The Findings of Brain Computed Tomography in Neonatal Seizure
Amjaad Majeed Hameed, Nasma Naji AL-Hijia
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Keywords : Findings of Brain, Neonatal Seizure,The Findings of Brain Computed Tomography in Neonatal Seizure
| Medical Journal of Babylon 8:1 , 2014 |
doi:1812-156X-8-1 |
| Published :2011 |
|
Abstract
Background: Seizure is the commonest neurological manifestation in the neonatal period, and usually it
shows an underlying problem in the brain due to brain damage and developmental defect in the central
nervous system. As CT(computed tomography ) scan is more reliable, more sensitive and more specific in
determining underlying brain lesion that cause seizure like ischemia, hemorrhage and brain structural
dysgenesis, so it became an important tool in assessment of neonatal convulsion.
Aim of study : To find abnormality in CT scan which are the possible causes for neonatal convulsion .
Patients and methods :A descriptive study ,performed for 70 neonates referred for CT scan of the head
from period of the first of the January 2008 to the first of April in 2010 in AL-Diawanyia teaching hospital
in Iraq after good history information, clinical examination and paraclincal investigation. All informations
are collected in check list, including time of occurring seizure & underlying causes. CT scan(Siemens)
used is with multiple axial sections, after general anesthesia to the neonate .
Results :From 70 neonates with neonatal seizures 28 were female and 42(60%) were male, 39 neonates
have normal CT scan and 31 have abnormal CT scan such as brain dysgenesis, intracranial hemorrhage,
brain ischemia and cerebrites.
Conclusion :High incidence of abnormal CT scan (87.5%) in seizure occurring during the first 72hours.
Among those positive CT scan of brain hypoxic ischemic was found in (45.9%) .
Introduction
eizure is the commonest
neurological manifestation in the
neonatal period (the first 28 days
of life), it can define as paroxysmal
alternation in neurological function e.g.
behavioral, motor, or autonomic function
and usually it shows an underlying
problem in the brain due to brain
damage and developmental defect in the
central nervous system[1-5].
Among the abnormal neurological signs,
neonatal seizure have a particularly poor
prognosis[6-8] . Early onset of seizures
is a strong predictor of later morbidity
and mortality in infant. Neonates are at
particular risk for the development of
seizure, because metabolic, toxic,
structural and infections disease manifest
more during this time, than any other
period of life. Sometime neonatal seizure
caused by treatable disorders that if not
diagnosed, can cause permanent brain
damage. Neonatal convulsion are
dissimilar from those in a child and adult
because generalized tonic-clonic
convulsions tend not to occur in the first
month of life [9.10].
The most common causes of neonatal
seizure in first 1-3days of life is: hypoxic
ischemic encephalopathy, intraventrcular
hemorrhage, hypocalcaemia,
hypoglycemia and inborn error of
metabolism . While in neonates with age
group 4-14 days the common causes of
seizure are infection, metabolic disorders
and kernicterus. In neonate between 2-
8week the causes of convulsion tend to
be infection, head injury and
malformation of cortical development
[10].
The work up in the management of
neonatal seizure should include a carful
prenatal and natal history as well as
complete physical examination and
laboratory studies which is should
include blood glucose, blood bilirubin
,electrolytes, calcium, phosphate and
magnesium are the next step .If there is
any suspicion of infection, a spinal tap
should be done to rule out meningitis
.Neuroimiging studies (cranial
ultrasound, CT scan or magnetic
resonance imaging (MRI)) are
mandatory to help us in the diagnosis of
ischemic, hemorrhagic changes and
brain dysgenesis which were observed in
high frequency in neonates with
seizure[5,11]. .Additional studies,
include blood level for ammonia, lactate,
pyrovate and urine studies for organic
and aminoacid analysis for possible
inborn error of metabolism. Serial EEGpolygraphy
can document persistent of
seizure [12, 13].
Among the radiological investigations
magnetic resonance imaging and CT
scan are commonly used to screen
neonatal intracranial lesions and both of
them have significant advantages over
sonography for diagnosing causes of
convulsion [14].
As CT scan is more reliable more
sensitive and more specific and even its
better than US in determine underlying
brain lesion that cause seizure like
ischemia, hemorrhage and brain
structural dysgenesis, so it became an
important tool in The assessment of
neonatal convulsion [15-18].
MRI seem to be more sensitive than CT
scan for detection of subtle brain
injuries & it plays an important role in
the work up of brain pathology, it has
advantages over CT scan (no expos to
ionizing radiation & provides better
brain morphological assessment). New
generations of MRI (included diffusion
weighted images & perfusion weighted
images) has made it possible to perform dynamic & functional analysis of
cerebral circulation ) & this lead to
increase its usefulness in diagnosing
acute brain ischemic changes. The major
drawback of MRI is the unavailabile of
MR-scanner, high cost, long
examination time and difficult
interpretation [19-24].
Materials and methods
A descriptive study, performed for 70
neonates referred for CT scan of the
head from period of the first of the
January 2008 to the first of April in
2010.
Those neonates were referred for CT
scan from the neonatal intensive care
unit or from pediatric outpatient clinic
in the maternity and children teaching
hospital in AL-Diawanyia in Iraq after
good history information, clinical
examination and investigation, all
information are collected in check list,
included neonatal demography (age, sex,
maturity index, referring complaint time
of onset of seizure, the possible
underlying causes).
The patients included in this study are
the neonates who had convulsion
diagnosed by a pediatrician during the
first twenty eight days of life and
cranial CT scan done for them.
Neonates excluded from this study if
have convulsion but CT scan was not
done because the family refused to do
CT scan or when there is
contraindication for anesthesia .
CT scan(Siemens. Emosion 4, VA47C )
with multiple axial sections, slice
thickness 3mm,( kv 130. Ms 30) without
contrast after general anesthesia to the
neonate using minimum dose of
fluthane inhalation by Penlon
anesthetic machine with about 1
MAC(minimal alveolar concentration ) .
Statistical analysis used in this study
include frequency, percentage, incidence
of abnormal brain CT in the first three
days of life, and incidence of ischemic
hypoxic encephalopathy in neonate with
positive CT scan findings .
Results
The total number of patients involved in
this study was 70, among them 42 was
male (60%) and 28 female (40%) .As
show in figure 1.
The mode of delivery in 45 neonates was
normal vaginal delivery (64.3%) and in
25 neonates was cesarean section
(35.7%) . The majority of neonates were
term 53 (75.7%) and only 17 were
preterm infant(24.3%).
Thirty nine neonates have normal CT
scan and 31 have abnormal CT scan (
Table – 1). The CT abnormality were
brain dysgenesis, intracranial
hemorrhage, brain ischemia and
cerebritis. The majority of neonatal
seizures with positive CT findings occur
during first three days of life 21(30.2%)
followed by 6(8.8%) and 4(5.2%)
during the next 4-14days and 2-4weeks
respectively. Intracranial hemorrhage
occur in 5 patients and all of them have
seizure during 1st three day of life.
Hypoxic ischemic encephalopathy found
in 15neonate, eleven of them have
seizure during 1st three days and only
one neonate have intracranial cerebrites .
Female
40%
Male
60%
Intracranial hemorrhage found in 5
patients and 4 of them are preterm
neonates
Hypoxic ischemic encephalopathy
found in 15 patients and only 3 of them
are preterm babies.
Three out five patients with intracranial
hemorrhage have normal vaginal
delivery and 11neonates out of 15 with
hypoxic ischemic encephalopathy had
normal vaginal delivery.
From table -2- we found high incidence
of abnormal CT scan (87.5%) in seizure
occurring during the first 72hours.
Among those abnormal CT findings
found high incidence of hypoxic
ischemic encephalophathy (48.34%).
The frequency of structural brain
abnormalities ( brain dysgenesis )
observed in 10 neonates (32.3%) as
shown in Table -3- large cistern magna
was observed in 3 neonates,
schizencephaly in one patient,
hydrocephaly in 2 neonates ,large cavum
septum pellucidum in one neonate,
porencephaly in 2 patients and
arteriovenous malformation in 1
neonate.
Figure -2-Shows the etiology of seizure
in neonates with normal CT scan
kernicterus found in 8 neonates
(20.5%), metabolic disorders in 6
patients (15.4%), (four patients had
hypoglycemia & other two patients had
hypocalcaemia), meningitis in 10
neonate (25.7%) and unknown causes in
15 neonates (38.5%)
Discussions
Seizure is the most frequent sign of
neurological dysfunction in the neonate
most neonatal seizure occur between 12
and 48 hours of life and its not only
more frequent in neonatal period but
also very difficult to diagnosis because
of subtle nature [25,26]. The most
common cause of neonatal seizure is
hypoxic –ischemic encephalopathy
(60%), many additional disorders are
likely to cause seizure including
intracranial hemorrhage(15%),
metabolic, infectious, traumatic,
structural, and maternal disturbances
[14,10].
In this study there is an overall male
preponderance (60%) which is consistent
and support with other studies
Moayedi et al[27], Taghdiri et al[28] and
Sanjeev et al[29] who also reported
male sex preponderance in their studies
for which no plausible mechanism has
been proposed, Moayedi et al
[27])reported a significant relationship
between occurrence of seizure and sex (p
0.05),Taghdiri et al [28]found (65%) of
neonate were male, while Sanjeev et
al[29] found (70.5%) were male and
Sanjeev et al believe that male babies
are cared better by their parents and are
brought to the hospital even with minor
complains but female babies are usually
neglected and are managed at home even
if they are very sick. This can be one
factor in causing male sex
preponderance.
Majority of neonates were term(75.7%)
and majority of them a product of
normal vaginal delivery (64.3%)which is
also go with Sanjeev et al and Moayedi
et al findings ,Sanjeev et al reported
(82.3%) of cases were term and
Moayedi et al report (65.6% )of cases
were product of normal vaginal delivery
and (73.6%) were term neonate.[28,29].
In this study we can explain this findings
by most common causes of neonatal
convulsion were postnatal
complications.
Thirty nine neonates(55.8%) had normal
CT scan of the head and other thirty one
(44.2%) neonates have positive CT scan
findings .This is in contrast to findings
of Taghdiri et al[28] who found that
35% of neonate had normal CT finding
and 65% had abnormal findings, our
findings can be explained that majority
of postnatal complications which are the
most common causes of seizure in our
study do not shows structural brain
changes until it have certain
complication or it became late stages
[30, 31].
We found that the majority of neonate
with positive CT findings had seizure
occurring in the first three days of life
which is also goes with the findings of
Taghdiri et al [28]who report that there
is a high incidence of abnormal CT scan
(65%) in seizures occurring during the
first 72 hours, also this finding goes
with Sanjeef et al[29] who found high
incidence of abnormal CT scan ( 67.6%)
in neonatal having convulsion during
the 1st 72 hours of life and goes with
findings of Erikson et al[32] who
reported that highest incidence of
positive CT findings occur in the 1st and
2nd days of life. In our study, we can
explain this by that early convulsions
may be caused by prematurity,
asphyxia and difficult labours which
gives positive CT findings [30]this
explanation is in line with Maharban
S[33] who found that birth asphaxia and
intracranial hemorrhage are together
account for about half of early onset
seizures followed by other causes. Also
this explanation goes with Tekgul et al
[34]who reported that cerebral hypoxia
and difficult labor are the most common
causes of early neonatal convulsions.
Among those neonates who presented
with abnormal CT scan, hypoxic
ischemic encephalopathy seen in
(45.9%) , which goes with Renon et al
study (40%) [35]& Arpino et al study
[36].
Conclusions
High incidence of abnormal brain CT
scan finding (87.5%)in neonatal seizure
occurring during the first 72 hours after
birth, high incidence of hypoxic
ischemic encephalopathy in neonatal
convulsions during first three day of life
(45.9%) which is occur in the preterm
and prolong , difficult labour,
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