신생아 경련과 예후에 관한 고찰

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: 2009 5 27 , : 2009 10 26

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Tel : 054)770-8254, Fax : 054)770-8500 E-mail : [email protected]

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대상 및 방법

신생아 경련과 예후에 관한 고찰

송 화 조은영 김애숙 이선주 이동석 최성민 김두권․ ․ ․ ․ ․ ․

= Abstract =

A Study of Clinical Features and Prognosis of Neonatal Seizures

Hwa Song, M.D., Eun Young Cho, M.D., Ae Suk Kim, M.D., Sun Ju Lee, M.D.

Dong Seok Lee, M.D., Sung Min Choi, M.D. and Doo Kwun Kim, M.D.

Department of Pediatrics, College of Medicine, Dongguk University, Gyeong-ju, Korea Purpose : Neonatal seizures are relatively common and the symptoms are clinically dif- ferent from those in older children and adults. The goal of this study is to help understand neonatal seizures by analyzing the etiology, clinical features, method of diagnosis and pro- gnosis of the affected patients in our hospital.

Methods : Twenty six cases with neonatal seizures who were admitted to the neonatal intensive care unit, Dongguk University Hospital from January 1999 to October 2008 were retrospectively reviewed. They were evaluated with risk factors, neurologic examinations, laboratory data, neuroimaging studies, EEG findings, seizure types, response to treatment, and outcomes.

Results : Subtle seizure came out to be the most common seizure type(9 patients: 34.6

%). The cause of neonatal seizures were hypoxic-ischemic encephalopathy(9 patients: 34.6

%), intracranial hemorrhage(8 patients: 30.8%), electrolyte imbalance(8 patients: 30.8%), meningitis(7 patients: 26.9%). Nineteen out of 25 patients showed abnormal lesion on neu- roimaging studies such as intracranial hemorrhage, periventricular leukomalacia, brain in- farction, etc. Abnormal EEG findings were noted in 19 patient(73.1%). Phenobarbital was tried as a first line antiepileptic drug and phenytoin was added if it failed to control seizures.

The overall outcome was relatively good except for those with abnormal EEG findings.

Conclusion : Neonatal seizures signify underlying diseases. Recognition of etiology is often helpful in prognosis and treatment. Neuroradiological and EEG findings are important in predicting neurologic outcomes in newborns with seizures.

Key Words : Neonatal seizures, EEG, Neurologic examinations, Prognosis

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1999 1 2008 10

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Rose

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결 과

성비 및 출생 기록 1.

26 15 ,

11 . 31 6 41

38.3±2.9 37

3 . 2,500 g

20 (76.9%) 2,500 g 6 (23.1

%) . 26 6 (23.1%)

Moro 4 (15.4%), 2 (7.7%) (Table 1, 2).

경련의 발생 시기 2.

26 24

7 (26.9%), 2-3 6 (23.1%),

4-7 6 (23.1%), 7 (26.9

%) . 3

20 (76.9%) , 3 30

5 (19.2%), 30 1 (3.8%)

. 3 6 (23.1%), 4

10 6 (23.1%), 11

14 (Table 3).

26 6 (23.1%) 3

3 (11.5%) 4 .

6 (23.1%) 3 2

(7.7%) 3 . 7

(19.2%) 3 (11.5%) 3 , 4 (15.4%)

3 . 4 (15.4%)

3 2 (7.7%)

1 3

Table 1. Baseline Characterstics of Patients

Characteristics Number

Number of patients Male:Female Gestational age

<37weeks 37weeks

≥

Birth weight

<2,500 g 2,500 g

≥

26 15:11

3(11.5%) 23(88.5%)

6(23.1%) 20(76.9%)

Table 2. Physical Finding at Time of Seizures Abnormal physical findings

Decreased Moro reflex Cephalohematoma Normal

6(23.1%) 4 2 20(76.9%)

Table 3. Characteristics of Seizures

Characteristics Number

Onset 24 hrs

≤

24 hrs< ≤ 72 hrs 72 hrs< ≤ 7 days 7 days< ≤ 28 days Duration

3 min

≤

3 min< ≤ 30 min

>30 min Frequency

3 ≤ 4< ≤ 10

>10

7(26.9%) 6(23.1%) 6(23.1%) 7(26.9%)

20(76.9%) 5(19.2%) 1( 3.8%)

6(23.1%)

14(53.8%)

(3)

. 2 (7.7%) 3

, 1 (3.8%) 3

(Table 4).

발작 형태 3.

9 (34.6%) ,

7 (26.9%),

5 (19.2%), 3 (11.5%),

2 (7.7%) , -

(Table 5).

뇌파 소견 4.

26 24 (92.3%) 19 (73.1%)

abundance of sharp transients 1 (3.8%), se- verely depressed electrical activity 3 (11.5%), (focal spike with normal background) 6 (23.1%),

(focal spike with abnormal background) 3 (11.5%), - (burst-suppression) 4

(15.4%), focal monorhythmic periodic pattern 1 (3.8%), (multifocal icteric pat-

terns) 1 (3.8%), (diffuse

continuous slow background activities) 1 (3.8

%) , 4 (15.4%) .

20 (76.9%) 17 (65.4%)

5 (19.2%),

5 (19.2%), - 1

(3.8%), 1 (3.8%) , 5 (19.2

%) (Table 6).

뇌영상 소견 5.

26 25 (96.2%) , 19 (73.1%)

. 8 (30.8%), 4 (15.4

%), 3 (12%) ,

(mild ventriculomegaly) 1 (3.8

%), (cyst on germinal matrix) 1 (3.8%), (cyst at caudothala-

mic groove) 1 (3.8%), (cyst

on pituitary gland) 1 (3.8%) (Table 7).

치료 및 반응 6.

, , ,

1 (3.8%) pheno-

barbital . 9 (34.6%) phenobarbi-

Table 4. Etiolgy of Neonatal Seizures

Onset age of seizure ≤ 3 days >3 days Total

Hypoxic-ischemic encephalopathy Intracranial hemorrhage

Meningitis

Electrolyte imbalance hypocalcemia hypoglycemia

hyponatremia and hypocalcemia hypernatremia

Unknown

6(23.1%) 6(23.1%) 3(11.5%)

2( 7.7%) 2( 7.7%) 2( 7.7%) 0( 0%) 1( 3.8%)

3(11.5%) 2(7.7%) 4(15.4%)

1( 3.8%) 0( 0%) 0( 0%) 1( 3.8%) 1( 3.8%)

9(34.6%) 8(30.8%) 7(26.9%)

3(11.5%) 2( 7.7%) 2( 7.7%) 1( 3.8%) 2( 7.7%) Table 5. Seizure Types

Subtle

Multifocal clonic Generalized clonic Focal clonic Generalized tonic

9(34.6%)

7(26.9%)

5(19.2%)

3(11.5%)

2( 7.7%)

(4)

tal , 4 (15.4%) phenobarbi-

tal phenytoin , 1 (3.8%)

phenobarbital, phenytoin, lorazepam

, 1

(3.8%) midazolam .

8.2±2.7 ,

16 2 (7.7%)

1 8 10 (38.4%), 8

4 (15.4%) (Table 8).

예 후 7.

26 16 (61.5%)

, 3 (11.5%) ,

(Table 9). 16 (61.5%)

2 (7.7%) 8 (30.8%)

, 3

(11.5%) .

10 (38.5%)

3 6 (23.1%) 3

. 3 (11.5%)

4 (15.4%)

5 (19.2%) 4 (15.4%) .

26 7 (26.9

%) 4 (15.4%), 3 (11.5%),

Table 8. Treatment and Duration of Therapy Treatment

Phenobarbital

Phenobarbital, phenytoin

Phenobarbital, phenytoin, lorazepam Calcium gluconate, phenobarbital Calcium gluconate

Glucose, sodium Midazolam drip Treatment duration

During admission 1 ≤ <8 weeks

8 weeks

≥

9(34.6%) 4(15.4%) 1( 3.8%) 1( 3.8%) 4(15.4%) 4(15.4%) 1( 3.8%)

2( 7.7%) 10(38.4%)

4(15.4%)

Table 9. Overall Prognosis Normal

Epilepsy

Developmental delay Cerebral palsy

Epilepsy, cerebral palsy developmental delay Unknown

16(61.5%) 3(11.5%) 2( 7.7%) 1( 3.8%) 1( 3.8%)

3(11.5%) Table 6. Electroencephalographic Finding

Initial F/U Abnormal

Abundance of sharp transients

Severely depressed electrical activity Focal spike with normal

background Focal spike with

abnormal background Burst-suppression pattern Focal monorhythmic

periodic pattern

Multifocal icteric patterns Diffuse continuous slow

background activity Normal

Not done

1( 3.8%)

3(11.5%)

6(23.1%)

3(11.5%)

4(15.4%) 1( 3.8%)

1( 3.8%) 1( 3.8%)

4(15.4%) 2( 7.7%)

5(19.2%)

1( 3.8%)

5(19.2%) 9(34.6%)

Table 7. Neuroimaging Findings of Patients Abnormal

Intracranial hemorrhage Infarction

PVL

Mild ventriculomegaly Cyst on germinal matrix Cyst at caudothalamic groove Cyst on pituitary gland Normal

Not done

19(73.1%)

8

4

3

1

1 6(26.9%)

1( 3.8%)

Abbreviations : PVL, periventricular leukomalacia

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2 (7.7%) 1 (3.8%)

, .

3 (11.5%)

, 2 (7.7%) . 2 (7.7

%) , 1 (3.8%)

.

3 (11.5%), 2 (7.7%),

2 (7.7%)

. 1 4 (15.4

%), 1 -3 3 (11.5%) , 2

(7.7%) 10 , 5 (19.2

%) 10 3 10

. 7 (26.9%)

6 (23.1%) , 4

(15.4%) . 7

(26.9%) 6 (23.1%) 6 (23.1

%) ,

1 (Table 10, 11).

고 찰

,

. Table 10. Clinical Features of Patients with Poor Prognosis(N=7)

Case Outcome GA(wk) BW Etiology Type Onset Duration Freq

1 2 3 4 5 6 7

Epilepsy+CP+DD Epilepsy

CP DD Epilepsy

DD Epilepsy

40 37+3 39+6 40 40+2

40 40+3

3,900 g 2,370 g 3,480 g 3,000 g 2,850 g 3,080 g 3,400 g

meningitis none HIE, ICH meningitis

HIE HIE SDH

subtle subtle subtle GT MC GT MC

2 days 4 days 1 day 23 days

4 days 2 days 28 days

3 min

≤ 3 min

≤

>10

>10 5

>10 Abbreviations : GA(wk), gestational age(weeks); BW, body weight; Freq, frequency; CP, cerebral palsy;

DD, developmental delay; HIE, hypoxic-ischemic encephalopathy; ICH, intracranial hemorrhage; SDH, subdural hemorrhage; GT, generalized tonic; MC, multifocal clonic

Table 11. EEG & Neurologic Image of Patients with Poor Prognosis(N=7)

Case Outcome EEG(initial) EEG(F/U) Neuroimage

1

2

3 4 5 6

7 Epilepsy+CP+DD

Epilepsy

CP

DD Epilepsy

DD

Epilepsy

Focal monorhythmic periodic pattern

Focal spike with normal background

Burst-suppression

Not done

Burst-suppression Focal spike with normal

background

Focal spike with normal background

Focal spikes with normal backbround

Focal spike with abnormal background

Focal spike with normal background

Not done

Multifocal icteric patterns Normal

Focal spike with normal background

PVL

Normal

ICH

Not done Infarction Normal

ICH

Abbreviations : CP, cerebral palsy; DD, developmental delay; PVL, periventricular leucomalacia; ICH, in-

tracranial hemorrhage

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24 20 (76.9%)

6 (23.1%), - 4 (15.4%),

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3 (11.5%), abundance of sharp transients 1 (3.8%), focal monorhythmic periodic pattern 1

(3.8%), 1 (3.8%),

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5 (19.2%),

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8 (30.8%), 7 (26.9%) ,

8 (30.8%), 2 (7.7%) . 25 19 (73.1%)

8 (31

%), 3 (12%), 4

(15.4%) , 1 (3.8%),

1 (3.8%),

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19 (73.1%)

abundance of sharp transients 1 (3.8%), 3 (11.5%),

6 (23.1%),

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1 (3.8%), 1

(3.8%) , 4 .

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