets both displayed slowing or brief suppression, then mild burst suppression, and then severe burst suppression during cooling. All piglets subsequently achieved isoelectricity at 22.4° ± 6.9°C, whereas only 1 human did at 20.2°C. Piglets and humans emerged from severe, mild, and then brief suppression patterns during rewarming. Among the patients, there were no seizures during postoperative monitoring and 1 instance of increased white matter injury on postoperative magnetic resonance imaging. CONCLUSIONS Our data suggest that current cooling strategies may not be sufficient to eliminate all EEG activity before circulatory arrest in humans but are sufficient in swine. This important difference between the swine and human response to DHCA should be considered when using this model.

Electroencephalographic monitoring for seizure identification and prognosis in term neonates

Seizures represent a manifestation of neurological disease in the neonatal period. Historically, neonatal seizures were identified by direct clinical observation. However, since most seizures are electroencephalographic (EEG)-only (subclinical, non-convulsive) and clinical manifestations may be subtle, many clinicians place increasing importance on EEG data including conventional EEG or amplitude-integrated EEG to identify seizures in neonates. Beyond seizure identification, the EEG is a robust source of information about brain function that can be useful for neurobehavioral prognostication in some neonates. This review summarizes the available data regarding EEG for neonatal seizure diagnosis and brain function assessment.

High electroencephalographic seizure exposure is associated with unfavorable outcomes in neonates with hypoxic-ischemic encephalopathy

PURPOSE Electroencephalographic seizures (ES) are common among neonates with hypoxic-ischemic encephalopathy (HIE), and they represent a treatable complication that might improve neurodevelopmental outcomes. We aimed to establish whether higher ES exposure was predictive of unfavorable outcomes while adjusting for other important clinical and electroencephalographic parameters. METHODS We performed a single-center, retrospective study of consecutive neonates with HIE managed with therapeutic hypothermia from June 2010 through December 2016. Neonates underwent continuous electroencephalographic (cEEG) monitoring during and after therapeutic hypothermia. Outcome measures included abnormal MRIs after rewarming and abnormal motor and language development. RESULTS Clinical data from the perinatal period were available for 116 neonates. Follow-up data were available for 93 of 116 (80%) neonates who survived to discharge, with a median follow-up period of 23 months (interquartile range 1236 months). Multivariate analysis demonstrated that high ES exposure (OR 5.2, 95% CI 1.3-21.2, p = 0.02) and moderate/severely abnormal EEG background (OR 8.3, 95% CI 1.6-43.9, p = 0.01) were independent predictors of abnormal motor development. High ES exposure was an independent predictor of abnormal language development (OR 4.2, 95% CI 1.1-15.9, p = 0.04). High ES exposure (OR 7.0, 95% CI 2.2-22.5, p = 0.01) and severe encephalopathy (OR 7.9, 95% CI 1.5-42.7, p = 0.02) were independent predictors of abnormal MRIs. CONCLUSIONS Among neonates with HIE managed with therapeutic hypothermia, high ES exposure was the most important predictor of abnormal developmental and neuroimaging outcomes, even after adjustment for multiple clinical and EEG variables. Adequate identification and management of ES with judicious use of anti-seizure medications may optimize outcomes.

Neuroimaging of Early Life Epilepsy

This study reveals the high yield of radiographic abnormalities in children presenting with epilepsy who are <3 years old regardless of multiple clinical factors. OBJECTIVES: We assessed the adherence to neuroimaging guidelines and the diagnostically relevant yield of neuroimaging in newly presenting early life epilepsy (ELE). METHODS: There were 775 children with a new diagnosis of epilepsy (<3 years old at onset) who were recruited through the ELE study at 17 US pediatric epilepsy centers (2012–2015) and managed prospectively for 1 year. The data were analyzed to assess the proportion of children who underwent neuroimaging, the type of neuroimaging, and abnormalities. RESULTS: Of 725 children (93.5%) with neuroimaging, 714 had an MRI (87% with seizure protocols) and 11 had computed tomography or ultrasound only. Etiologically relevant abnormalities were present in 290 individuals (40%) and included: an acquired injury in 97 (13.4%), malformations of cortical development in 56 (7.7%), and other diffuse disorders of brain development in 51 (7.0%). Neuroimaging was abnormal in 160 of 262 (61%) children with abnormal development at diagnosis versus 113 of 463 (24%) children with typical development. Neuroimaging abnormalities were most common in association with focal seizure semiology (40%), spasms (47%), or unclear semiology (42%). In children without spasms or focal semiology with typical development, 29 of 185 (16%) had imaging abnormalities. Pathogenic genetic variants were identified in 53 of 121 (44%) children with abnormal neuroimaging in whom genetic testing was performed. CONCLUSIONS: Structural abnormalities occur commonly in ELE, and adherence to neuroimaging guidelines is high at US pediatric epilepsy centers. These data support the universal adoption of imaging guidelines because the yield is substantially high, even in the lowest risk group.

S95. EEG factors after pediatric cardiac arrest

Introduction We aimed to determine whether conventional standardized EEG features could be consolidated into a more limited number of factors and whether the derived factor scores changed during the acute period after pediatric cardiac arrest. Methods Children resuscitated after cardiac arrest underwent conventional continuous EEG monitoring. The EEG was scored in 12-h epochs for up to 72-h after return of circulation by an electroencephalographer using standardized critical care EEG terminology. We performed a polychoric factor analysis to determine whether numerous observed EEG features could be represented by a smaller number of derived factors. Linear mixed-effects regression models and heat maps evaluated whether the factor scores remained stable across epochs. Results We performed EEG monitoring in 89 consecutive children which yielded 453 EEG segments. We identified two factors which were not correlated. The Background Features Factor loaded with the features continuity, voltage, and frequency. The Intermittent Features Factor loaded with the features of seizures, periodic patterns, and inter-ictal discharges. Factor scores were calculated for each EEG segment. Linear mixed-effect regression results indicated that the factor scores did not change over time for the Background Features Factor (coefficient 0.18, 95%CI 0.04–0.07, p = 0.52) or the Intermittent Features Factor (coefficient −0.003, 95%CI −0.02–0.01, p = 0.70). However, heat maps showed that some individual subjects did experience factor score changes over time, particularly if they had medium initial factor scores. Conclusion Subsequent studies assessing whether EEG is informative for neurobehavioral outcomes after pediatric cardiac arrest could combine numerous EEG features into two factors, each reflecting multiple Background and Intermittent features. Further, the factor scores would be expected to remain stable during the acute period for most subjects.