Risk Factors for Seizures and Epilepsy in Children with Congenital Heart Disease
Ghosh S, Philip J, Patel N, Munoz-Pareja J, Lopez-Colon D, Bleiweis M, Winesett SP.
J Child Neurol. 2020 Feb 27:883073820904912. doi: 10.1177/0883073820904912. [Epub ahead of print]
PMID: 32103693
Select item 32107587
Take Home Points:
- Neonates and infants <3 months with CHD undergoing cardiac surgery are at risk for seizures during the perioperative period and years after cardiac surgery.
- Children who were more likely to have seizures include those with brain injury, lower birth weight, higher STAT scores, high RACHS category, and genetic syndromes.
- Those children with CHD who went on to develop epilepsy were more likely to have had an ischemic or hemorrhagic stroke but not necessarily a history of perioperative seizures.
Commentary from Dr. Charlotte Van Dorn (Rochester, MN), section editor of Pediatric Cardiology Journal Watch: This is a single institution retrospective cohort study of neonates and infants <3 months of age with congenital heart disease undergoing cardiopulmonary bypass. The objective of this study was to identify potential risk factors for pre- and postoperative seizures and epilepsy in children with congenital heart disease.
The incidence of seizures in children with CHD during their hospitalization is estimated at 8% but increases to 11.5% in children assessed with 48-hour video EEG monitoring. The overall incidence of epilepsy in CHD, but operated and unoperated CHD, is 5% by 15 years of age. Seizure in CHD has been found to be associated with higher RACHS scores, delayed sternal closure, longer hospital stays, and use of ECMO; while epilepsy has been associated with ECMO use and longer hospital stay.
Methods included inclusion of all neonates and infants <3 months undergoing cardiopulmonary bypass. Seizures were identified as clinical with electrographic correlate or electrographic correlate only. All patients underwent imaging (brain MRI or head CT) prior to or after cardiac surgery. Patients were excluded if they did not complete the required postoperative follow-up visits.
Results: In those infants with seizures prior to surgery (n=6), none progressed to epilepsy during their follow up (mean follow up 4.1 years). Early post-operative seizures occurred in 4 patients and only 1 progressed to epilepsy (mean follow up 5.5 years). Children who were more likely to have seizures include those with brain injury, lower birth weight, higher STAT scores, high RACHS category, and genetic syndromes and were associated with delayed sternal closures and longer hospital stay. Epilepsy occurred in 5.3% of this cohort at a mean age of 1.53 years and only a single patient had a seizure during their initial ICU hospitalization. Of those children with epilepsy, 5 weaned off medications, 3 died due to cardiac complications, and 4 developed intractable epilepsy. Children with CHD who went on to develop epilepsy were more likely to have had an ischemic or hemorrhagic stroke.
Discussion: Children with CHD who also suffered a stroke (either ischemic or hemorrhagic) were more likely to develop epilepsy. Other risk factors for seizures include high risk surgery, low birth weight, presence of a genetic syndrome and delayed sternal closure. These findings support that seizures seen during the initial perioperative hospitalization may not lead to the diagnosis of epilepsy.
Limitations: this is a retrospective and single center study. The use of preoperative imaging (head CT and brain MRI) as well as EEG monitoring is not routinely used before or after cardiac surgery and may have contributed to preselection bias. Longer duration of follow up is needed to fully assess the risk for epilepsy in children with CHD undergoing cardiopulmonary bypass surgery.
Next steps: Neonates and infants <30 days with CHD undergoing cardiopulmonary bypass surgery are risk for developing seizures and epilepsy. This requires diligent monitoring with clinical examination and EEG assessment during the perioperative period and later in childhood in those children at higher risk.
