Developmental Changes Including Neonatal EEG. Gregory L. Holmes, MD

Transcription

1 Developmental Changes Including Neonatal EEG Gregory L. Holmes, MD

2 A A + B =: B + A.Dravet Syndrome B.Menkes syndrome C.West syndrome D.Ohtahara shyndrome

3 The Difficult Delivery 1 day old male transferred to DHMC with history of R- sided seizure. Baby was 3200gm, 42 2/7 GTA born to 28 yog1p1 following induction of labor, with >48 hrs of ruptured membranes. C-section performed after attempted vacuum extraction, secondary to failure to progress and maternal exhaustion. Meconium was noted at delivery, prompting intubation and deep suction, with initial APGAR of 1 at 1 minute, improving to 7 at 5 min, 8 at 10 min.

4 The Difficult Delivery At 11:00 am on day of admission, pt was noted to have R-sided twitching while nursing, lasting ~11 minutes witnessed by nursing, prompting call for transfer to DHMC. While team was en route, patient had second episode of R-sided twitching, beginning in R arm and spread to R leg with desaturation, but no apnea. Entire episode lasted 15 min, and patient was loaded with 10 mg/kg phenobarbital x 2. Seizures persisted despite phenobarbital.

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18 Normal or abnormal?

19 Normal or abnormal?

20 Normal or abnormal?

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25 NORMAL NEONATAL EEG <29 WEEKS CA Predominately discontinuous EEG (tracé discontinu) Long periods of low voltage/inactivity Slow delta brushes over Rolandic area Synchrony within hemispheres poor; high synchrony between hemispheres Poor relationship between eye movements, respirations, and EMG with EEG state changes

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28 NORMAL NEONATAL EEG WEEKS CA Decrease in discontinuity during awake and REM sleep Shorter period of inactive EEG activity Delta brushes frequent in active sleep Temporal lobe theta prominent Low synchrony between hemispheres Poor relationship between eye movements, respirations, and EMG with EEG state changes

29 Interhemispheric Synchrony as a Function of Conceptional Age

30 Delta Brush in a 32 CA Infant

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33 Delta Brush as a Function of Conceptional Age Number of Brushes Conceptional Age (CA) Quiet Active

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35 Premature Temporal Theta Activity Incidence (%) of Records Conceptional Age (Weeks)

36 33 CA 30 CA 28 CA 29 CA 35 CA 28 CA

37 NORMAL DISCONTINUOUS EEG PATTERNS IN NEONATES Tracé discontinu term used to describe the normal discontinuous EEG prevailing in infants under 35 weeks CA in which interburst intervals of low voltage or inactivity alternate with higher amplitude, mixed-frequency activity. Tracé alternant term used to to describe the discontinuous pattern of non-rem sleep evolving the eruption of slow activity (1-4 Hz), with irregular faster activity of μv appearing roughly every 4-5 sec and lasting 2-4 sec. The interburst activity consists of low-voltage continuous activity in the theta range.

38 NORMAL NEONATAL EEG WEEKS CA Increased continuity during awake/rem sleep Quiet sleep continues to be discontinuous (tracé discontinu) Sharp transients (spikes and sharp waves) are frequent, particularly in frontal region Increasing synchrony between hemispheres Increasing correlation between eye movements, respirations, and EMG with EEG state changes

39 NORMAL NEONATAL EEG WEEKS CA Clear differences between active and quite sleep Active sleep demonstrates continuous activity Quiet sleep continues to be discontinuous but shows increasing amplitude of activity between bursts (tracé alternant) Delta brush is prominent during quiet sleep Good correlation between eye movements, respirations, and EMG with EEG state changes

40 NORMAL NEONATAL EEG WEEKS CA Distinct differences between active and quite sleep Active sleep demonstrates continuous activity Quiet sleep Tracé alternant High voltage slow wave sleep Delta brush decreases and is infrequent by 40 weeks CA Interhemispheric synchrony Good correlation between eye movements, respirations, and EMG with EEG state changes

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46 EEG BACKGROUND ABNORMALITIES IN NEONATES (1) Abnormalities of amplitude Electrocerebral inactivity no cerebral electrical activity at a sensitivity of 2 μv Low-voltage undifferentiated pattern activity between 5-15 μv in all states Abnormalities of continuity Burst-suppression pattern Excessive discontinuity/permanent discontinuous activity

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48 Non-Ketotic Hyperglycinemia

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52 EEG BACKGROUND ABNORMALITIES IN NEONATES (2) Abnormalities of symmetry Interhemispheric amplitude asymmetry pattern asymmetries of >25% between two hemispheres Focal attenuation pattern persistent attenuation of voltage involving only region Focal slowing Abnormalities of interhemispheric synchrony Interhemispheric asynchrony - Assessed during tracé alternant - Near 100% synchrony by term

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54 EEG BACKGROUND ABNORMALITIES IN NEONATES (3) Abnormalities of sleep states No recognizable states distinct sleep states not recognized despite long recordings Excessively labile states rapid transition between sleep states Abnormalities of maturation

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57 EKG Artifact

58 Artifact

59 Startle

60 Quiet Sleep

61 REM Sleep

62 Tracé Discontinu

63 Positive Sharp Wave

64 Seizure Onset

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