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Diagnosing neonatal seizures.

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basal ganglia does not occur in most individuals with severe
metabolic acidosis, but seems to occur specifically in those
with methanol intoxication or organic acidemias. We therefore favor the hypothesis that the associated necrosis of the
basal ganglia is the result of selective toxicity caused by these
substances, or by some related metabolic abnormality, and
not the metabolic acidosis alone.
‘Department of Neurology and Mental Retarhion Program
The Children’s Hospital
Department of Neurology, Haward Medical School
Boston, M A
fDepartrnent of Radiology
Lahey Clinic
Burlington, M A
$IEM-PKU Program
The Children’s Hospital
Joseph P . Kennedy, Jr. Laboratories of the Neurology Service
Massachusetts General Hospital
Department of Neurology, Haward Medical School
Boston, M A
Diagnosing
Neonatal Seizures
Michael S. Duchowny, MD, and Trevor J. Resnick, MD
Younkin and colleagues {l]are to be commended for their
investigation of the metabolic consequences of convulsive
seizures in the postnatal period. As they point out, there are
many unanswered questions regarding the effects of seizures
on brain function. They found that seizures in the newborn
result in decreased phosphocreatine content and increased
oxidative metabolism and suggested that excessive energy
demands may themselves contribute to permanent neurological injury.
We think the study findings should be interpreted
cautiously. Without simultaneous electroencephalographic
(EEG) monitoring during spectroscopy, the seizure state may
be difficult to define, especially in neonates. Newborns may
manifest prolonged electrographic seizure discharges while
showing no clinical manifestations 12). Our experience with
ictal EEG recording in infants confirms that interictal recording alone is insufficient to assess seizures reliably {3]. We
have observed many infants with partial seizure disorders
(diagnosed as “generalized” seizures) who demonstrated multifocal interictal discharges on routine EEG. EEGs recorded
during the ictus provided clear evidence of a localized seizure focus. Hemispheric EEG asymmetry at the onset of
partial seizures in infancy has also been observed 141.
Because of the difficulty characterizing seizure disorders
and defining ictal events in newborns and infants, we suggest
that all subjects undergoing metabolic studies also have longterm EEG monitoring. Greater confidence could then be
placed in the observations during spectroscopy.
Department of Neumlogy
Miami Children’s Hospital
Miami,FL 33IJ5
References
1. Younkin DP, Delivoria-Papadopodos M, Maris J, et al. Cerebral
metabolic effects of neonatal seizures measured with in vivo 3’P
NMR spectroscopy. Ann Neurol 1986;20:513-5 19
2. Hellstrom-Westas L, Rosen I, Swenningsen NW. Silent seizures
in sick infants in early life. Diagnosis by continuous cerebral
function monitoring. Acta Paediatr Scand 1985;74:741
3. Duchowny MS, Deray MJ, Bonis I. Electroclinical manifestations
of partial seizures of infancy. Epilepsia 1985;26:526
4. Duchowny MS, Levin BE.Hemispheric lateralization of complex
partial seizures in infancy: implications for development. Neurology 1986;36(no. 1, suppl):191
Reply
Donald Younkin. MD
We agree that the clinical recognition and characterization of
neonatal seizures are insensitive, and have reported findings
similar to those mentioned by Drs Duchowny and Resnick
{l].In our report on changes in cerebral metabolism during
neonatal seizures {Z], all of the patients with seizures in the
immediate neonatal period had ictal recordings, and seizure
classificationwas based on electrical and clinical observations.
We are confident that seizures were classified correctly.
Simultaneous electroencephalographic recording and nuclear magnetic resonance spectroscopy can be performed
easily in animals 131; however, because of safety considerations, it is not a trivial problem in newborns. We are currently working on equipment that will permit simultaneous
studies in babies, and hope to use this equipment in the near
future.
Departments of Neurology, Pediatrics, Biochemistry
and Biophysics
Univwsity of Pennsylvania School of Medicine
PhiIdeIphia, PA 191 04
References
1. Clancy RR,Legido A, Lewis D. The effects of mental status and
ictal duration on the clinical visibility of EEG-proved neonatal
seizures. Ann Neurol (abstract) 1986;20:411
2. Younkin DP, Delivoria-Papadopoulous M, Maris J, et al. Cerebral metabolic effects of neonatal seizures measured with in vivo
3‘P NMR spectroscopy. Ann Neurol 1986;205 13-5 19
3. Petroff OAC, PrichardJW, Behar KL, et al. In vivo phosphorus
nuclear magnetic resonance spectroscopy in status epilepticus.
Ann Neurol 1984;16:169-177
Still Another Cause
of Monocular Oscdlopsia
Michael L. Rosenberg, MD, Lt Col USAF, MC
It has been a neuroophthalmological axiom that one could
make the diagnosis of superior oblique myokymia over the
telephone based on the history of intermittent vertical diplopia with a monocular oscillopsia. It was intriguing to note
the report of Murray and Ajax { 11of a physician with a more
anterior cause of monocular oscillopsia (lens subluxation),
although they do not report the direction of apparent move-
Annals of Neurology Vol 22 N o 1 July 1987 97
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