Neonatal EEG Maturation

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1 Neonatal EEG Maturation Cindy Jenkinson, R. EEG T., CLTM October 7, 2017

2 Fissure Development

3 3

4 ment-human-embryonic-brain 4

5 WHAT IS IMPORTANT TO KNOW BEFORE I START??

6 Gestational age is the common term used during pregnancy to describe how far along the pregnancy is. It is measured in weeks, from the first day of the woman's last menstrual cycle to the current date. A normal pregnancy can range from 38 to 42 weeks. Infants born before 37 weeks are considered premature 6

7 Corrected age is gestational age plus age since birth. So if born at 28 weeks GA and now is 4 weeks since birth, CA is 32 weeks Adjusted age is a baby's age based on his due date. Healthcare providers may use this age when evaluating the baby's growth and development. So if a baby is 6 months old but was born two months early, his adjusted age is 4 months 7

8 Apgar score is a simple assessment of how a baby is doing at birth, which helps determine whether newborn requires additional medical assistance. Breathing effort Heart rate Muscle tone Reflexes Skin color Each category is scored with 0, 1, or 2, depending on the observed condition 8

9 Maternal history-prenatal care, infections, gestational diabetes, medications, ilicit drugs, etc Birth history-vaginal delivery, C-Section, trauma, medicationsantibiotics, infections, etc 9

10 Technical Considerations Electrode application Montage Polygraphic channels Respirations Electrocardiogram Electro-oculogram Electromyogram 10

11 Montage FP1-C3 C3-O1 FP1-T3 T3-O1 FP2-C4 C4-O2 FP2-T4 T4-O2 T3-C3 C3-CZ CZ-C4 C4-T4 P3-Pz Pz-P4 Cz-Pz EKG EOC EMG RESP 11

12 20-24 weeks Brain is lissencephalic Who knows what EEG shows? Probably occasional bursts? Some people think bursts increase as gyrus increase 12

13 Can we do an EEG on a 24 week CA?? 13

14 Under 28 weeks CA Can t tell awake state on EEG No basic difference between active and awake sleep Non reactive to stimulus Usually synchronous activity ie not individual waves Sometimes see STOP Sharp theta rhythm on the occipital region of premies seen here, declines 14 until term

15 29-30 weeks No basic difference between active and awake sleep Temporal theta bursts (aka temporal sawtooth) Delta Brushes (ripples of prematurity)-more central Occipital slow activity 15

16 31-33 Weeks CA Difference in awake and sleep Active sleep is continuous Quiet sleep can be discontinuous (trace discontinua) Delta Brushes in occipital temporal regions (maximal delta brush activity) Rhythmic 1.5 hzin frontal leads (anterior dysrhythmia) in transitional sleep Temporal alpha bursts by 33 weeks instead of temporal theta Continuous irregular activity diffuse slowing with ripples seen in active sleep 16

17 33 Week CA 17

18 33 week twin A-trace discontinua 18

19 33 weeks =peak of Ripples 19

20 33 weeks- asynchronous is ok 20

21 34-35 weeks Active sleep and Awake states are continuous Quiet sleep can be discontinuous (trace discontinua) Frontal sharp wave transients (frontales encoches) Encoches frontales uV check mark shape in frontal leads Temporal alpha bursts disappear Extremely high voltage delta brushes 21

22 36-37 Weeks CA More defined (3 stages) of wake/sleep cycles Delta brushes still seen in quiet sleep; frontal sharp persist About 80% of EEG activity is synchronous At 37 weeks CA, fully developed wake sleep cycles Quiet sleep-trace alternant appears 22

23 38-40 Weeks CA About 100% synchronous by 40 weeks Discontinuous only in trace alternant during quiet sleep Delta brushes still present in quiet sleep and are rare in wakefulness and active sleep Does react to sensory stimulus Two types of quiet sleep-trace alternant and continuous Hz delta activity in frontals 23

24 38 weeks sleep 24

25 40 week Sleep Trace alternans 25

26 Age? 26

27 27

28 28

29 26 weeks CA 29

30 Active Sleep in Term Lots of it See rapid eye movements, irregular respiration, less EMG 2 patterns Low voltage irregular pattern with 1-5 hz Mixed high voltage slow and low voltage polythythmicwithout periodicity 30

31 Quiet sleep in Term Regular respiration, no eye movements 2 patterns Trace alternans pattern Medium to high voltage slow activity with somewhat rhythmic patternanterior dysrhythmia 31

32 32

33 Maximum Inter burst intervals 60 seconds weeks 35 seconds < 30 weeks 20 seconds between weeks 10 seconds between weeks 6 seconds weeks 33

34 What s bad Marked asynchrony of bursts >36 weeks Spikes if consistently unilateral and prominent Large positive sharp waves in Rolandicareas (think IVH) Flatness Stretches of rhythmical alpha rhythm Largely prehypsarhythmia rhythm Burst suppression pattern 34

35 What is Burst suppression if every thing under 32 weeks looks like a burst then suppression? Invariant No reactivity (sure like a neonatologist is going to let you shake a basinet) No normal features in burst 35

36 Respiration artifact 36

37 Artifacts 37

38 Respiration artifact head on right side 38

39 Confirming respiration artifact 39

40 Mouth movement artifact 40

41 Sucking pacifier 41

42 Sucking Artifact 42

43 Neonatal Seizures BEFORE 32 WEEKS GA-ELECTROGRAPHIC SEIZURES ARE RARE. BY TERM SEIZURES BECOME MORE COMMON. THE MOST COMMON PATTERN OF A FOCUS IS A REPETATIVE SHARP OR SLOW WAVE FROM ONE AREA OF THE CORTEX. CENTRAL AND OCCIPITAL ARE MORE OFTEN INVOLVED THEN FRONTAL AND TEMPORAL REGIONS. 43

44 Seizures Sudden Repititive Duration >10 seconds (less than 10=BIRDS) Usually status is when >50% of EEG in an hour is seizure 44

45 Typical right hemispheric seizure- Note evolution 45

46 Abnormalities in background Most random sharps are normal variants, unlike when older Look for : 1. Asymmetry 2. Persistent sharps in one area (suggest focal process-i.e.bleed) 3. Runs of sharps 46

47 What is pathologic? Persistent low voltage Frequent persistent sharp waves Continuous focal slowing Positive sharp waves (IVH) Persistent asynchrony 47

48 What NOT to get excited about in premature neonatal EEGs Asynchronous slowing that switches hemispheres or is bilateral Medium to high voltage slow activity Sharp waves in frontal temporal or occipital regions unless very frequent, persistent and focal Frontal sharp transients ( encoches frontales )-34 weeks Sharp theta of occipital in Premies-<28 weeks Temporal sawtooth weeks 48

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