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Nonconvulsive electrographic seizures are common in children with abusive head trauma*
Daphne M Hasbani1, Alexis A Topjian, Stuart H Friess
11Division of Neurology, The Children's Hospital of Philadelphia, Department of Pediatrics and Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 2Division of Critical Care Medicine, The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 3Division of Critical Care Medicine, St. Louis Children's Hospital, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO. 4Division of Pediatrics, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
Insights
Nonconvulsive seizures are common in abusive head trauma (AHT) cases in children. Most of these electrographic seizures lack clinical signs, highlighting the need for electroencephalographic monitoring in AHT diagnosis.
Area of Science:
- Pediatric Neurology
- Child Abuse Pediatrics
- Neurocritical Care
Background:
- Abusive head trauma (AHT) is a significant cause of pediatric brain injury.
- Seizures are a known complication of AHT, but the prevalence and nature of nonconvulsive seizures remain under-investigated.
Purpose of the Study:
- To determine the prevalence of nonconvulsive seizures in children diagnosed with abusive head trauma.
- To explore the clinical and electroencephalographic characteristics associated with seizures in this population.
Main Methods:
- Retrospective study of children under 2 years old with confirmed abusive head trauma.
- Continuous electroencephalographic (EEG) monitoring was performed in a pediatric intensive care unit (PICU).
- Data collected included clinical presentation, neuroimaging, and EEG findings.
Main Results:
- Electrographic seizures occurred in 57% of monitored children with AHT, with 67% being entirely nonconvulsive.
- Electrographic status epilepticus was present in 67% of those with seizures.
- Nonconvulsive seizures were associated with specific EEG background patterns and neuroimaging evidence of ischemia, but not with clinical seizures or imaging abnormalities.
- Mortality was 19%, with no deaths among children with electrographic seizures.
Conclusions:
- Nonconvulsive seizures and electrographic status epilepticus are frequent in children with abusive head trauma.
- The majority of these seizures lack clinical manifestations, underscoring the importance of EEG.
- Further research is required to ascertain if early seizure detection and intervention improve outcomes in pediatric AHT.
Objective:
To determine the prevalence of nonconvulsive seizures in children with abusive head trauma.
Design:
Retrospective study of children with abusive head trauma undergoing clinically indicated continuous electroencephalographic monitoring.
Setting:
PICU of a tertiary care hospital.
Subjects:
Children less than or equal to 2 years old with evidence of abusive head trauma determined by neuroimaging, physical examination, and determination of abuse by the Child Protection Team.
Interventions:
None.
Measurements And Main Results:
Thirty-two children with abusive head trauma were identified with a median age of 4 months (interquartile range 3, 5.5 months). Twenty-one of 32 children (66%) underwent electroencephalographic monitoring. Those monitored were more likely to have a lower admission Glasgow Coma Scale (8 vs 15, p = 0.05) and be intubated (16 vs 2, p = 0.002). Electrographic seizures occurred in 12 of 21 children (57%) and constituted electrographic status epilepticus in 8 of 12 children (67%). Electrographic seizures were entirely nonconvulsive in 8 of 12 children (67%). Electroencephalographic background category (discontinuous and slow-disorganized) (p = 0.02) and neuroimaging evidence of ischemia were associated with the presence of electrographic seizures (p = 0.05). Subjects who had electrographic seizures were no more likely to have clinical seizures at admission (67% electrographic seizures vs 33% none, p = 0.6), parenchymal imaging abnormalities (61% electrographic seizures vs 39% none, p = 0.40), or extra-axial imaging abnormalities (56% electrographic seizures vs 44% none, p = 0.72). Four of 21 (19%) children died prior to discharge; none had electrographic seizures, but all had attenuated-featureless electroencephalographic backgrounds. Follow-up outcome data were available for 16 of 17 survivors at a median duration of 9.5 months following PICU admission, and the presence of electrographic seizures or electrographic status epilepticus was not associated with the Glasgow Outcome Scale score (p = 0.10).
Conclusions:
Electrographic seizures and electrographic status epilepticus are common in children with abusive head trauma. Most seizures have no clinical correlate. Further study is needed to determine whether seizure identification and management improves outcome.
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