Seizures and Apneas as clinical manifestations of brain lesions in term infants: a single center experience

Seizures and apneas are always concerning symptoms in near-term and term newborns, but finding a clear explanation is not always easy. In addition, it is not always clear which investigations should be promptly conducted. We aimed to evaluate the relationship (or lack thereof) between apneas and seizures and the role of MRI and EEG in their investigation. We conducted a retrospective analysis including infants born at ≥ 36 + 0 weeks of gestational age who presented with seizures or apneas soon after birth and underwent brain magnetic resonance imaging (MRI) during their stay at a tertiary-level academic Neonatal Intensive Care Unit (NICU) in Italy between January 2016 and July 2024. Brain MRI was systematically planned for to all term infants with clinical presentations of seizures, recurrent unexplained apneas, or abnormal aEEG/EEG. Our inclusion criteria were met by 58 (18%) patients; 31/58, (53%) presented with seizures and 27/58 (47%) with apneas without overt seizures manifestation. Apgar scores at 1 and 5 min were similar across clinical subgroups. Neurophysiological monitoring (EEG/aEEG) was performed in 50/58 (86%) infants; all 31 infants with clinical motoric seizures had abnormality on the EEG, though in 20 (65%) apneas were still their primary manifestation. Of the 27 presenting with apneas without documented EEG seizures, 6 experienced apneas only shortly after birth, 6 only with feeding (EEGs not done consistently) and of the other 15 the EEG was normal in the 12 who were monitored. Abnormal MRI findings were present in 27/31 (87%) infants with seizures and in 10/27 (37%) in the apnea only group. Focal arterial territory ischemic stroke was the commonest single diagnosis. Seizure-related apneas were associated with punctate white matter injury, focal ischemic stroke and severe intraventricular hemorrhage. Seizures and apneas occur with similar frequency in newborns born near or at term investigated with cerebral MRI for seizures and apneeas-related encephalopathy. The majority of infants had abnormal brain imaging, almost all of an ischaemic or haemorrhage nature. We strongly recommend brain imaging to assess potential brain injury in (near)term neonates with either of these clinical signs.