Electroencefalograma integrado por amplitud para la detección de convulsiones neonatales. Un punto de vista electrofisiológico

Las convulsiones neonatales están asociadas a una alta morbi-mortalidad por lo que su correcto diagnóstico y tratamiento es fundamental. Las convulsiones en los recién nacidos son frecuentemente subclínicas lo que hace que su detección sea dificultosa. La electroencefalografía integrada por amplitud es una técnica de monitoreo electroencefalográfico simplificado que ha encontrado una creciente aplicación clínica en las unidades de terapia intensiva neonatales. Su principal ventaja es la relativa simplicidad de su interpretación lo que permite a personal no especializado del equipo neonatal diagnosticar convulsiones electrográficas en tiempo real. Sin embargo, para evitar diagnosticar erróneamente artefactos rítmicos como crisis epilépticas es necesario reconocer los patrones electrofisiológicos ictales en el EEG convencional disponible en los dispositivos actuales. El objetivo de este artículo es describir las bases electrofisiológicas para la diferenciación de convulsiones neonatales y artefactos extracraneanos para evitar errores diagnósticos con el uso de EEG integrado por amplitud.

Palabras-clave:
Eletroencefalografia; convulsiones; convulsiones neonatales

Autoria

Sebastián Gacio Correspondence: Sebastián Gacio; División de Neurología, Hospital de Niños R. Gutiérrez. Gallo 1330 (C1425EFD), Ciudad Autónoma de Buenos Aires, Argentina. E-mail: neurogacio@gmail.com

Hospital de Niños Ricardo Gutiérrez, División de Neurología, Ciudad Autónoma de Buenos Aires, ArgentinaHospital de Niños Ricardo GutiérrezArgentinaBuenos Aires, ArgentinaHospital de Niños Ricardo Gutiérrez, División de Neurología, Ciudad Autónoma de Buenos Aires, Argentina

Hospital Juan A. Fernández, División de Neonatología, Ciudad Autónoma de Buenos Aires, ArgentinaHospital Juan A. FernándezArgentinaBuenos Aires, ArgentinaHospital Juan A. Fernández, División de Neonatología, Ciudad Autónoma de Buenos Aires, Argentina

http://orcid.org/0000-0002-0017-0208

Correspondence: Sebastián Gacio; División de Neurología, Hospital de Niños R. Gutiérrez. Gallo 1330 (C1425EFD), Ciudad Autónoma de Buenos Aires, Argentina. E-mail: neurogacio@gmail.com

Conflict of interest: There is no conflict of interest to declare

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Figuras

Figuras (4)

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Figure 1
(A) Continuous background pattern, with prominent sleep-wake cycle: upper-margin voltage is > 10 mV and lower margin voltage is > 5 mV (arrow). The sleep-wake cycle is characterized by smooth cyclic variations, mainly of minimum amplitude, with periods of broader bandwidth that represent quiet sleep (circle) and periods of narrow bandwidth that correspond to wakefulness or active sleep (arrowhead). (B) Discontinuous background pattern: upper margin is > 10 mV and lower margin is < 5 mV. The sleep- wake cycle is not present. (C) Burst suppression pattern: upper and lower margin voltages are < 10 mV and <5 mV respectively reflecting voltage suppression, vertical lines (arrow) show periods of burst. Conventional EEG row shows a brief burst of cerebral activity (circle) between periods of voltage suppression. (D) Isoelectric or flat tracing: both margins are < 5 mV and prominent spikes are likely due to patient movement. (E) Ictal pattern: seizures are shown as a sudden rise in lower and upper margin (circle).

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Figure 2
Conventional EEG of a newborn with an electrographic seizure. The beginning of a rhythmic repetitive activity in left occipital area (01) is marked with the arrow in Figure 2A. The rhythmic discharge evolves in morphology, amplitude and frequency (A and B). Figure 2B shows diffusion to surrounding areas (circle) and the end of the seizure (arrow).

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Figure 3
A suspected seizure in the aEEG (circle in A) is reviewed. Each figure (A-E) shows three hours of aEEG trace in the upper row and the corresponding 15 seconds of conventional EEG in the lower row, both traces available simultaneously in current devices. The vertical line in the aEEG shows the part of the trace displayed in the conventional EEG. A repetitive high amplitude slow wave with a rhythmic pattern is noted in the beginning of the seizure (A). In B, C, D and E the ictal pattern evolves progressively in morphology, frequency and amplitude. F shows the end of the seizure (marked with the arrow in E). The spikes are of lower amplitude and lower frequency and at the end of the seizure, voltage flattening is observed (arrow). This figure shows the epileptic seizure typically evolving in frequency, amplitude and morphology.

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Figure 4
Each figure shows three hours of aEEG (upper row) with the corresponding 15 seconds of conventional EEG in the lower row (arrowhead A marks one hour of trace). The vertical line in the aEEG shows the portion of the trace displayed in the conventional EEG. A sudden rise in lower margin is noted and reviewed (circle in A). In the conventional EEG, the pattern is monorhythmic all along the suspected ictal trace with the same frequency, amplitude and morphology at the beginning (A); 60 minutes later (B); and 120 minutes later at the end of the event (C) refuting the ictal origin of the event.

Figure 1 (A) Continuous background pattern, with prominent sleep-wake cycle: upper-margin voltage is > 10 mV and lower margin voltage is > 5 mV (arrow). The sleep-wake cycle is characterized by smooth cyclic variations, mainly of minimum amplitude, with periods of broader bandwidth that represent quiet sleep (circle) and periods of narrow bandwidth that correspond to wakefulness or active sleep (arrowhead). (B) Discontinuous background pattern: upper margin is > 10 mV and lower margin is < 5 mV. The sleep- wake cycle is not present. (C) Burst suppression pattern: upper and lower margin voltages are < 10 mV and <5 mV respectively reflecting voltage suppression, vertical lines (arrow) show periods of burst. Conventional EEG row shows a brief burst of cerebral activity (circle) between periods of voltage suppression. (D) Isoelectric or flat tracing: both margins are < 5 mV and prominent spikes are likely due to patient movement. (E) Ictal pattern: seizures are shown as a sudden rise in lower and upper margin (circle).

Figure 2 Conventional EEG of a newborn with an electrographic seizure. The beginning of a rhythmic repetitive activity in left occipital area (01) is marked with the arrow in Figure 2A. The rhythmic discharge evolves in morphology, amplitude and frequency (A and B). Figure 2B shows diffusion to surrounding areas (circle) and the end of the seizure (arrow).

Figure 3 A suspected seizure in the aEEG (circle in A) is reviewed. Each figure (A-E) shows three hours of aEEG trace in the upper row and the corresponding 15 seconds of conventional EEG in the lower row, both traces available simultaneously in current devices. The vertical line in the aEEG shows the part of the trace displayed in the conventional EEG. A repetitive high amplitude slow wave with a rhythmic pattern is noted in the beginning of the seizure (A). In B, C, D and E the ictal pattern evolves progressively in morphology, frequency and amplitude. F shows the end of the seizure (marked with the arrow in E). The spikes are of lower amplitude and lower frequency and at the end of the seizure, voltage flattening is observed (arrow). This figure shows the epileptic seizure typically evolving in frequency, amplitude and morphology.

Figure 4 Each figure shows three hours of aEEG (upper row) with the corresponding 15 seconds of conventional EEG in the lower row (arrowhead A marks one hour of trace). The vertical line in the aEEG shows the portion of the trace displayed in the conventional EEG. A sudden rise in lower margin is noted and reviewed (circle in A). In the conventional EEG, the pattern is monorhythmic all along the suspected ictal trace with the same frequency, amplitude and morphology at the beginning (A); 60 minutes later (B); and 120 minutes later at the end of the event (C) refuting the ictal origin of the event.

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Electroencefalograma integrado por amplitud para la detección de convulsiones neonatales. Un punto de vista electrofisiológico

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[1] Correspondence: Sebastián Gacio; División de Neurología, Hospital de Niños R. Gutiérrez. Gallo 1330 (C1425EFD), Ciudad Autónoma de Buenos Aires, Argentina. E-mail: neurogacio@gmail.com