Risk factors for perinatal arterial stroke: a study of 60 mother-child pairs

Lipoprotein (a) and cerebrovascular disease

The role of lipoprotein (a) [Lp(a)] in cerebrovascular disease is a topic of importance. In this narrative review, pertinent studies have been leveraged to comprehensively examine this relationship from diverse perspectives.Lp(a) shares structural traits with low-density lipoprotein cholesterol. Lp(a) is synthesized by hepatocytes, and its plasma levels are genetically determined by the LPA gene, which produces apolipoprotein (a).Numerous epidemiological studies have confirmed the positive correlation between elevated serum Lp(a) levels and the occurrence or recurrence of cerebrovascular events, especially ischemic strokes, in adults. It should be noted that the correlation strength varies among studies and is marginal in Mendelian randomization studies.Regarding pediatric patients, screening is currently limited to those with a relevant medical history. Lp(a) seems to play a significant role in the pathogenesis of arterial ischemic stroke in children because environmental thrombotic and atherogenic factors are generally not present.Phase 3 trials of novel Lp(a) targeting agents, such as pelacarsen and olpasiran, are anticipated to demonstrate their efficacy in reducing the incidence of stroke. Given the richness of the literature, new guidelines regarding Lp(a) screening and management in targeted populations are warranted to provide more effective primary and secondary prevention.

Arterial Presumed Perinatal Ischemic Stroke: A Mini Review and Case Report of Cognitive and Speech-Language Profiles in a 5-Year-Old Girl

Arterial presumed perinatal ischemic stroke is a type of perinatal stroke that emerges due to late or delayed diagnostics of perinatal or neonatal arterial ischemic stroke. It is usually recognized before one year of life due to hemiparesis. This injury may lead to cognitive, behavioral, or motor symptoms, and life-long neurodevelopmental disabilities. In this case report, we describe a five-year-old girl with a history of arterial presumed perinatal ischemic stroke in the left hemisphere, which adversely affected her cognitive and language outcomes. The girl's cognitive development has been uneven, ranging from below average to average, and she had specific language acquisition deficits in comprehension, vocabulary, morphology, use of complex syntax, and narrative structure. The obtained results point to the specificity of each child whose development is influenced not only by the timing of the brain lesion and the degree of damage, but also by the child's neurobiological capacity. In addition, we provide an updated review of the literature that includes information on epidemiology, risk factors, diagnostics, clinical manifestations, outcomes, and potential therapies. The present article highlights the importance of early intervention and systematic monitoring of children with perinatal stroke with the aim of improving the child's development.

Inherited Thrombophilia Associated With Ischemic Pediatric Stroke in Parent-Child Pairs

BACKGROUND

We aimed to examine inherited thrombophilia frequencies by extending genetic profile to previously rarely or not investigated polymorphisms in children with ischemic pediatric stroke (IPS) and their parents.

METHODS

The study included 33 children: 23 with perinatal arterial ischemic stroke (PAIS), eight with childhood arterial ischemic stroke (CAIS), and two with sinovenous thrombosis and their parents (33 mother-child, 12 father-child, and 12 mother-father-child pairs). Genotyping of FV-Leiden, FV-H1299R, FII-G20210A, β-fibrinogen-455G>A, FXIII-A-Val34Leu, PAI-1(4G/5G), HPA-1, MTHFR-C677T, MTHFR-A1298C, ACE(I/D), and APOE(ε2-4) was performed using CVD Strip assay (ViennaLab, Austria).

RESULTS

At least one and up to seven simultaneously present polymorphisms were observed in all children with IPS, mothers, and fathers. More than five simultaneously present polymorphisms were identified threefold more frequently in children with IPS (10 of 33; 30%) compared with the child control group (17 of 150; 11%), yielding a statistically significant difference between the two groups (odds ratio [OR] = 3.40; 95% confidence interval [CI] = 1.39 to 8.35; P = 0.012). Stronger association was revealed for PAIS (OR = 4.17; 95% CI = 1.55 to 11.29; P = 0.008) and CAIS subgroups (OR = 7.82; 95% CI = 1.79 to 34.20; P = 0.012). Complete match of polymorphisms was not identified in any parent-child pair. A partial match (one to four mutual polymorphisms) was found in 11 of 12 parent-child pairs where until three mutual polymorphisms was present in 11 of 12 (91.7%) father-child compared with 21 of 33 (63.6%) mother-child pairs.

CONCLUSIONS

According to obtained results the simultaneous presence of more than five polymorphisms is associated with a higher risk for IPS occurrence, suggesting the risk enhancement for PAIS in the presence of pregnancy complications or for CAIS in conjunction with maternal comorbidity and positive family history. The presence of up to three mutual polymorphisms more frequently in father-child than mother-child pairs suggests significant paternal contribution of inherited thrombophilia to increased risk of IPS.

Risk factors for perinatal stroke in term infants: A case-control study in Australia

AIM

The aetiology of perinatal stroke is poorly understood. This study aimed to prospectively confirm the risk factors and identify any previously unknown variables.

METHODS

A prospective case-control study was conducted in Australia. Univariate odds ratios (ORs), associated 95% confidence intervals (CIs) and multivariable logistic regression models fitted with backwards stepwise variable selection were used.

RESULTS

Sixty perinatal stroke cases reported between 2017 and 2019 included 95% (57/60) with multiple risk factors. Univariate analysis identified emergency caesarean section rather than NVD (P < 0.01), low Apgar score (<7) at 1, 5 and 10 min of age (P < 0.01), resuscitation at birth (P < 0.01), abnormal cord blood gas (P < 0.01), neonatal infection/sepsis (P < 0.01), congenital heart disease (P < 0.01) and hypoglycaemia (P < 0.01) as significant risk factors. Multivariate analysis found smoking during pregnancy (OR: 1.48; 95% CI: 1.09-1.99), 1-min Apgar score < 7 (OR: 1.54; 95% CI: 1.15-2.08), 10-min Apgar score < 7 (OR: 1.26; 95% CI: 1.02-1.54) and hypoglycaemia (OR: 1.49; 95% CI: 1.07-2.06).

CONCLUSIONS

Perinatal stroke is associated with multiple risk factors. Exposure to smoking, 10-min Apgar score < 7, neonatal infection and hypoglycaemia were independent risk factors. Emergency caesarean section, resuscitation at birth and abnormal cord blood gas were additional risk factors.

Cerebral Blood Flow Autoregulation in Offspring From Experimentally Preeclamptic Rats and the Effect of Age

Preeclampsia is a hypertensive disorder of pregnancy that causes significant, long term cardiovascular effects for both the mother and offspring. A previous study demonstrated that middle cerebral arteries in offspring from an experimental rat model of preeclampsia were smaller, stiffer, and did not enlarge over the course of maturation, suggesting potential hemodynamic alterations in these offspring. Here we investigated the effect of experimental preeclampsia on cerebral blood flow autoregulation in juvenile and adult offspring that were born from normal pregnant or experimentally preeclamptic rats. Relative cerebral blood flow was measured using laser Doppler flowmetry, and cerebral blood flow autoregulation curves were constructed by raising blood pressure and controlled hemorrhage to lower blood pressure. Immunohistochemistry was used to assess middle cerebral artery size. Heart rate and blood pressure were measured in awake adult offspring using implanted radiotelemetry. Serum epinephrine was measured using enzyme-linked immunosorbent assay. Offspring from both groups showed maturation of cerebral blood flow autoregulation as offspring aged from juvenile to adulthood as demonstrated by the wider autoregulatory plateau. Experimental preeclampsia did not affect cerebral blood flow autoregulation in juvenile offspring, and it had no effect on cerebral blood flow autoregulation in adult offspring over the lower range of blood pressures. However, experimental preeclampsia caused a right shift in the upper range of blood pressures in adult offspring (compared to normal pregnant). Structurally, middle cerebral arteries from normal pregnant offspring demonstrated growth with aging, while middle cerebral arteries from experimentally preeclamptic offspring did not, and by adulthood normal pregnant offspring had significantly larger middle cerebral arteries. Middle cerebral artery lumen diameters did not significantly change as offspring aged. Serum epinephrine was elevated in juvenile experimentally preeclamptic offspring, and a greater degree of hemorrhage was required to induce hypotension, suggesting increased sympathetic activity. Finally, despite no evidence of increased sympathetic activity, adult experimentally preeclamptic offspring were found to have persistently higher heart rate. These results demonstrate a significant effect of experimental preeclampsia on the upper range of autoregulation and cerebrovascular structure in juvenile and adult offspring that could have an important influence on brain perfusion under conditions of hypo and/or hypertension.

Placental pathologic lesions associated with stroke in term neonates

OBJECTIVE

To determine the birth prevalence of perinatal stroke in term born infants at our high-volume delivery center and assess the frequency of both gross and histologic placental pathologies associated with perinatal stroke using the Amsterdam Placental Workshop Group Consensus Statement guidelines and definitions.

STUDY DESIGN

A single-center retrospective cohort study spanning 2010-2020.

RESULTS

There were 129,759 live births at Parkland Hospital during the study period and a total of 18 term born infants leading to a birth prevalence of 1 in 6,829 infants. Perinatal risk factors were found in all but one patient, and 74% presented with seizures. Pathologic placental examination was available in 56% of the cohort and only one patient had normal placental examination. Acute histologic chorioamnionitis was described in five placentas (50%) and an additional two had isolated umbilical and/or chorionic plate vasculitis with or without funisitis compared to a rate of 28% with acute inflammation in a Control group. Chronic inflammation in the form of villitis of unknown etiology was described in three of the acutely inflamed placentas and was high-grade in each of those while none of the placentas from our Control group showed evidence of any chronic lesion.

CONCLUSION

Both acute and chronic placental inflammation are common in perinatal stroke; placental examination should be considered an essential component to the diagnostic workup.

Neonatal stroke: Clinical characteristics and neurodevelopmental outcomes

BACKGROUND

Neonatal stroke can potentially result in significant neurological sequelae in affected infants. Studies on neurodevelopmental outcomes and the need for rehabilitation therapies in the first two years are limited. We aimed to describe the clinical characteristics, diagnostic evaluation, and neurodevelopmental outcomes of a cohort of infants with neonatal stroke.

METHODS

A retrospective cohort study of infants with neonatal stroke, from 2011 to 2020. Maternal and infant characteristics were described. Placental pathology, echocardiogram results, and prothrombotic evaluations were reported. The neurodevelopmental outcomes using Bayley scale of infant development (BSID III), rates of epilepsy and cerebral palsy, and the need for rehabilitation therapies at two years were described.

RESULTS

During the study period, 55 infants had neonatal stroke. Majority (93%) were term or late preterm infants. Maternal chorioamnionitis and perinatal HIE were diagnosed in about a third of the infants. Most (66%) of the infants presented with seizures. On brain MRI, the lesions were unilateral in 76% and arterial in origin in 86% of the infants. Meconium exposure (42%), intrauterine inflammation/infection (37%) and fetal vascular malperfusion (16%) were seen on placental histopathology. At two-year BSID III assessment, median (min, max) composite cognitive, language, and motor scores were 100 (55-145), 97 (47-124), and 100 (46-141), respectively. Among this cohort, epilepsy (27%), cerebral palsy (16%) and the need for rehabilitation therapies (physical -24%, occupational -18%, speech -21%) were reported at two years.

CONCLUSION

Neonatal stroke presented commonly in term or late preterm infants with seizures. It was unilateral and arterial in origin in most infants. Maternal chorioamnionitis and perinatal HIE were the most commonly associated conditions at birth. About one-fifth of the infants had mild or severe developmental delays at two years. Epilepsy, cerebral palsy, and need for rehabilitation therapies were noted in a significant proportion of infants at two years.

Cerebral blood flow and cognitive outcome after pediatric stroke in the middle cerebral artery

Adaptive recovery of cerebral perfusion after pediatric arterial ischemic stroke (AIS) is sought to be crucial for sustainable rehabilitation of cognitive functions. We therefore examined cerebral blood flow (CBF) in the chronic stage after stroke and its association with cognitive outcome in patients after pediatric AIS. This cross-sectional study investigated CBF and cognitive functions in 14 patients (age 13.5 ± 4.4 years) after pediatric AIS in the middle cerebral artery (time since AIS was at least 2 years prior to assessment) when compared with 36 healthy controls (aged 13.8 ± 4.3 years). Cognitive functions were assessed with neuropsychological tests, CBF was measured with arterial spin labeled imaging in the anterior, middle, and posterior cerebral artery (ACA, MCA, PCA). Patients had significantly lower IQ scores and poorer cognitive functions compared to healthy controls (p < 0.026) but mean performance was within the normal range in all cognitive domains. Arterial spin labeled imaging revealed significantly lower CBF in the ipsilesional MCA and PCA in patients compared to healthy controls. Further, we found significantly higher interhemispheric perfusion imbalance in the MCA in patients compared to controls. Higher interhemispheric perfusion imbalance in the MCA was significantly associated with lower working memory performance. Our findings revealed that even years after a pediatric stroke in the MCA, reduced ipsilesional cerebral blood flow occurs in the MCA and PCA and that interhemispheric imbalance is associated with cognitive performance. Thus, our data suggest that cerebral hypoperfusion might underlie some of the variability observed in long-term outcome after pediatric stroke.

Pediatric Patient with Ischemic Stroke: Initial Approach and Early Management

Acute Ischemic Stroke (AIS) in children is an acute neurologic emergency associated with significant morbidity and mortality. Although the incidence of AIS in pediatric patients is considerably lower than in adults, the overall cumulative negative impact of the quality of life could be even higher in children. The age-related variable clinical presentation could result in a delay in diagnosis and could negatively influence the overall outcome. The early management should be based on early recognition, acute transfer to pediatric AIS centre, standardised approach (ABCDE), early neurologic examination together with neuroimaging (preferable Magnetic Resonance Imaging—MRI). The treatment is based on supportive therapy (normoxemia, normocapnia, normotension and normoglycemia) in combination with intravenous/intraarterial thrombolytic therapy and/or mechanical thrombectomy in selected cases. Pediatric stroke centres, together with the implementation of local stroke management protocols, could further improve the outcome of pediatric patients with AIS.

Different antecedents and neonatal condition in neonatal arterial ischemic stroke and hypoxic-ischemic neonatal encephalopathy

Objective

To define similarities and differences between neonatal arterial ischemic stroke (NAIS) and hypoxic‐ischemic neonatal encephalopathy (HINE).

Methods

A retrospective case‐control study was conducted of neonates born at 35 weeks or more and weighing 1800 g or more at a tertiary care university hospital, between 2005 and 2016, with NAIS (group A), perinatal asphyxia (PA) with Stage II–III HINE (group B), and PA with or without Stage I HINE (group C). Ante‐ and intrapartum data, neonatal characteristics, and placental histopathology were compared.

Results

Eleven neonates were identified in group A, 10 in group B, and 227 in group C. Sentinel events occurred exclusively in groups B (80%) and C (41.4%). Umbilical cord blood gas values and Apgar score were worse in groups B and C compared to group A. No group A neonates required resuscitation at birth, whereas all group B and one‐third of group C neonates did. Seizures developed only in neonates in groups A and B. One neonatal death occurred in group A. There were no significant differences in placental histopathology.

Conclusion

NAIS and PA/HINE cases have different intrapartum and neonatal features. PA does not seem necessary for the occurrence of NAIS. More research is needed regarding associated placental abnormalities.

Birth asphyxia does not seem necessary for neonatal arterial ischemic stroke occurrence. The two conditions have different ante‐/intrapartum and neonatal features.

The Role of the Placenta in Perinatal Stroke: A Systematic Review

CONTEXT

Placental pathology may be an important missing link in the causal pathway of perinatal stroke. The study aim was to systematically review the literature regarding the role of the placenta in perinatal stroke. MEDLINE, Embase, Scopus, and Web of Science electronic databases were searched from 2000 to 2019. Studies were selected based on predefined criteria. To enable comparisons, placental abnormalities were coded using Redline's classification.

RESULTS

Ten studies met the inclusion criteria. Less than a quarter of stroke cases had placental pathology reported. Placental abnormalities were more common among children with perinatal stroke than in the control group. The most frequent placental abnormality was Redline's category 2 (thrombo-inflammatory process).

CONCLUSIONS

Placental abnormalities appear to be associated with perinatal stroke, supporting additional indirect evidence and biological plausibility of a causative role. However, the results should be interpreted cautiously considering the low frequency of placental examination and lack of uniformity in placental pathology reporting.

CLINICAL TRIAL REGISTRATION

PROSPERO Registration no: CRD42017081256.

Perinatal stroke

Perinatal stroke is a heterogeneous syndrome resulting from brain injury of vascular origin that occurs between 20 weeks of gestation and 28 days of postnatal life. The incidence of perinatal stroke is estimated to be between 1:1600 and 1:3000 live births (approximately 2500 children per year in the United States), though its actual incidence is difficult to estimate because it is likely underdiagnosed. Perinatal arterial ischemic stroke (PAIS) accounts for approximately 70% of cases of perinatal stroke. Cerebral sinovenous thrombosis, while less common, also accounts for a large proportion of the morbidity and mortality seen with perinatal stroke. Hemorrhagic stroke leads to disruption of neurologic function due to intracerebral hemorrhage that is nontraumatic in origin. While most cases of PAIS fall into one of these three categories, other patterns of injury should also be considered perinatal stroke. In some cases, the etiology of PAIS is not known but is idiopathic. This chapter will review the classification, risk factors, pathogenesis, clinical presentation, management, and long-term sequelae of perinatal stroke.

Perinatal arterial ischemic stroke

Perinatal arterial ischemic stroke is a relatively common and serious neurologic disorder that can affect the fetus, the preterm, and the term-born infant. It carries significant long-term disabilities. Herein we describe the current understanding of its etiology, pathophysiology and classification, different presentations, and optimal early management. We discuss the role of different brain imaging modalities in defining the extent of lesions and the impact this has on the prediction of outcomes. In recent years there has been progress in treatments, making early diagnosis and the understanding of likely morbidities imperative. An overview is given of the range of possible outcomes and optimal approaches to follow-up and support for the child and their family in the light of present knowledge.

Placental Pathology in Neonatal Stroke: A Retrospective Case-Control Study

OBJECTIVE

To assess the association of placental abnormalities with neonatal stroke.

STUDY DESIGN

This retrospective case-control study at 3 academic medical centers examined placental specimens for 46 children with neonatal arterial or venous ischemic stroke and 99 control children without stroke, using a standard protocol. Between-group comparisons used χ² and Fisher exact t test. Correlations used Spearman correlation coefficient.

RESULTS

Case placentas were more likely than controls to meet criteria for ≥1 of 5 major categories of pathologic abnormality (89% vs 62%; OR, 5.1; 95% CI, 1.9-14.0; P = .0007) and for ≥2 categories (38% vs 8%; OR, 7.3; 95% CI, 2.9-19.0; P < .0001). Fetal vascular malperfusion occurred in 50% of cases and 17% of controls (OR, 4.8; 95% CI, 2.2-10.5; P = .0001). Amniotic fluid inflammation occurred in 46% of cases with arterial ischemic stroke vs 25% of controls (OR, 2.6; 95% CI, 1.1-6.1; P = .037). There was evidence of a "stress response" (meconium plus elevated nucleated red blood cells) in 24% of cases compared with 1% of controls (OR, 31; 95% CI, 3.8-247.0; P < .0001).

CONCLUSIONS

Placental abnormality was more common in children with neonatal stroke compared with controls. All placental findings represent subacute-to-chronic intrauterine stressors. Placental thrombotic processes were associated with both arterial and venous stroke. Our findings provide evidence for specific mechanisms that may predispose to acute perinatal stroke. Amniotic fluid inflammation associated with neonatal arterial ischemic stroke deserves further investigation.

Neonatal Arterial Ischemic Stroke: Risk Related to Family History, Maternal Diseases, and Genetic Thrombophilia

The objective of this study was to evaluate the heritability of neonatal arterial ischemic stroke (NAIS) in relation to family history of thromboembolic event, maternal diseases, and thrombophilia in both parents ( F5G1691A, F2G20210A, and MTHFRC677 T mutations). Forty-two consecutive infants ≥36 weeks of gestation <28 days of life with acute symptomatic NAIS and their parents, as well as 129 controls, were prospectively recruited. Information on maternal data (age, body mass index, oral contraception, migraine, epilepsy, hypertension, and immune disease) and a 3-generation pedigree regarding myocardial infarction, pulmonary embolism, cerebrovascular event, and deep vein thrombosis were obtained. Thrombophilia and maternal diseases did not differ between cases and controls, except for the use of oral contraceptives (more frequent in mothers of controls). No differences were found regarding each studied antecedent of thromboembolic event in the families. The NAIS group showed a higher presence of positive family history among second-degree maternal relatives than did the control infants (odds ratio 4.10; 95% confidence interval 1.29-12.99). Our study does not support the hypothesis that common genetic thrombophilia or familial predisposition to thromboembolic events is associated with the occurrence of idiopathic NAIS.

[Neonatal arterial ischemic stroke: Which thrombotic biological risk factors to investigate and which practical consequences?]

All biological risk factors that have been previously identified to increase the risk of thrombosis in adults, have also been studied in neonates with arterial Ischemic Stroke (NAIS), but most studies were retrospective and included relatively low numbers of affected children. We therefore could not suggest recommendations with a strong level of evidence and only expert proposals potentially useful for clinical practice will be presented in this text. Despite these limitations, the extensive analysis of published data supported that factor V Leiden (FVL) and increased levels of Lp(a) could be significant risk factors for NAIS. Importantly, these 2 risk factors cannot be considered as having provoked NAIS, and moreover, they do not influence the prognosis and the immediate treatment. However, since the FVL may have an impact for the prescription of a thromboprophylaxis when the neonate will become adult, to look for its presence in affected patients may be justified. For clinical practice, the following propositions can be applied: 1. Routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocystein or Lp(a) levels, MTHFR thermolabile variant, should not be considered in neonates with NAIS. 2. Testing for FV Leiden can be performed in case of documented family history of venous thromboembolic disease. 3. Testing neonates for the presence of antiphospholipid antibodies (APA) is mandatory in case of clinical events suggesting antiphospholipid syndrome in the mother (vascular thrombosis, and/or pregnancy morbidity). 4. Routine testing for thrombophilia is not proposed in both parents in case of early death of the neonate, apart from APA in the mother.

[Biological monitoring and other explorations in the acute phase of a neonatal arterial ischemic stroke (excluding hemostasis)]

Neonatal monitoring and other explorations required just after neonatal arterial ischemic stroke (NAIS) diagnosis remain elusive. This review attempts to propose guidelines on this topic. During neonatal period, three major contexts related to NAIS emerge: 1) Metabolic disorders including hypoglycemia; 2) Early post-natal infections; 3) Cardio-vascular anomalies. Different patient profiles have been defined (typical, atypical and at risk profiles). According to these profiles, a final decisional tree including biological monitoring and complementary explorations has been suggested to caregivers.

Distinguishing Arterial Ischemic Stroke From Hypoxic-Ischemic Encephalopathy in the Neonate at Birth

OBJECTIVE

To identify perinatal risk factors that can distinguish arterial ischemic stroke from hypoxic-ischemic encephalopathy at birth.

METHODS

This is a cohort study of all neonates born at 35 weeks of gestation or greater admitted to our neonatal intensive care unit from January 1, 2010, to December 31, 2015, that compares neonates with stroke with those with hypoxic-ischemic encephalopathy undergoing whole-body hypothermia with abnormal brain magnetic resonance imaging.

RESULTS

During this 6-year period, there were 22 neonates with stroke and 47 with hypoxic-ischemic encephalopathy undergoing whole-body hypothermia with abnormal magnetic resonance imaging. Three neonates triaged to hypothermia initially thought to have hypoxic-ischemic encephalopathy were later diagnosed with stroke. All neonates with stroke had a negative thrombophilia workup. Neonates with stroke had a significantly higher incidence of seizures and increased initial platelet counts on univariate analysis. A multivariable model of variables with P<.1 on univariate analysis present within 6 hours of birth found significant increases in nonreassuring fetal heart rate tracings, sentinel events, low Apgar score at 5 minutes, and metabolic acidosis at birth with hypoxic-ischemic encephalopathy. Stroke was associated with a significantly increased initial platelet count.

CONCLUSION

Stroke is associated with increased initial platelet counts and is not associated with cesarean delivery for nonreassuring fetal heart rate tracings, sentinel events, or perinatal metabolic acidosis. Stroke is a form of neonatal brain injury not associated with perinatal risk factors that allow early identification.

Clinical Manifestations, Outcomes, and Etiologies of Perinatal Stroke in Taiwan: Comparisons between Ischemic, and Hemorrhagic Stroke Based on 10-year Experience in A Single Institute

BACKGROUND

Perinatal stroke is a common cause of established neurological sequelae. Although several risk factors have been identified, many questions regarding causes and clinical outcomes remain unanswered. This study investigated the clinical manifestations and outcomes of perinatal stroke and identified its etiologies in Taiwan.

METHODS

We searched the reports of head magnetic resonance imaging and computed tomography performed between January 2003 and December 2012. The medical records of enrolled infants with perinatal stroke were also reviewed.

RESULTS

Thirty infants with perinatal stroke were identified; 10 infants had perinatal arterial ischemic stroke (PAIS) and 20 had perinatal hemorrhagic stroke (PHS). Neonatal seizure was the most common manifestation and presented in 40% of infants with PAIS and 50% of infants with PHS. All survivors with PAIS and 77% of the surviving infants with PHS developed neurological sequelae. Acute seizure manifestation was associated with poststroke epilepsy in infants with PHS but not in infants with PAIS (86% vs. 0%, p=0.005). PAIS was mostly caused by dysfunctional hemostasis (20%) and embolism (20%), whereas PHS was mostly attributable to birth asphyxia (30%).

CONCLUSION

Perinatal stroke is associated with high mortality and morbidity rates in infants. Clinically, it can be difficult to distinguish PAIS and PHS. One should keep a high level of suspicion, especially for PHS, if infants develop unexplained seizure, cyanosis, conscious change, anemia, and/or thrombocytopenia. A systematic diagnostic approach is helpful in identifying the etiologies of perinatal stroke.

Thrombophilia risk is not increased in children after perinatal stroke

Thrombophilia in children with perinatal stroke is rare, with rates similar to those in the normal population. Routine testing in childhood is not indicated.

Pathways for Neuroimaging of Neonatal Stroke

PURPOSE

To provide consensus-based, suggested imaging protocols to facilitate the accurate and timely diagnosis of a neonate with symptoms concerning for stroke.

METHODS

The Writing Group, an international collaboration of pediatric neurologists and neuroradiologists with expertise in perinatal and childhood stroke, participated in a series of pediatric stroke neuroimaging symposia. These discussions, in conjunction with extensive literature review, led to a consensus for imaging protocols to guide practitioners in the diagnosis of neonatal stroke subtypes as defined by the National Institute of Neurological Disorders and Stroke Common Data Elements. The epidemiology, clinical presentation, and associated risk factors for arterial ischemic stroke, cerebral sinovenous thrombosis, and hemorrhagic stroke are reviewed, with a focused discussion regarding the role of neuroimaging for each subtype.

RESULTS

In a neonate with suspected stroke, magnetic resonance imaging is the preferred modality, given the lack of X-irradiation, superior anatomic resolution, and sensitivity for acute ischemia. Core recommended sequences include diffusion-weighted imaging and apparent diffusion coefficient mapping to diagnose acute ischemia, gradient-recalled echo or susceptibility-weighted imaging to detect intracranial blood and its breakdown products, and T1- and T2-weighted imaging to assess for myelination, extra-axial blood, and edema. Magnetic resonance angiography of the brain may be useful to detect vascular abnormalities, with venography if venous sinus thrombosis is suspected. The application of more novel sequences, as well as the utility of follow up-imaging, is also discussed.

Pediatric arterial ischemic stroke: Epidemiology, risk factors, and management

Pediatric arterial ischemic stroke (AIS) is an uncommon but important cause of neurologic morbidity in neonates and children, with consequences including hemiparesis, intellectual disabilities, and epilepsy. The causes of pediatric AIS are unique to those typically associated with stroke in adults. Familiarity with the risk factors for AIS in children will help with efficient diagnosis, which is unfortunately frequently delayed. Here we review the epidemiology and risk factors for AIS in neonates and children. We also outline consensus-based practices in the evaluation and management of pediatric AIS. Finally we discuss the outcomes observed in this population. While much has been learned in recent decades, many uncertainties sill persist in regard to pediatric AIS. The ongoing development of specialized centers and investigators dedicated to pediatric stroke will continue to answer such questions and improve our ability to effectively care for these patients.

Abnormal neurodevelopmental outcomes are very likely in cases of bilateral neonatal arterial ischaemic stroke

AIM

Neonatal arterial ischaemic stroke (AIS) is an important cause of severe neurological disability. This study aimed to analyse the clinical manifestations and outcomes of AIS patients.

METHODS

We enrolled neonates with AIS admitted to Severance Children's Hospital and Gangnam Severance Hospital between 2008 and 2015. AIS was confirmed using magnetic resonance imaging (MRI). We retrospectively reviewed the clinical manifestations, MRI findings, electroencephalography (EEG) findings and neurodevelopmental outcomes.

RESULTS

The study comprised 29 neonates (18 boys). The mean follow-up period was 15.4 months (range 6-44 months), and the mean age at diagnosis was 8.1 days. Seizure was the most common symptom (66%). Bilateral involvement was more common than unilateral involvement (52%). The middle cerebral artery was the most commonly identified territory (79%). Abnormal EEG findings were noted in 93% of the cases. Neurodevelopment was normal in 11 (38%) patients, while cerebral palsy and delayed development were noted in eight (28%) and six (21%) patients, respectively. Patients with bilateral involvement were very likely to have abnormal neurodevelopmental outcomes.

CONCLUSION

Our study showed that abnormal neurodevelopmental outcomes were very likely after cases of neonatal AIS with bilateral involvement, and clinicians should consider early and more effective interventions in such cases.

Impact of Thrombophilia on the Risk of Hypoxic-Ischemic Encephalopathy in Term Neonates

BACKGROUND

The incidence of neonatal hypoxic-ischemic encephalopathy (HIE) is reportedly high in countries with limited resources. Its pathogenesis is multifactorial. A role for thrombophilia has been described in different patterns of preterm and full-term perinatal brain injury.

AIM

This study aims to identify risk factors associated with neonatal HIE and also to determine the contributions of genetic thrombophilia in the development of neonatal HIE.

METHODS

Sixty-seven neonates with HIE and 67 controls were enrolled in the study. Clinical history and examination were undertaken. Patients and controls were tested for the presence of factor V G1691A and prothrombin G20210A mutations. In addition, protein S, protein C, and antithrombin III levels were assessed.

RESULTS

Parental consanguinity and performing emergency cesarean section (CS) were significant risk factors for neonatal HIE (odds ratio [OR] 6.5, 95% confidence interval [CI] 2.6-15.3, P < .001, OR 12.6, 95% CI 2.52-63.3, P = .002, respectively). No significant difference was found regarding maternal age and parity. About 33% of cases and 6% of controls were found to have at least 1 thrombophilic factor ( P < .001). Factor V G1691A mutation significantly increased the risk of neonatal HIE (OR 4.5, 95% CI 1.4-14.5, P = .012), while prothrombin G 20210A mutation and protein C deficiency were not.

CONCLUSION

Parental consanguinity, emergency CS, and factor V mutation may contribute to the higher risk of developing neonatal HIE.

Perinatal arterial ischemic stroke related to carotid artery occlusion

BACKGROUND

The aetiology of perinatal arterial ischemic stroke remains speculative. It is however widely accepted that the aetiology is multifactorial, involving various maternal, placental, foetal and neonatal risk factors. A resulting thromboembolic process is hypothesized and the placenta identified as the most plausible source. An arteriopathy, as observed in a significant proportion of childhood ischemic stroke, is thought to be rare.

METHODS

We report here five cases of perinatal stroke that differ from the vast majority by documented carotid occlusion, and add eleven other similar cases from the literature.

RESULTS

In the majority, an intraluminal thrombus of placental origin is the most probable hypothesis, while in the remaining ones, one can reasonably presume a direct vessel wall injury related to a traumatic delivery, yet generally unproven by imaging.

CONCLUSION

We hypothesize that most of these cases share similar pathophysiology with the more common perinatal arterial ischemic stroke but differ by a persistent identified thrombus in the carotid artery at the time of first imaging, leading to a more severe and extended ischemic damage responsible for an adverse neurological outcome.

Risk Factors for Neonatal Arterial Ischemic Stroke: The Importance of the Intrapartum Period

OBJECTIVE

To investigate risk factors for neonatal arterial ischemic stroke (NAIS), and compare them with those present in term controls and infants with hypoxic-ischemic encephalopathy (HIE).

STUDY DESIGN

Antepartum and intrapartum data were collected at presentation from 79 infants with NAIS and compared with 239 controls and 405 infants with HIE. The relationships between risk factors and NAIS were explored using univariable and multivariable regression.

RESULTS

Compared with controls, infants with NAIS more frequently had a family history of seizures/neurologic diseases, primiparous mothers, and male sex. Mothers of infants with NAIS experienced more intrapartum complications: prolonged rupture of membranes (21% vs 2%), fever (14% vs 3%), thick meconium (25% vs 7%), prolonged second stage (31% vs 13%), tight nuchal cord (15% vs 6%), and abnorm8al cardiotocography (67% vs 21%). Male sex (OR 2.8), family history of seizures (OR 6.5) or neurologic diseases (OR 4.9), and ≥1 (OR 5.8) and ≥2 (OR 21.8) intrapartum complications were independently associated with NAIS. Infants with NAIS and HIE experienced similar rates though different patterns of intrapartum complications. Maternal fever, prolonged rupture of membranes, prolonged second stage, tight nuchal cord, and failed ventouse delivery were more common in NAIS; thick meconium, sentinel events, and shoulder dystocia were more frequent in HIE. Abnormal cardiotocography occurred in 67% of NAIS and 77.5% of infants with HIE. One infant with NAIS and no infant with HIE was delivered by elective cesarean (10% of controls).

CONCLUSIONS

NAIS is multifactorial in origin and shares risk factors in common with HIE. Intrapartum events may play a more significant role in the pathogenesis of NAIS than previously recognized.

A Primer for Nurses on Perinatal/Neonatal Stroke

Perinatal or neonatal stroke is not uncommon, but diagnosis is often missed. Perinatal nurses are often the first health professionals in the position to observe the most typical symptom of stroke in a newborn, which is focal seizure. Etiology, symptoms and outcomes are reviewed and discussed through the context of the author's personal story.

Cerebral ultrasound abnormalities in offsprings of women with C677T homozygous mutation in the MTHFR gene: a prospective study

BACKGROUND

Perinatal stroke is a common cause of neurologic disability. Being clinically under-recognized, its true incidence is not known. Maternal thrombophilia is likely to be a predisposing factor. To date, a general consensus for evaluation of babies born to mothers with genetic thrombotic predisposition is missing. This study was undertaken to assess the frequency of cerebral abnormalities in the offspring of women with homozygous C677T mutation in the MTHFR gene, and to seek for association with additional maternal or pregnancy risk factors.

METHODS

Mother-infant pairs were consecutively recruited from October 2006 through February 2013. Neonates underwent a thorough physical examination at birth, and a cerebral ultrasound examination (cUS) was performed within 24 hours of their life. In neonates with major cerebral lesions, a thrombophilia panel test was obtained. Follow-up cUS was performed in babies with major or minor cerebral abnormalities.

RESULTS

Ninety-one neonates (47 males) were enrolled. By cUS, abnormalities were detected in 18 (19.8%) neonates. Twelve neonates were diagnosed with a minor lesion; a major ischemic/hemorrhagic lesion was found in 6 neonates. There were a neat male preponderance and significant associations with a history of suspected miscarriage, maternal coagulation factors gene mutations, and reduced protein S or protein C activity.

CONCLUSIONS

Our data confirmed a high incidence of cerebral abnormalities in neonates born to women with C677T homozygous mutation in the MTHFR gene. cUS at birth proved to be an effective screening tool or a diagnostic test, that should be routinely performed in babies born to mothers with known thrombotic predisposition.

Systematic review: hereditary thrombophilia associated to pediatric strokes and cerebral palsy

OBJECTIVES

This review aimed to organize and consolidate the latest knowledge about mutations and genetic polymorphisms related to hereditary thrombophilia and their potential association with pediatric stroke and cerebral palsy (CP).

SOURCES

Scientific articles published from 1993 to 2013, written in Portuguese, English, French, and Spanish, were selected and reviewed. The publications were searched in electronic databases, and also in the collections of local libraries. The terms "hereditary thrombophilia", "polymorphisms", "mutation", "pediatric strokes", and "cerebral palsy" were used for the research.

SUMMARY OF THE FINDINGS

The search in databases and in the bibliographic references retrieved 75 articles for inclusion in this review. Studies that investigated hereditary thrombophilias and their associations to CP and arterial and venous pediatric stroke presented contradictory results. The meta-analysis and case-control studies that showed positive results for this association described only slightly increased relative risks and sometimes had questionable conclusions. The association of two or more hereditary thrombophilias, or the association between thrombophilia and other specific clinical risk factors, suggest a higher risk of CP and pediatric stroke than isolated hereditary thrombophilia.

CONCLUSIONS

Larger, multicenter studies should be developed in order to elucidate the role of mutations leading to hereditary thrombophilia and the development of CP and pediatric stroke. The complex and multifactorial etiology of CP and stroke makes this an arduous and difficult task; however, the benefits generated by these studies are immeasurable.

Perinatal arterial ischemic stroke: presentation, risk factors, evaluation, and outcome

BACKGROUND

Perinatal arterial ischemic stroke is as common as large vessel arterial ischemic stroke in adults and leads to significant morbidity. Perinatal arterial ischemic stroke is the most common identifiable cause of cerebral palsy and can lead to cognitive and behavioral difficulties that are amortized over a lifetime.

METHODS

The literature on perinatal arterial ischemic stroke was reviewed and analyzed.

RESULTS

Risk factors for perinatal arterial ischemic stroke include those that are maternal, neonatal, and placental. The most common clinical signs at presentation are seizures and hemiparesis. Evaluation should begin with thorough history acquisition and physical examination followed by magnetic resonance imaging of the brain, with consideration of magnetic resonance angiography of the head and neck, echocardiogram, and thrombophilia evaluation. Treatment beginning early to include physical, speech, and occupational therapies including constraint-induced movement therapy and close cognitive and developmental follow-up may be beneficial. Future treatments may include transcranial magnetic stimulation, hypothermia, and erythropoietin.

CONCLUSIONS

Perinatal arterial ischemic stroke comprises a group of arterial ischemic injuries that can occur in the prenatal, perinatal, and postnatal periods in term and preterm infants with different types of perinatal arterial ischemic stroke having different clinical presentations, risk factors, and long-term outcomes.

Mechanisms of perinatal arterial ischemic stroke

The incidence of perinatal stroke is high, similar to that in the elderly, and produces a significant morbidity and severe long-term neurologic and cognitive deficits, including cerebral palsy, epilepsy, neuropsychological impairments, and behavioral disorders. Emerging clinical data and data from experimental models of cerebral ischemia in neonatal rodents have shown that the pathophysiology of perinatal brain damage is multifactorial. These studies have revealed that, far from just being a smaller version of the adult brain, the neonatal brain is unique with a very particular and age-dependent responsiveness to hypoxia-ischemia and focal arterial stroke. In this review, we discuss fundamental clinical aspects of perinatal stroke as well as some of the most recent and relevant findings regarding the susceptibility of specific brain cell populations to injury, the dynamics and the mechanisms of neuronal cell death in injured neonates, the responses of neonatal blood-brain barrier to stroke in relation to systemic and local inflammation, and the long-term effects of stroke on angiogenesis and neurogenesis. Finally, we address translational strategies currently being considered for neonatal stroke as well as treatments that might effectively enhance repair later after injury.

Pediatric thrombophilia

Pediatric thrombosis and thrombophilia are increasingly recognized and studied. In this article, both the inherited and acquired factors for the development of thrombosis in neonates and children are categorized using the elements of Virchow's triad: stasis, hypercoagulable state, and vascular injury. The indications and rationale for performing thrombophilia testing are described. Also included are discussions on who, how, when, and why to test. Finally, recommendations for the use of contraceptives for adolescent females with a family history of thrombosis are outlined.

Intrauterine upper limb ischemia: an unusual presentation of fetal thrombophilia-a case report and review of the literature

Upper limb ischemia presenting in neonatal period is extremely rare. Moreover, presenting newborn with evidence of intrauterine upper limb vascular occlusion is even rarer. It needs prompt intervention to restore perfusion and avoid morbidity. We present a newborn with right upper limb brachial artery thrombosis causing ischemia that was noted at birth and appeared later to be homozygous for factor V Leiden and glycoprotein IIIa with no other identifiable risk factors. In this report, we present the case, its successful medical management, proper counseling, and review of the literature. We recommend investigating the neonates and their parents for thrombophilia mutations when they present with unusual vascular occlusion site as newborns.

Inherited prothrombotic risk factors in children with first ischemic stroke

Stroke in children is a heterogeneous disorder. Over 100 risk factors for stroke have been reported and genetic predisposition to stroke has been established. The most frequently reported risk factors are congenital heart malformations, hemolytic anemias, collagen vascular diseases, some rare inborn metabolic disorders, trauma, infection and thrombophilia. The aim of this article is to provide an overview of investigated inherited prothrombotic risk factors in children with first ischemic stroke. Various prothrombotic risk factors have been investigated in pediatric stroke including elevated homocysteine and lipoprotein (a), antithrombin, protein C and protein S deficiency, Factor V Leiden, Factor II G20210A and plasminogen activator inhibitor-1 4G/5G polymorphism. Despite similar criteria for inclusion of different studies in meta-analyses investigating first ischemic stroke in children, the obtained results were not consistent for all prothrombotic risk factors. The discrepancies found could be explained by methodological issues like different sample sizes, patient populations included and lack of controls. In order to provide the necessary power for randomized control trials, multi-center, multi-national approaches like International Pediatric Stroke Study have been initiated with the aim to describe risk factors for childhood stroke and explore their relationship with presentation, age, geography, and infarct characteristics. Although it is evident from numerous studies that the frequency of inherited prothrombotic factors is increased in pediatric stroke, single thrombophilia does not fully explain stroke in a child as it represents only a mild risk factor. Further studies are needed, as improved understanding of underlying mechanisms will improve primary and secondary prevention of childhood stroke.

The current status of lipoprotein (a) in pregnancy: a literature review

BACKGROUND AND PURPOSE

Lipoprotein (Lp) (a) is a neglected element of the blood lipid profile. It is now recognized as a determinant of coronary heart disease progression and its role in atherosclerosis and its ability to induce thrombosis make it potentially important in the course of normal and complicated pregnancies. Pregnancy involves a major transformation of metabolism to sustain fetal growth. Multiple studies have been conducted on Lp(a) in pregnancy, and it is timely to synthesize and evaluate this evidence.

METHODS AND SUBJECTS

We reviewed the MEDLINE database for all articles published concerning "lipoprotein a" and "pregnancy" from May 2003 to May 2012. A previous comprehensive review assessed the literature up to May 2003.

RESULTS

We critically analyzed 14 studies detailing the effect of complications in pregnancy on Lp(a) profile, and subsequent pregnancy outcomes where available. Studies evaluating the normal metabolic response to pregnancy, pregnancies complicated by pre-eclampsia and intra-uterine growth restriction were reviewed.

CONCLUSIONS

A substantial mass of data has accumulated describing Lp(a) changes in pregnancy. The diversity of study design limits the ability to draw broad-ranging conclusions, but brings into focus the important questions remaining, which we discuss.

Epidemiologic associations with cerebral palsy

OBJECTIVE

To estimate epidemiologic risk factors for cerebral palsy.

METHODS

Data were collected by linkage to state-based perinatal repositories and cerebral palsy registers and using a maternal questionnaire. The cohort included 587 individuals with cerebral palsy and 1,154 non-cerebral palsy controls.

RESULTS

The following factors were associated with cerebral palsy: recorded maternal infection during pregnancy (41.4% patients compared with 31.3% controls; odds ratio [OR] 1.55, 95% confidence interval 1.26-1.91), small for gestational age ([birth weight less than third customized centile] 43.9% patients compared with 6.3% controls; OR 11.75, 6.25-22.08), gestational age less than 32 weeks (29.3% patients compared with 0.7% controls; OR 59.20, 28.87-121.38), multiple birth (OR 6.62, 4.00-10.95), a relative with cerebral palsy (OR 1.61, 1.12-2.32), breech position (13.7% patients compared with 6.0% controls; OR 2.48, 1.76-3.49), bleeding at any time in pregnancy (29.3% patients compared with 16.9% controls; OR 2.04, 1.61-2.58), male sex (58.8% patients compared with 45.8% controls; OR 1.68, 1.38-2.06), multiple miscarriage (7.7% patients compared with 3.5% controls; OR 2.30, 1.38-3.82), smoking (14.0% patients compared with 10.6% controls; OR 1.37, 1.02-1.85), and illicit drug use (3.3% patients compared with 1.5% controls; OR 2.22, 1.14-4.30). Factors not associated with cerebral palsy were "disappearing twin," diabetes, maternal body mass index, hypertension, alcohol consumption, anemia, maternal hypothyroidism, forceps or vacuum delivery, and maternal age.

CONCLUSION

Preterm birth, intrauterine growth restriction, perinatal infection, and multiple birth present the largest risks for a cerebral palsy outcome. Reassuringly, upper respiratory tract and gastrointestinal infections during pregnancy were not associated with cerebral palsy.

LEVEL OF EVIDENCE

II.

Developmental origins of cerebrovascular disease II: considering gene-environment interactions when developing neuroprotective strategies

The second part of this review of the developmental origins of cerebrovascular disease discusses prenatal gene-environment interactions concerning maternal, placental, and fetal conditions that culminate in specific injuries such as perinatal stroke, as well as complications of intrauterine growth restriction and congenital heart disease. A greater understanding of gene-environment influences on cerebrovascular health and disease in early life will contribute to the successful development of neuroprotective strategies throughout the lifespan.

Etiological analysis of presumed perinatal stroke

This study aimed to investigate the maternal, pre- and perinatal, and prothrombotic factors with congenital hemiparesis due to presumed perinatal stroke (PPS). Prothrombotic risk factors including protein C and S, antithrombin III, lipoprotein (a), homocystein, factor VIII levels; anticardiolipin antibodies and lupus anticoagulant; methylenetetrahydrofolate reductase mutations, factor V Leiden, prothrombin G20210A mutations were investigated. Arterial ischemic stroke was detected in 60% and periventricular venous infarction in 40%. At least one prothrombotic risk factor was present in 69%, two in 17%, and three or more in 8.5% of cases. The most common combination was methylenetetrahydrofolate reductase C677T and factor V Leiden heterozygosity. The etiology and pathogenesis of PPS is still unclear. According to this study, most of the patients with PPS might have one or more prothrombotic risk factors and certain prenatal risk factors including intrauterine growth retardation, twin gestation and preeclampsia might be related to PPS.

Perinatal stroke: a case-based review

Neonatal stroke is a diverse clinical entity. Terminology and aetiology described in the literature are very varied. While numerous risk factors are cited, only few case-control studies have investigated them in a systematic fashion. This equipoise extends to the investigational and management profile of perinatal stroke too. Controversy persists about the suitability of detailed haematological thrombophilia workup in the neonatal period. This case-based review details the variable clinical presentation in term and preterm neonates, discusses the current literature, ascertains the respective roles of various imaging modalities, explores relevant new neuroprotective interventions and proposes a systematic approach to clinical and neuroimaging workup. Long-term follow-up is important as many infants suffer neuro-disability, which might need early intervention strategies.

Preterm infant with a catastrophic hemorrhagic-thromboembolic incident

Thrombotic disease of the newborn is uncommon but usually associated with serious morbidity and mortality. Although the operating mechanisms of coagulation and fibrinolysis are the same in all age groups, plasma concentrations of the two systems' components are significantly different in neonates compared to children and adults. This places neonates at greater risk for thrombosis that may rise considerably if a predisposing factor is present or a genetic or medical condition predisposing to thrombosis coexists. While marginal, the possibility of abnormal bleeding secondary to congenital prothrombotic disorders has been described. A significant association between thromboembolic/hemorrhagic disease in newborns and each of factor V(Leiden) and prothrombin G20210A mutations has been reported. Although not a frequent occurrence in adults and children, congenital 'multigenic' thrombophilia is well known. However, the combined heterozygote state of both mutations is perhaps underreported in preterm infants. We present a severely intrauterine growth-restricted preterm baby born to consanguineous parents. He had stroke as part of a generalized bleeding-thromboembolic incident caused by combined heterozygote mutation of factor V(Leiden) and prothrombin G20210A, each of which was then found in a heterozygote form in each of the 2 parents.

Arterial ischemic stroke in an adolescent with presumed perinatal ischemic stroke

The risk of recurrent ischemic stroke after presumed perinatal stroke and the risk factors for such recurrence are rarely reported. Here, we present an adolescent with a history of presumed perinatal stroke who presented with arterial ischemic stroke recurrence at the age of 15 years. Hereditary thrombophilia screening performed at the time of his stroke recurrence demonstrated protein S deficiency. No evidence-based consensus guidelines on thrombophilia screening in children with presumed perinatal stroke exist, nor has the role of secondary prophylaxis been addressed. There is a risk of stroke recurrence after presumed perinatal stroke, and routine thrombophilia screening may identify those children who are at higher risk for recurrence and who might therefore benefit from secondary prophylaxis. Clear guidelines should be developed to standardize investigations and management of children with presumed perinatal ischemic stroke.

Symptomatic neonatal arterial ischemic stroke: the International Pediatric Stroke Study

BACKGROUND

Neonatal arterial ischemic stroke (AIS) has emerged as a leading cause of perinatal brain injury, cerebral palsy, and lifelong disability. The pathogenesis is poorly understood, which limits the development of treatment and prevention strategies. Multicenter studies must define epidemiology, risk factors, treatment practices, and outcomes to advance clinical trials and improve the adverse outcomes suffered by most survivors.

METHODS

The International Pediatric Stroke Study is a global research initiative of 149 coinvestigators (30 centers in 10 countries). Patients with clinical and neuroimaging confirmation of symptomatic neonatal AIS were enrolled (2003-2007). Standardized, Web-based data entry collected clinical presentations, risk factors, investigations, treatments, and early outcomes. We examined predictors of infarct characteristics and discharge outcome by using multivariate logistic regression.

RESULTS

Two hundred forty-eight neonates were studied (57% male, 10% premature). Most of them presented with seizure (72%) and nonfocal neurologic signs (63%). MRI was completed for 92% of the infants, although <50% had vascular imaging. Infarcts preferentially involved the anterior circulation and left hemisphere and were multifocal in 30%. Maternal health and pregnancies were usually normal. Neonates often required resuscitation (30%) and had systemic illnesses (23%). Cardiac and prothrombotic abnormalities were identified in <20% of the infants. Antithrombotic treatment was uncommon (21%) and varied internationally. Half (49%) of the infants had deficits at discharge, and data on their long-term outcomes are pending.

CONCLUSIONS

Newborns with AIS are often systemically sick, whereas their mothers are usually healthy. Definitive causes for most neonatal AISs have not been established, and large-scale case-control studies are required to understand pathogenesis if outcomes are to be improved.

New insights in perinatal arterial ischemic stroke by assessing brain perfusion

Perinatal arterial ischemic stroke (AIS) is an important cause of long-term morbidity in children. Thus, there is an urgent need to better understand the mechanisms of stroke in newborns in order to develop effective treatment and prevention strategies. The purpose of this study was to assess brain perfusion within the first month of life in newborns with AIS. In this study, magnetic resonance imaging (MRI) and perfusion imaging by arterial spin labeling (ASL) were used to assess brain perfusion in four term newborns with AIS. One patient had a stroke within the territory of the right middle cerebral artery (MCA); the other three patients had a stroke within the territory of the left MCA. None of them displayed any hemorrhagic component. All four patients demonstrated abnormal brain perfusion in the stroke area. Cerebral blood flow (CBF) within the stroke area was increased in patient # 1. In all other three patients, CBF was decreased within the stroke center and increased in the periphery of the stroke area. These results show the feasibility of the ASL sequence in newborns with AIS and support its addition to the current MRI protocol used in these newborns as it provides useful information on brain hemodynamics. Its value for identifying salvageable tissue in newborns needs to be further assessed, as well as its potential role in stroke follow-up and for tissue-specific treatment screening.