DRUGS
What is the first-line antiseizure medication (ASM) recommended by ILAE and WHO guidelines for neonatal seizures?
A) Phenobarbital
B) Levetiracetam
C) Phenytoin
D) Benzodiazepines
A) Phenobarbital
Which of the following is a challenge in determining the exact incidence of neonatal seizures?
A) Inaccurate prenatal care data
B) Lack of mothers qualified as advanced maternal age included in studies
C) Difficulty in visual detection and inconsistent use of EEG
D) High-quality population-based data from low-income countries
C) Difficulty in visual detection and inconsistent use of EEG
Why can clinical assessment alone be unreliable for diagnosing neonatal seizures?
Neonatal seizures can be subtle and may be mistaken for nonseizure movements, and only half of the movements are correctly identified by experts
What additional test should be considered if intracranial infection is a potential diagnosis in a neonate with seizures?
LP
What specifically is associated with worse neurodevelopmental outcome after HIE?
More seizures and longer duration of seizures OR longer duration of neonatal status epilepticus.
Which of the following is NOT a recommended second-line agent for neonatal seizures according to the WHO and ILAE guidelines?
A) Midazolam
B) Lidocaine
C) Topiramate
D) Levetiracetam
C) Topiramate
What factor is NOT associated with an increased risk of neonatal seizures?
A) Advanced maternal age
B) Fetal distress
C) Low birthweight
D) Prenatal care
D) Prenatal care
What phenomenon describes the situation where antiseizure medications (ASMs) suppress outward signs of a seizure but electrographic seizures continue?
A) Electroclinical dissociation
B) Seizure uncoupling
C) Clinical-EEG coupling
D) Subclinical masking
A) Electroclinical dissociation
Which imaging modality is preferred for assessing neonatal brain injury and identifying characteristic patterns of common etiologies like HIE and stroke?
MRI
Name 2 things neonates with seizures are at higher risk for.
Neonates with seizures are at higher risk for
neurodevelopmental delays, intellectual disability,
cerebral palsy, later epilepsy, and death compared
with neonates without seizures.
A 10-hour-old infant (former 33-week estimated gestational age [EGA]) of a mother being treated with oral B12 supplementation develops episodes of sustained contractions of both legs lasting 13 to 20 seconds. aEEG and head ultrasonography are ordered but results are not available yet. The infant's vital signs are normal. Which one of the following is the best next step in management?
A. Administer levetiracetam.
B. Administer phenobarbital.
C. Administer pyridoxine.
D. Wait for aEEG interpretation.
E. Wait for head ultrasonography results.
B. Administer phenobarbital. (When neonatal seizures are refractory to multiple ASMs, empirical trials of vitamin supplementation for potential vitamin-responsive epilepsies should be used.)
What is the most common cause of neonatal seizures in term neonates?
A) Intracranial hemorrhage
B) Neonatal encephalopathy
C) Hypoxic-ischemic encephalopathy (HIE)
D) Metabolic derangements
C) Hypoxic-ischemic encephalopathy.
In the absence of continuous conventional video EEG (cEEG), how does amplitude-integrated EEG (aEEG) compare for seizure detection in neonates?
A) aEEG is more effective than cEEG in detecting each individual seizure
B) aEEG eliminates the risk of false positives and is highly reliable for all seizure types
C) aEEG provides a more detailed and accurate assessment of seizure burden compared to cEEG
D) aEEG is less sensitive and may miss seizures, particularly those that are slow, brief, or in regions not covered by the electrodes
D) aEEG is less sensitive and may miss seizures, particularly those that are slow, brief, or in regions not covered by the electrodes
In the initial evaluation of neonatal seizures, what is one of the primary laboratory tests to check for reversible causes?
A) Serum ammonia levels
B) Complete blood cell count (CBC)
C) Electrolyte levels (glucose, sodium, potassium, calcium, magnesium)
D) Urine toxicology screen
C) Electrolyte levels (glucose, sodium, potassium, calcium, magnesium)
Which factor is most strongly associated with a worse neurodevelopmental outcome in neonates with seizures?
Severe, irreversible brain injury or genetic etiology
Which medication should be used with caution due to its potential to cause cardiac arrhythmias and is limited to a 24- to 48-hour maximum duration of use?
A) Phenobarbital
B) Phenytoin
C) Levetiracetam
D) Lidocaine
D) Lidocaine
Which of the following is NOT typically a cause of seizures in preterm neonates?
A) Intraventricular hemorrhage
B) Stroke or vascular insult
C) Neonatal-onset epilepsy
D) HIE
B) Stroke or vascular insult
According to the 2021 ILAE classification, why is EEG crucial for diagnosing neonatal seizures?
A) EEG can confirm the presence of clinical signs of seizures
B) EEG is required to identify subclinical seizures that have no outward clinical signs
C) EEG provides a complete clinical assessment without the need for other diagnostic tools
D) EEG is primarily used to measure the severity of clinical signs
B) EEG is required to identify subclinical seizures that have no outward clinical signs
What is the gold standard of neuromonitoring for seizure diagnosis.
Continuous conventional video EEG
A former 38-week EGA girl had focal seizures on day 2 after birth. Phenobarbital was started. Magnetic resonance imaging (MRI) of the brain showed an ischemic stroke with a large middle cerebral artery distribution. Focal seizures stopped by day 3 after birth, and aEEG for 24 hours on day 5 after birth did not identify any further seizures. On day 10 after birth, the infant is feeding well and her neurologic examination findings are normal. You are preparing to discharge her. Which one of the following is the most appropriate next step in management:
A. Perform continuous conventional video EEG for 24 hours.
B. Obtain a serum phenobarbital level.
C. Repeat MRI of the brain.
D. Stop phenobarbital.
E. Taper off phenobarbital.
D. Stop phenobarbital. (Risk of poor neurodevelopmental outcomes with prolonged ASM therapy has prompted a shift from long-term treatment to limiting ASM administration to the neonatal period for acute symptomatic seizures.)
What is the primary action of Phenobarbital in the treatment of neonatal seizures?
A) Inhibition of sodium channels
B) Modulation of the GABA-A receptor
C) Decreasing excitatory neurotransmission through calcium channel inhibition
D) Blocking the sodium-potassium-chloride cotransporter
B) Modulation of the GABA-A receptor
While covering the well-baby nursery, you are called to a mother's bedside to evaluate a 1-day-old term girl who was delivered vaginally after an uncomplicated pregnancy. The mother received prenatal care. Apgar scores were 9 and 10 at 1 and 5 minutes, respectively. The infant’s physical examination findings immediately at birth were normal. The infant was breastfeeding when her mother noticed that she stopped feeding and had focal twitching of her right face and right arm lasting 45 seconds. Which one of the following is the most likely cause of these symptoms in this patient?
A. Brain malformation.
B. Genetic syndrome.
C. Hypoxic-ischemic encephalopathy.
D. Intraventricular hemorrhage.
E. Neonatal stroke.
E. Neonatal stroke.
What is the primary advantage of using continuous conventional video EEG (cEEG) over amplitude-integrated EEG (aEEG) for neonatal seizure diagnosis?
A) cEEG is less resource-intensive and easier to apply
B) cEEG provides a more comprehensive assessment, including seizure detection, classification, burden assessment, and response to treatment, with concurrent video and ancillary channels
C) cEEG has a higher sensitivity and specificity for identifying individual seizures compared to aEEG
D) cEEG is quicker to apply and does not require formal neurophysiology training
B) cEEG provides a more comprehensive assessment, including seizure detection, classification, burden assessment, and response to treatment, with concurrent video and ancillary channels
Forty-eight hours after vaginal delivery of a 37-week-old boy at a tertiary care medical center, the mother reports that the infant has occasional episodes of unilateral arm twitching lasting 3 to 5 seconds. The infant has been feeding well; there are no other clinical concerns. Amplitude-integrated electroencephalography (aEEG) is started and 2 typical episodes are captured. There is no aEEG correlation to the episodes. Which one of the following is the next best step in management?
A. Change to continuous conventional video EEG.
B. Continue aEEG for 24 hours.
C. Discharge the infant with close follow-up.
D. Involve a neurogeneticist and genetic counselor.
E. Start patient on a sodium channel blocker such as phenytoin.
A. Change to continuous conventional video EEG.
A 38-week EGA girl with a prenatal diagnosis of trisomy 21 was born in a tertiary care hospital. At 6 hours after birth, the infant had difficulty feeding and became lethargic. Laboratory results show hypoglycemia. Head ultrasonography was normal. aEEG was started and raised concern for subclinical seizures. Glucose was administered, and phenobarbital was started. For this infant, which one of the following is a potentially favorable prognostic indicator for the seizures?
A. Absence of clinical seizures.
B. Adverse effect profile of phenobarbital.
C. Genetic cause for seizures.
D. Hypoglycemia causing seizures.
E. Increased NMDA and AMPA receptors.
D. Hypoglycemia causing seizures.