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Diagnosis of Neonatal Seizure by Continuous Recording and Rapid Analysis of the Electroencephalogram

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Diagnosis of Neonatal Seizure by Continuous Recording and Rapid Analysis of the Electroencephalogram Arch Dis Child: first published as 10.1136/adc.58.10.785 on 1 October 1983. Downloaded from Archives of Disease in Childhood, 1983, 58, 785-790 Diagnosis of neonatal seizure by continuous recording and rapid analysis of the electroencephalogram J A EYRE, R C OOZEER, AND A R WILKINSON Department ofPaediatrics, John Radcliffe Maternity Hospital, Oxford SUMMARY Clinical diagnosis of neonatal seizure is difficult and repeated seizures may be unrec- ognised. To assist in early diagnosis we recorded continuously the electroencephalogram (EEG) of very sick newborns while intensive care continued. In 25 babies at high risk of seizure a continuous record of two channels of EEG, ECG, and respiration was made for periods varying from 11 hours to 16 days. The method employed produced an EEG largely free of movement and electrical artefact which was analysed rapidly using a visual display unit. Electroencephalographic seizure activity was recorded in 20 babies, and continuous monitoring-of the EEG allowed earlier recognition of seizure than was possible with clinical observation. Seizures during the neonatal period are a consider- need to monitor continuously the EEG of very sick able problem, not only because they are a symptom babies receiving intensive care. There are major of neurologic or metabolic disorder, but because problems associated with a making prolonged copyright. there is a strong association between seizure and record of a standard EEG. Firstly, the record is permanent handicap in the survivors. Recent studies subject to artefact during the babies' spontaneous in animals by Wasterlain et al. suggest that the poor movements and during nursing and medical pro- prognosis may not be a consequence solely of the cedures; secondly, electrical interference poses underlying illness, but that the neonatal brain is appreciable difficulties; and finally, the recorder is susceptible to permanent damage as a consequence large and may obstruct access to the baby. We aimed of the seizures.'-6 to assess a new method of making a continuous Watanabe, in a study of 215 newborns with record of the EEG in very sick babies receiving http://adc.bmj.com/ clinical signs of seizure confirmed by electro- intensive care and to evaluate the usefulness of these encephalogram (EEG), found that 11 .3 % had records in the diagnosis ofseizure. atypical or subtle physical signs. He described the presence of subclinical seizures but did not give an Patients incidence.7 Rose and Lombroso also found that 19 of 137 babies (14%) with EEG evidence of seizures had very few accompanying clinical signs.8 Electro- Twenty five babies who were considered to be at high encephalographic seizure activity has been reported risk of seizure because of perinatal complications on September 28, 2021 by guest. Protected in newborns who were paralysed to facilitate artificial were studied. The clinical details are summarised in ventilation.9 10 The diagnosis of seizure in the the Table. Their birthweights ranged from 790- newborn is therefore difficult, and repeated seizures 4160 g, and their gestational ages at the time of may be unrecognised. the record ranged from 26-41 weeks. The reported incidence of seizures in the newborn varies from - 5-144-0/1000 live births."-16This may Methods be the result of differences in the population at risk and in perinatal care, but it may also reflect the A small battery powered four channel tape recorder difficulty in making an accurate clinical diagnosis of which measured 112 x 86 x 36 mm was used to seizure. In babies who are admitted to an intensive record two channels of EEG, one channel of ECG, care nursery the incidence is as high as 3 %.17 and on the fourth channel a time signal and an event The high incidence of seizures, the difficulty in mark or else transthoracic impedance. (Medilog making a diagnosis, and the increasing use of 4-24 Recorder and HDX-82 Preamplifiers. Oxford paralysis to facilitate artificial ventilation indicate a Medical Systems). The tape speed allowed 24 hours 785 Arch Dis Child: first published as 10.1136/adc.58.10.785 on 1 October 1983. Downloaded from 786 Eyre, Oozeer, and Wilkinson Z 0YZ Q ° z Q Y < Q o; Z O ° 0 8 0 0 0 0 OA 0~~~~~~~~~~~~~0 00%~~E0 0E 04 0 0 N~ ~ ~ ~~~0LVC z04440~~~~~~~~~u z 0 'O -NI 0 0 )'0)e 4 c >r w'o r 0 00 0) '0 0d0 0 c 0 U d .0. .0 o5%o '~ 0: 0 No 0 5% '5 0 0 0 N N NNN. r. r.0 0 0 0 rNrN 00d0 00 0..0~ 0' c:06 0 0 Oa O644no NOR 26 g0 , .0 I o N- %0o .0 . 0 e 000 00 ^ 00_O o >on 0 0 0% en0 .0 A~ 0 A C 1; - ; en00 00 0 ° I I I .C-0 E 0 0 _e en a .0 N -_ 0 r O 0 exn 00 000_ 0% 0000% 0% 00 I I I :3 AZ) 0 - 0p* - N k3 0 e. .0 n - 0 00 t- .,0 U" 0n -00 ID I I copyright. _- F _oo 4z r- o"t - - t o 00 t- oen0 ^ en _ o -000 00 o in oo-* en o % o00 W,ot>,en _- - _ 0'-' 00 0 00 o 0 0 -R o 00 N - r 4 0 eC-N g 0 _00 v t oo00 00en .4 % t-- t- o Cso4 'O. %I_ U N_4 0000) http://adc.bmj.com/ 't:`2 . .0) L. C'I 'I 00 0 ItI 0 N- 4 -4 0 o-o N la .0 N N _ .4 _ c~~~~~~~. on September 28, 2021 by guest. Protected c co E. c 0D 0 0 0 0 0 0 0 0 0 00- I 080 08 00 ot 0 en en ON ,t en 4n ONi m en I'9 -0 o F at a ks en(I -1n "o - 't en It en en-_ 4 en 0a%en .0 00 v 0 I 0 0 en 000 00 - N 00 c) I' vIt en° en en en eq c v N 't en en en e oa'C4c P : a vL. [J. :~ L4I0v.': ~ Arch Dis Child: first published as 10.1136/adc.58.10.785 on 1 October 1983. Downloaded from Recording and rapid analysis ofthe neonatal electroencephalogram 787 of record to be stored on a conventional 120 minute recorded signal as 'pages' of data comprising 8 or 16 cassette tape (TDK AD-C 120, TDK Electronic). seconds of EEG, ECG, and thoracic impedance The EEG was recorded using silver/silver chloride record. The 'pages' were presented at a 20th or a cup electrodes filled with saline jelly. These were 60th of the real time; in the latter case allowing fixed to the scalp with collodion and the holes in the rapid visual scanning of 24 hours of data in 24 electrode were sealed with collodion to prevent minutes. Sections of the record showing abnormality evaporation of the conducting gel (Fig. 1). The could then be reviewed at a manually operated speed. skin/electrode impedance was measured at 6-8 During the recording, a bedside monitor (Oxford hourly intervals and kept below 5 K ohm. When Medical Systems) was used to display simultaneously necessary the collodion seal was dissolved with the EEG, the ECG, the heart rate, the chest wall acetone and additional conducting jelly was injected. movement and, in those babies with intra-arterial The hole was then resealed with collodion. The EEG catheters, the blood pressure wave form. record was bipolar between F3-P3 and F4-P4 with an A standard definition of an electroencephalo- indifferent electrode placed on the scalp. The filter graphic seizure discharge was used. This was an band width was set at 0 * 5-100 Hz. orderly build up and termination of rhythmic sharp The transthoracic impedance was measured using and slow waves, where the discharge persisted for silver/silver chloride cup EEG electrodes filled with longer than 20 seconds (Fig. 2), or the sudden onset saline jelly attached to the chest with collodion and and termination ofrepetitive and rhythmical waves of the ECG was recorded from silver/silver chloride a single frequency in the 4-13 Hz range (Fig. 3) when disposable electrodes. the discharge persisted for longer than 20 seconds.'8 The tape record was reviewed at intervals deter- In a preliminary study in which a standard EEG mined by the clinical condition of the baby and by recorder was used, we found that if the electrodes the previous findings. The tape was replayed on a alone were fixed to the skin then artefact resulting visual display unit (PMD 12 Virgo Special, Oxford from movement was an appreciable problem. This Medical Systems) that automatically presented the copyright. Boy Age 2days (26 weeks gestation) ECG -l- , ,& ,-s 4 Resp F3-P3 http://adc.bmj.com/ F4-P4 00JuV Ilis I~414-1 4-4V-4--44- on September 28, 2021 by guest. Protected j44-~P~444- II 44A4444A-4 Fig. 2 Siezure discharge with abrupt onset of Fig. 1 Attachment ofelectrodes andpreamplifiers synchronous and symmetrical rhythmic sharp and to the scalp wjth collodion. slow waves in the right and left channel ofthe EEG. Arch Dis Child: first published as 10.1136/adc.58.10.785 on 1 October 1983. Downloaded from 788 Eyre, Oozeer, and Wilkinson Girt Age 6 weeks (24weeks gestation) ECGpJ ½-' 1 1 FP2 -FS ' Resp 7<<<t-<<>ti t^ ^ F,8 T4 k/- ~~~~~T4-02 loo,uv L. ioo,uvL ls F7 T3 ls \J J V\ono t <\J7. .. ~~~~~F 104,CVEMG ! ~~~~~~nght 4T is-T zv > F4 P4 Fig.
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