Seizures in small brains

Neonatal seizures are the most common neurological emergency in newborns; often signalling significant neurological dysfunction. Their pathophysiology is complex and relates to the imbalance between excitatory and inhibitory neurotransmitters in the immature brain. During the neonatal period, excitatory circuits mediated via neuro-transmitters like glutamate predominate while inhibitory circuits mediated via gamma-aminobutyric acid (GABA) signalling are underdeveloped. Additionally, immature ion channels, such as sodium, chloride, potassium, and calcium, increase neuronal excitability. The most common aetiology of seizures is attributed to neonatal hypoxic cerebral injury. However, metabolic vulnerabilities, such as hypoglycaemia and electrolyte imbalances, can also precipitate seizures. Identifying the underlying cause, which in a large majority is acute symptomatic, is critical for prompt treatment. Early intervention is essential to prevent long-term neurodevelopmental consequences.Diagnosing neonatal seizures is challenging due to their subtle presentations. Distinguishing them from non-seizure events is crucial. Accurate diagnosis is essential for appropriate treatment and management. Continuous electroencephalography (cEEG) is the gold standard for diagnosis, but an amplitude-integrated EEG (aEEG) is a useful alternative tool in neonatal intensive care units (NICUs), for high-risk infants. This facilitates diagnosis of electroclinical as well as electrical seizures; commonly encountered in the very sick newborns and those born prematurely. Neuroimaging, like magnetic resonance imaging (MRI) and computed tomography (CT) is required to identify structural causes, while laboratory and genetic tests check for infectious, metabolic and genetic aetiologies. The new classification proposed by the International League Against Epilepsy (ILAE), underscores the importance of recognition of electrical seizures and highlights the value of recognising the seizure semiology for the diagnosis of the underlying aetiology.