Neuro

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Examining a multidisciplinary approach to

detecting abnormal brain patterns and seizure
diagnosis for neonates in the NICU

This article will explore the benefits of incorporating amplitude-integrated electroencephalography (aEEG) to
supplement conventional electroencephalography (cEEG) to help facilitate the determination of a neonate’s
neurological status, thus promoting prompt treatment and improve prognostication. We will also discuss the
characteristics of successful NICU team collaboration and finally, consider the promising future of continuous
brain monitoring for neonates.
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Detection and diagnosis of abnormal brain patterns and
seizures in neonates
While the detection of abnormal brain patterns, including those
indicating seizures, can be challenging with neonates, it is crucial
for improving health outcomes for critically ill newborns in the
neonatal intensive care unit (NICU). For example, seizures are rare
for most neonates, occurring at a rate of approximately 3 per 1000.
Yet seizure rates for pre-term infants are very high, between 57
– 132 per 1000 live births, and they occur most often in the first
week of life. Despite their frequency, neonatal seizures still present
a significant challenge for clinicians due to their subtle and diverse
manifestations. Abnormal brain patterns that indicate non-seizure-
related problems can also be prevalent. It’s important to recognize
that any abnormality at such an early stage of brain development can
have lifelong negative consequences if not diagnosed and treated
quickly.
Conventional electroencephalography (cEEG) remains the gold
standard for identifying and diagnosing abnormal neonate brain
patterns, including seizures. Even when cEEG is available there are
often logistical challenges, such as speed of availability, constraints
for the duration at which a test can be performed, and delay of
interpretation. This is why neonatologists and other specialists
working in the NICU increasingly recommend using amplitude-
integrated electroencephalography (aEEG) as an adjunct to cEEG for
continuous brain monitoring, particularly when cEEG is performed
intermittently.
Continuous multimodal monitoring holds great promise for neonatal
neurocritical care. The results of continuous monitoring with aEEG
are often striking for first-time users. aEEG provides continuous
real-time data that can quickly capture changes in baseline and
abnormalities between diagnostic cEEG workups. aEEG patterns
are easy to identify, even for individuals who have not had formal
EEG interpretation training. As a result, NICU staff are able to timely
identify changes in brain activity that might otherwise have gone
unnoticed earlier or altogether. In addition, aEEG results can inform
referrals to neurologists, creating a more rapid roadmap toward
diagnosis and treatment for the multidisciplinary care team.
Current research and empirical evidence show the effectiveness
of complementing cEEG diagnostics with aEEG for continuous
monitoring, especially when conventional EEG is not readily
available. Current research demonstrates the benefits of using
aEEG for predictive use as well as a way to further improve short
and long-term outcomes. To understand the primary benefits of
this multidisciplinary diagnostic and monitoring approach, experts
suggest classifying abnormal brain patterns into three categories:
background patterns, sleep-wake cycling, and seizures.
Background patterns
Abnormal brain background patterns in neonates indicate atypical
or irregular electrical activity in the brain’s baseline waveform. These
patterns deviate from the expected normal range and can point to
various conditions or abnormalities. Examples of abnormal patterns
include reduced or absent background activity, excessive or irregular
oscillations, asymmetry, or seizure activity. A combined and careful
use of both cEEG and aEEG is crucial for detecting these patterns
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and thereby identifying neonates’ brain injuries, developmental
disorders, or neurological conditions. This approach allows for timely
intervention, ongoing monitoring, and appropriate management
strategies to optimize neurodevelopmental outcomes.
Sleep-wake cycling
Sleep-wake cycling in neonates has a significant impact on the
infant’s overall development and well-being, playing a critical role
in brain maturation, memory consolidation, and the regulation
of various physiological processes. By monitoring sleep-wake
patterns with aEEG, healthcare providers can assess the adequacy
and quality of sleep, identify any disruptions or abnormalities, and
address potential issues, such as sleep disorders or disturbances.
This information helps guide appropriate interventions (including
further evaluation using cEEG) to establish healthy sleep routines
and promote optimal neurodevelopment in neonates. Simply
put, understanding sleep-wake patterns can assist in recognizing
potential signs of discomfort, illness, or neurological abnormalities,
allowing for timely intervention and individualized care.
Continuous multimodal monitoring holds
great promise for neonatal neurocritical
care.
The results of continuous monitoring with aEEG are
often striking for first-time users.
Seizures
Some neonates experience a high seizure burden that remains
challenging to detect due to the subtlety and ambiguity of clinical
signs. For example, newborns with abnormal brain activity may
exhibit behaviors that closely resemble seizures but are, in fact,
symptomatic of an entirely different problem. Additionally, the
immature nature of the neonatal brain may result in seizures with
atypical electrographic patterns, further complicating their detection.
Lastly, neurologists may not be readily available to quickly interpret
cEEG recordings, making timely diagnosis and treatment an issue.
In such cases, the convenience and clarity of aEEG data can make a
difference.
Seizures among neonates require rapid intervention to avoid
potentially dangerous short-and-long-term health outcomes.
Because rapid detection, accurate diagnosis, and clinical expertise
are crucial for seizure diagnosis and treatment, a multidisciplinary
approach that encourages close collaboration between neurologists,
neonatologists, and NICU staff, utilizing both aEEG and cEEG, is the
most effective.
Combining aEEG and EEG as the standard of care in
the NICU
Most neonatologists, neurologists, epileptologists, and NICU staff
understand the complexities of detecting abnormal brain patterns
and diagnosing seizures and other potential brain issues in infants,
and they continually seek ways to improve health outcomes. While
organizations like the International Neonatal Consortium and others
have named conventional EEG the gold standard for diagnosing brain
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conditions in neonates, its limited availability can pose a challenge
for detecting certain abnormal brain activity, especially within the
first week of life. In short, conventional EEG is labor-intensive to set
up and highly specialized to interpret, often making it unavailable in
real-time.
On the other hand, aEEG provides a simplified and compressed
representation of the brain’s electrical activity. It offers continuous
monitoring and allows for quick interpretation of seizure activity,
enhancing real-time detection while providing a simple yet
meaningful visual display of a neonate’s brain activity. The
simplicity of aEEG makes it particularly useful for continuous
bedside monitoring in resource-limited provider settings, for many
neonatologists can read and understand aEEG without the extensive
training required for EEG interpretation.
By monitoring the aEEG trace, clinicians can identify abnormal
patterns indicative of various conditions, including hypoxic-ischemic
encephalopathy, cerebral dysfunctions, and seizures. Reduced
amplitude or complete absence of background activity may suggest
brain injury or impaired brain development. Alternately, excessive
or abnormal oscillations may indicate seizures or other pathological
processes.
The continuous nature of aEEG monitoring enables healthcare
providers to assess the progression of brain activity over time,
aiding in the early detection of neurological changes and the
response to interventions. It also allows for timely adjustments in
treatment strategies and medication dosages to mitigate potential
complications. NICU teams can better understand the neonate’s
brain activity and improve the accuracy of both abnormal pattern
detection and seizure diagnosis by incorporating aEEG and EEG.
The complementary nature of aEEG and EEG technologies enhances
the NICU team’s ability to detect abnormalities and make a more
detailed assessment of their characteristics, leading to improved
clinical decision-making.
Collaboration between neurologists, neonatologists, and
NICU staff
Close collaboration with neurologists and neurophysiologists is,
therefore, recommended, and standard EEGs should be recorded
frequently in infants along with aEEG, especially when the aEEG
tracing is abnormal.
Understanding each specialist’s role in diagnosing and treating
neonatal seizures is key to supporting a multidisciplinary approach
to the diagnosis and care of neonates. This is particularly important
for NICU settings, where healthcare teams can be large, due to the
complex nature of treating critically ill newborns.
Neurologists, for example, bring expertise in interpreting EEG
patterns and distinguishing seizure activity from other neurological
phenomena. Their involvement ensures accurate diagnosis and
appropriate management strategies. These specialists are skilled in
recognizing subtle electrographic features indicative of seizures, and
they provide valuable insights into interpreting complex EEG patterns.
Neonatologists possess in-depth knowledge of the neonatal
population and are expert at identifying subtle clinical manifestations
of seizures. Also, their training and experience are crucial for
recognizing and describing clinical events associated with seizures.
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Neonatologists provide the right clinical context to help interpret
technology outputs, and their specific expertise helps inform the
best decisions when it comes to determining treatment options.
And, of course, nurses and other NICU staff provide valuable input
regarding observed clinical signs that could indicate a need to initiate
continuous brain monitoring.
Finding ways to promote collaboration among these specialists will
facilitate comprehensive evaluation, timely intervention, and optimal
management of neonatal seizures. By combining their expertise,
the multidisciplinary team can navigate the challenges of neonatal
seizure diagnosis much more effectively.
Combining cEEG and aEEG in the NICU
aEEG is a tremendously helpful tool, however, most clinicians do not
recommend it as the sole mainstay for diagnosing and managing
neonatal seizures. Many NICUs rely heavily on aEEG to confirm and
diagnose suspected seizures but as a complement to the use of
conventional EEG.
Combining aEEG and EEG makes sense to help diagnose
neonatal seizures more quickly and accurately. Fortunately,
advanced technology often allows EEG and aEEG to be recorded
simultaneously. Also, when specialized expertise is unavailable
locally, neurologists or other specialists can be consulted remotely
to help assess neonate brain activity, making multidisciplinary care
(from a technology perspective) available wherever needed.
aEEG is useful for detecting subclinical seizures, providing data on
sleep/waking cycles, and monitoring changes in neurological status.
These are important predictors of health outcomes during the perinatal
period. In addition, the simplicity of aEEG facilitates continuous
bedside monitoring, enabling early identification of abnormal trends
or seizures. When further details and precise localization are required,
EEG can provide in-depth insights into brain activity, facilitating
accurate diagnosis and tailored treatment strategies.
Continuous brain monitoring holds promise as the future standard
for neonatal care. The challenges posed by neonatal brain
abnormalities require a multidisciplinary approach combining aEEG
and cEEG in the NICU, and close collaboration among neurologists,
neonatologists, and NICU staff to ensure proper diagnosis and
treatment.
Using both aEEG and EEG in the NICU means that clinicians can
harness the complementary advantages of both technologies,
leading to a more comprehensive evaluation of neonatal brain
function. Real-time detection with the right use of available
technologies combined with individualized treatment plans created
by a team of close-knit specialists can significantly improve health
outcomes for neonates experiencing brain abnormalities within the
first few days of life.
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Making sense of the body’s signals

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