Developmental Changes Including Neonatal EEG Gregory L. Holmes, MD
A A + B =: B + A.Dravet Syndrome B.Menkes syndrome C.West syndrome D.Ohtahara shyndrome
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.
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.
Normal or abnormal?
Normal or abnormal?
Normal or abnormal?
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
NORMAL NEONATAL EEG 29-31 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
Interhemispheric Synchrony as a Function of Conceptional Age
Delta Brush in a 32 CA Infant
Delta Brush as a Function of Conceptional Age Number of Brushes 45 40 35 30 25 20 15 10 5 0 31-32 32-33 33-34 34-35 35-36 36-37 37-38 38-40 Conceptional Age (CA) Quiet Active
Premature Temporal Theta Activity Incidence (%) of Records 90 80 70 60 50 40 30 20 10 0 26 28 30 32 34 36 38 40 42 Conceptional Age (Weeks)
33 CA 30 CA 28 CA 29 CA 35 CA 28 CA
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 50-200 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.
NORMAL NEONATAL EEG 32-34 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
NORMAL NEONATAL EEG 35-37 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
NORMAL NEONATAL EEG 38-40 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
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
Non-Ketotic Hyperglycinemia
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
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
EKG Artifact
Artifact
Startle
Quiet Sleep
REM Sleep
Tracé Discontinu
Positive Sharp Wave
Seizure Onset