case_images: PMC8669778_01
case_images: EEG background evolution in the first week of life.. Day 2 of life - encephalopathic background with continuous delta activity with moderate theta activity, but paucity of fast frequencies, no sleep cycling; Day 3 of life - highly suppressed background activity post escalation of anti-seizure treatment, showing only low amplitude asynchronous transients of 1-2 sec against a highly suppressed background; Day 4 of life - some return of background activity with longer bursts of approximately 5 seconds duration but background remaining highly discontinuous with inter-burst intervals >20 seconds; Day 5 of life - remaining highly discontinuous with increased frequency of mechanical brushes/delta crown (circled image). Red vertical line indicates the position of EEG selection on the aEEG trace.
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case_images: PMC8669778_01_hrbopenres-4-14650-g0000.jpg
case_images: f1
case_images: EEG background activity ( Figure 1) deteriorated over the first week of life, becoming more discontinuous and suppressed, which may be explained by the evolution of the disease but likely also due to the rapid escalation of anti-seizure treatment with partial response. EEG seizures consisted of either rhythmic delta patterns at 1-2Hz, or sharp wave/slow wave complexes with variable onset over the left hemisphere, right anterior quadrant or central midline, some with secondary generalisation and some occurring concurrently at times ( Figure 2).
case_images: Seizures.. Focal seizures were seen over several regions with variable seizure morphology including:
  A) Left sided seizure with sharp wave/slow wave morphology.
  B) 2 Hz delta seizure over the midline.
  C)~1 Hz delta seizure over the right anterior quadrant.
  D) Concurrent multifocal seizures with ~2Hz delta seizure over the central midline and ~1 Hz delta seizure over the right anterior. Red vertical line indicates the position of EEG selection on the aEEG trace.
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case_images: PMC8669778_01_hrbopenres-4-14650-g0001.jpg
case_images: f2
case_images: EEG background activity ( Figure 1) deteriorated over the first week of life, becoming more discontinuous and suppressed, which may be explained by the evolution of the disease but likely also due to the rapid escalation of anti-seizure treatment with partial response. EEG seizures consisted of either rhythmic delta patterns at 1-2Hz, or sharp wave/slow wave complexes with variable onset over the left hemisphere, right anterior quadrant or central midline, some with secondary generalisation and some occurring concurrently at times ( Figure 2). TDS) and Folinic acid (2.5mg up to 5mg BD) supplemented the initial antiseizure treatment. The predominant patterns of the EEG recording were: (1) frequent and refractory multifocal seizures ( Figure 2); (3) bursts of synchronous, or more often asynchronous delta activity with overlying rhythmic fast activity at 10-25Hz, separated by periods of suppression of 10-30 seconds ( Figure 4). The bursts of delta with overlying fast activity resembled 'mechanical brushes' frequently seen in preterm infants   .
case_images: Evolution of hourly seizure burden and antiseizure management (loading/start doses) during first week of life.
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case_images: PMC8669778_01_hrbopenres-4-14650-g0002.jpg
case_images: f3
case_images: All electrographic seizures over the first week of life were annotated and the evolution of the hourly seizure burden and initial anti-seizure therapy is shown in Figure 3. EEG monitoring, during which time the background EEG became increasingly discontinuous with refractory multifocal seizures. Electroclinical seizures persisted, therefore commenced treatment with Midazolam infusion (150 micrograms/kg loading, continued with infusion titrated between 1-3 micrograms/kg/minute) and then Levetiracetam (10mg/kg loading increased to 30mg/kg BD) with partial response ( Figure 3). TDS) and Folinic acid (2.5mg up to 5mg BD) supplemented the initial antiseizure treatment. The predominant patterns of the EEG recording were: (1) frequent and refractory multifocal seizures ( Figure 2); (3) bursts of synchronous, or more often asynchronous delta activity with overlying rhythmic fast activity at 10-25Hz, separated by periods of suppression of 10-30 seconds ( Figure 4). The bursts of delta with overlying fast activity resembled 'mechanical brushes' frequently seen in preterm infants   .
case_images: Delta-beta complexes.. High voltage delta activity with overlying rhythmic fast activity at 10-25Hz, separated by periods of suppression of 10-30 seconds.
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case_images: PMC8669778_01_hrbopenres-4-14650-g0003.jpg
case_images: f4
case_images: TDS) and Folinic acid (2.5mg up to 5mg BD) supplemented the initial antiseizure treatment. The predominant patterns of the EEG recording were: (1) frequent and refractory multifocal seizures ( Figure 2); (3) bursts of synchronous, or more often asynchronous delta activity with overlying rhythmic fast activity at 10-25Hz, separated by periods of suppression of 10-30 seconds ( Figure 4). The bursts of delta with overlying fast activity resembled 'mechanical brushes' frequently seen in preterm infants   .
case_images: MRI Brain.. on day of life 3 -
  A (DWI sequence) and
  B (axial T2): diffuse symmetrical abnormal restricted diffusion involving the cortical and subcortical regions of the cerebral hemispheres bilaterally, diffuse oedema of the white matter symmetrical abnormal diffusion restriction involving the caudate nuclei, lentiform nucleus, and dorsal thalami bilaterally; Repeat MRI Brain at 2 weeks of age -
  C (DWI sequence) and
  D (axial T2): interval development of cystic encephalomalacia with white matter and deep grey volume loss, persistent cortical/subcortical and deep grey abnormal diffusion restriction.
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case_images: PMC8669778_01_hrbopenres-4-14650-g0004.jpg
case_images: f5
case_images: Brain magnetic resonance imaging (MRI) on day 3 ( Figure 5. Repeat MRI at 2 weeks of age ( Figure 5.