Nonconvulsive Electrographic Seizures are Common in Children With Abusive Head Trauma*

Abstract

Objective To determine the prevalence of nonconvulsive seizures in children with abusive head trauma. Design Retrospective study of children with abusive head trauma undergoing clinically indicated continuous electroencephalographic monitoring. Setting PICU of a tertiary care hospital. Subjects Children less than or equal to 2 years old with evidence of abusive head trauma determined by neuroimaging, physical examination, and determination of abuse by the Child Protection Team. Interventions None. Measurements and Main Results Thirty-two children with abusive head trauma were identified with a median age of 4 months (interquartile range 3, 5.5 months). Twenty-one of 32 children (66%) underwent electroencephalographic monitoring. Those monitored were more likely to have a lower admission Glasgow Coma Scale (8 vs 15, p = 0.05) and be intubated (16 vs 2, p = 0.002). Electrographic seizures occurred in 12 of 21 children (57%) and constituted electrographic status epilepticus in 8 of 12 children (67%). Electrographic seizures were entirely nonconvulsive in 8 of 12 children (67%). Electroencephalographic background category (discontinuous and slow-disorganized) (p = 0.02) and neuroimaging evidence of ischemia were associated with the presence of electrographic seizures (p = 0.05). Subjects who had electrographic seizures were no more likely to have clinical seizures at admission (67% electrographic seizures vs 33% none, p = 0.6), parenchymal imaging abnormalities (61% electrographic seizures vs 39% none, p = 0.40), or extra-axial imaging abnormalities (56% electrographic seizures vs 44% none, p = 0.72). Four of 21 (19%) children died prior to discharge; none had electrographic seizures, but all had attenuated-featureless electroencephalographic backgrounds. Follow-up outcome data were available for 16 of 17 survivors at a median duration of 9.5 months following PICU admission, and the presence of electrographic seizures or electrographic status epilepticus was not associated with the Glasgow Outcome Scale score (p = 0.10). Conclusions Electrographic seizures and electrographic status epilepticus are common in children with abusive head trauma. Most seizures have no clinical correlate. Further study is needed to determine whether seizure identification and management improves outcome.

Incidence of seizures on continuous EEG monitoring following traumatic brain injury in children

“…Hasbani et al reviewed 32 patients with AHT less than 2 years old, 21 of whom (a more severely injured cohort) underwent cEEG. 12 Fifty-seven percent of the cEEG group (12 patients) had seizures while monitored. Two-thirds (67%) of these had only subclinical seizures, and two-thirds had status epilepticus.…”

“…The majority of accidental trauma victims (72, 91%) had moderate or severe brain injuries (GCS score of [3][4][5][6][7][8][9][10][11][12] and therefore underwent cEEG according to the protocol. In contrast, 45% of AHT victims who underwent cEEG (29 patients) had mild brain injury according to initial GCS score (13)(14)(15) and were most likely monitored with cEEG for suspicion of seizures by the care team, a wit- …”

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

“…The patient populations and/or pathologies evaluated in the 66 studies included in the final review were: general PICU patients (n=15 studies) (9–23), seizures and/or status epilepticus (SE) (n=7) (24–30), traumatic brain injury (TBI) (n=17) (31–47), cardiac arrest (n=22) (48–69), and infectious diseases (n=5) (70–74). …”

Continuous EEG monitoring in children in the intensive care unit (ICU)

“…Children who had seizures had a poorer short-term prognosis and were at greater risk of developing epilepsy later on [7]. This prognostic element was not found in another study on a smaller cohort of 21 children [13]. Febrile status epilepticus.…”