eMedicine Specialties > Neurology > Pediatric Neurology

Neonatal Seizures: Differential Diagnoses & Workup

Author: Raj D Sheth, MD, Professor of Neurology, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic
Contributor Information and Disclosures

Updated: Nov 16, 2009

Differential Diagnoses

Abnormal Neonatal EEG
Seizures and Epilepsy: Overview and Classification
Benign Neonatal Convulsions
Shuddering Attacks
Cerebellar Hemorrhage
Subarachnoid Hemorrhage
Early Myoclonic Encephalopathy
Subdural Hematoma
EEG in Common Epilepsy Syndromes
Tuberous Sclerosis
EEG Seizure Monitoring
Vein of Galen Malformation
Epileptiform Discharges
Viral Encephalitis
Herpes Simplex Encephalitis
Viral Meningitis
Neonatal Injuries in Child Abuse
Neonatal Meningitis

Other Problems to Be Considered

Anoxia
Benign epilepsy syndromes
Mitochondrial cytopathies
Myoclonic epilepsy
Myoclonus
Organic acidurias
Pyridoxine-dependent epilepsy

Workup

Laboratory Studies

  • Serum glucose and electrolytes, including calcium: Transient neonatal hypocalcemia is a cause of neonatal seizures during the first 3 weeks of life. Hypocalcemia associated with chromosome 22q11 deletion syndrome may also be a consideration.
  • CSF analysis: This should include tests checking for pleocytosis, xanthochromia (suggestive of blood breakdown products, particularly if jaundice is not present), lactic acid and pyruvate (for evidence of mitochondrial cytopathies), polymerase chain reaction (PCR) for herpes virus, and glucose concentration (low glucose concentration is suggestive of bacterial meningitis). In the absence of bacterial meningitis, persistently low CSF glucose concentrations may suggest a glucose transporter defect.
  • TORCH (toxoplasmosis, rubella, CMV, herpes) infection studies
  • Urine organic acids
  • Serum amino acid assay
  • Renal function tests: These tests rule out posthypoxic renal dysfunction. Hypoxic damage to multiple organ systems may also be suggested by elevated liver transaminase levels.

Imaging Studies

  • Cranial ultrasonography
    • Cranial ultrasonography is performed readily at the bedside; it is a valuable tool to quickly ascertain whether intracranial hemorrhage, particularly intraventricular hemorrhage, has occurred.
    • A limitation of this study is the poor detection rate of cortical lesions or subarachnoid blood.
  • Cranial CT scan
    • Cranial CT scan is a much more sensitive tool than ultrasound in detecting parenchymal abnormalities.
    • The disadvantage is that the sick neonate must be transported to the imaging site.
    • A distinct advantage is that with modern CT techniques, a study can be obtained in approximately 10 minutes.
    • Cranial CT scan can delineate congenital malformations. Subtle malformations may be missed on CT scan, requiring an MRI study.
  • MRI
    • MRI is the most sensitive imaging modality to determine etiology for neonatal seizures.2  
    • Cranial MRI is the most sensitive test in determining the etiology of neonatal seizures, particularly when electrolyte imbalance has been excluded as a cause for seizures.
    • A major disadvantage is that it cannot be performed quickly and, in an unstable infant, it is best deferred until the acute clinical situation resolves.

Other Tests

  • EEG plays a vital role in properly identifying and differentiating neonatal seizures from nonepileptic events.6 See Media files 1-3.
  • Video EEG monitoring may be helpful when infrequent neonatal seizures persist.7
  • Echocardiography: This study can rule out cardiac hypomotility as a result of more diffuse hypoxia.
Onset of neonatal seizure demonstrating a focal o...

Onset of neonatal seizure demonstrating a focal onset in the right frontal (FP4) region. At this point, the child had head and eye deviation to the left.

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Onset of neonatal seizure demonstrating a focal o...

Onset of neonatal seizure demonstrating a focal onset in the right frontal (FP4) region. At this point, the child had head and eye deviation to the left.


Twenty seconds into a seizure that had focal onse...

Twenty seconds into a seizure that had focal onset in the right frontal (FP4) region (see Image 1), the seizure shows a rhythmic buildup of activity in the right frontocentral region.

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Twenty seconds into a seizure that had focal onse...

Twenty seconds into a seizure that had focal onset in the right frontal (FP4) region (see Image 1), the seizure shows a rhythmic buildup of activity in the right frontocentral region.


This seizure had focal onset in the right frontal...

This seizure had focal onset in the right frontal (FP4) region and subsequent buildup of activity in the right frontocentral region (see Images 1 and 2). As the seizure evolves, the EEG shows diffuse involvement of both cerebral hemispheres.

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This seizure had focal onset in the right frontal...

This seizure had focal onset in the right frontal (FP4) region and subsequent buildup of activity in the right frontocentral region (see Images 1 and 2). As the seizure evolves, the EEG shows diffuse involvement of both cerebral hemispheres.


More on Neonatal Seizures

Overview: Neonatal Seizures
Differential Diagnoses & Workup: Neonatal Seizures
Treatment & Medication: Neonatal Seizures
Follow-up: Neonatal Seizures
Multimedia: Neonatal Seizures
References
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References

  1. Volpe JJ. Hypoxic-Ischemic Encephalopathy: Biochemical and Physiological Aspects. In: Neurology of the Newborn. 4th ed. Philadelphia: WB Saunders; 2000:217-276.

  2. Scher MS, Trucco GS, Beggarly ME, et al. Neonates with electrically confirmed seizures and possible placental associations. Pediatr Neurol. Jul 1998;19(1):37-41. [Medline].

  3. Silverstein FS, Jensen FE. Neonatal seizures. Ann Neurol. Aug 2007;62(2):112-20. [Medline].

  4. Sheth RD, Hobbs GR, Mullett M. Neonatal seizures: incidence, onset, and etiology by gestational age. J Perinatol. Jan 1999;19(1):40-3. [Medline].

  5. Vigevano F. Benign familial infantile seizures. Brain Dev. Apr 2005;27(3):172-7. [Medline].

  6. Sheth RD, Buckley DJ, Gutierrez AR, et al. Midazolam in the treatment of refractory neonatal seizures. Clin Neuropharmacol. Apr 1996;19(2):165-70. [Medline].

  7. Sheth RD. Electroencephalogram in developmental delay: specific electroclinical syndromes. Semin Pediatr Neurol. Mar 1998;5(1):45-51. [Medline].

  8. Sankar R, Painter MJ. Neonatal seizures: after all these years we still love what doesn't work. Neurology. Mar 8 2005;64(5):776-7. [Medline].

  9. Lombroso CT. Neonatal seizures: gaps between the laboratory and the clinic. Epilepsia. 2007;48 Suppl 2:83-106. [Medline].

  10. Painter MJ, Scher MS, Stein AD, et al. Phenobarbital compared with phenytoin for the treatment of neonatal seizures. N Engl J Med. Aug 12 1999;341(7):485-9. [Medline].

  11. Sheth RD. Electroencephalogram confirmatory rate in neonatal seizures. Pediatr Neurol. Jan 1999;20(1):27-30. [Medline].

  12. Sheth RD. Frequency of neurologic disorders in the neonatal intensive care unit. J Child Neurol. Sep 1998;13(9):424-8. [Medline].

  13. Sheth RD, Bodensteiner JB. Delayed postanoxic encephalopathy: possible role for apoptosis. J Child Neurol. Jul 1998;13(7):347-8. [Medline].

  14. [Best Evidence] Pisani F, Sisti L, Seri S. A scoring system for early prognostic assessment after neonatal seizures. Pediatrics. Oct 2009;124(4):e580-7. [Medline].

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Further Reading

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Keywords

neonatal seizures, benign familial neonatal convulsions, benign neonatal convulsions, fifth day convulsions, fifth day fits, myoclonic seizures, newborn fits, hypoxic-ischemic encephalopathy, intracranial hemorrhage in a newborn, subarachnoid hemorrhage in infants, germinal matrix-intraventricular hemorrhage, subdural hemorrhage, cerebral contusion, metabolic disturbances, hypoglycemia, hypocalcemia, hypomagnesemia, meningitis, encephalitis, herpes encephalitis, toxoplasmosis, cytomegalovirus, CMV infection, lissencephaly, pachygyria, polymicrogyria, linear sebaceous nevus syndrome, benign neonatal seizure syndromes, benign idiopathic neonatal seizures, benign sleep myoclonus

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Contributor Information and Disclosures

Author

Raj D Sheth, MD, Professor of Neurology, Mayo College of Medicine; Chief, Division of Pediatric Neurology, Nemours Children's Clinic
Raj D Sheth, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, American Neurological Association, and Child Neurology Society
Disclosure: Nothing to disclose.

Medical Editor

Robert Stanley Rust Jr, MD, MA, Thomas E Worrell Jr Professor of Epileptology and Neurology, Co-Director of FE Dreifuss Child Neurology and Epilepsy Clinics, Director, Child Neurology, University of Virginia; Chair-Elect, Child Neurology Section, American Academy of Neurology
Robert Stanley Rust Jr, MD, MA is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, American Headache Society, American Neurological Association, Child Neurology Society, International Child Neurology Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kenneth J Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic
Kenneth J Mack, MD, PhD is a member of the following medical societies: American Academy of Neurology, Child Neurology Society, Phi Beta Kappa, and Society for Neuroscience
Disclosure: Nothing to disclose.

Chief Editor

Amy Kao, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Neurology, Department of Neurology, Oregon Health and Science University; Consulting Staff, Shriners Hospital for Children
Amy Kao, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

 
 
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