Clinical Implementation of Amplitude-Integrated Electroencephalography for Neonatal Seizure Detection and Prognostication: First National Experience From North Macedonia.

BACKGROUND: Neonatal seizures are among the most common neurological emergencies in newborns, yet accurate diagnosis remains challenging because many seizures are electrographic-only and lack clear clinical manifestations. Amplitude-integrated electroencephalography (aEEG) has emerged as a practical bedside neuromonitoring tool, particularly in settings where continuous electroencephalography is not widely available. The study aimed to evaluate the clinical utility of aEEG for seizure detection, treatment guidance, and prediction of neurodevelopmental outcomes in neonates with suspected seizures or increased seizure risk. METHODS: The prospective observational study included neonates who were monitored with aEEG at a tertiary neonatal center in North Macedonia. Patients were classified into neonates with clinically suspected seizures and neonates monitored because of established seizure risk factors without overt clinical manifestations. aEEG background patterns, sleep-wake cycling, electrographic seizures, anti-seizure treatment, and neurodevelopmental outcomes at 12-18 months were analyzed. RESULTS: Sixty-four neonates were included. Electrographic seizures were significantly more frequent in neonates with clinically suspected seizures compared with high-risk neonates without clinical events (51.5% vs 25.8%, P = 0.04). A total of 82 electrographic seizure episodes were identified on aEEG. Clinical suspicion corresponded with electrographic seizure activity in only 48% of cases. Abnormal aEEG background pattern was the strongest predictor of adverse neurodevelopmental outcome (odds ratio 9.62; 95% confidence interval 1.38-67.25; P = 0.022). Absence of sleep-wake cycling was also associated with an unfavorable outcome. CONCLUSIONS: aEEG significantly improved seizure detection and provided valuable prognostic information in neonates. Its successful implementation in North Macedonia demonstrates feasibility and clinical utility in resource-limited settings where continuous electroencephalography availability remains restricted.