Uncoupling of EEG-clinical neonatal seizures after antiepileptic drug use
Mark S Scher1, John Alvin, Lisa Gaus
1Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA.
Insights
Phenobarbital and phenytoin were studied for neonatal seizure cessation. Serial electroencephalographic monitoring revealed that even with reduced clinical seizures, electrographic seizures can persist, a phenomenon termed uncoupling.
Area of Science:
- Neonatal neurology
- Clinical pharmacology
- Pediatric epilepsy
Background:
- Neonatal seizures are a critical concern requiring effective treatment.
- Phenobarbital and phenytoin are commonly used antiepileptic drugs (AEDs) for neonatal seizures.
- Understanding treatment efficacy requires assessing both clinical and electrographic seizure activity.
Purpose of the Study:
- To compare the efficacy of phenobarbital versus phenytoin in achieving seizure cessation in neonates.
- To investigate the phenomenon of 'uncoupling' where electrographic seizures persist despite clinical seizure suppression.
Main Methods:
- A prospective study involving 59 neonates with electrically-confirmed seizures.
- Neonates were assigned to phenobarbital or phenytoin and monitored for 24 hours.
- Clinical and electroencephalographic (EEG) seizure expressions were assessed before and after drug administration.
Main Results:
- Twenty-four infants achieved complete seizure cessation with the first AED choice.
- Of the 26 infants with persistent seizures, 15 (58%) exhibited uncoupling.
- Uncoupling occurred similarly regardless of the AED used, prematurity, or gender.
Conclusions:
- Serial EEG monitoring is crucial for evaluating AED efficacy in neonatal seizures.
- The phenomenon of uncoupling highlights the need to monitor electrographic seizure activity beyond clinical observation.
- Phenobarbital and phenytoin demonstrated similar efficacy profiles concerning uncoupling in this cohort.
Abstract:
A prospective study of the efficacy of seizure cessation by phenobarbital versus phenytoin administration utilized both clinical and electroencephalographic expressions of seizure behaviors. The phenomenon of uncoupling was defined as the persistence of electrographic seizures despite the suppression of >or=50% clinical seizures after either one or both antiepileptic drugs use. Fifty-nine neonates (25 to 43 weeks estimated gestational age) with electrically-confirmed seizures were assigned to either of two drugs and continuously monitored over a 24-hour period. Nine of the fifty-nine patients had only electrographic seizure expression both before and after drug administration. Of the remaining 50 patients who had both electrical and clinical seizure expression before treatment, 24 infants responded to the first choice of an antiepileptic drug with no further seizures. Fifteen of the remaining 26 infants (58%) with persistent seizures after treatment had uncoupling of electrical and clinical expressions of seizures; no difference in the uncoupling effect was noted for neonates who were treated with either antiepileptic drug or based on prematurity or gender. Serial electroencephalographic monitoring helps document continued electrographic seizure expression after antiepileptic drug use, following complete or partial suppression of clinical seizure behaviors.
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