Is thrombophilia a factor in the development of hemiplegic cerebral palsy?

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.

Cerebral palsy in eastern Denmark: declining birth prevalence but increasing numbers of unilateral cerebral palsy in birth year period 1986-1998

The Cerebral Palsy Registry in eastern Denmark has been collecting cases using a uniform data sampling procedure since birth year 1979. Children are included by two child neurologists and an obstetrician. Information on pregnancy, birth, neonatal period, impairments and demographic data are registered. The total cerebral palsy birth prevalence has been significantly decreasing since the birth period 1983-1986 with 3.0 per 1000 live births until the period 1995-1998 with 2.1 per 1000 live births. The overall decrease was seen in preterm infants (<31 weeks) as well as in term infants and despite a simultaneous fall in perinatal and early neonatal mortality in the preterm group. Analysing the subtypes of CP we found a significant increase in the numbers as well as the rate of unilateral CP with a simultaneous fall in the numbers as well as the rate of bilateral CP. The explanation of this rise is not obvious. A change from bilateral periventricular lesions to unilateral is a possibility, but no major change in the neonatal handling could be documented. Regarding associated impairments, developmental delay/learning disabilities as well as motor function assessed by ability to walk (unassisted/assisted), both have changed toward higher percentage of children with unassisted walking and in need of special education.

The genomic basis of cerebral palsy: a HuGE systematic literature review

Cerebral palsy has been associated with a number of candidate genes. To date, no systematic review has been conducted to synthesise genetic polymorphism associations with cerebral palsy. We apply the HuGE NET guidelines to search PubMed and EMBASE databases for publications investigating single nucleotide polymorphisms (SNPs) and cerebral palsy outcome. 22 papers were identified and are discussed in this review. Candidate genes were grouped as (1) thrombophilic, (2) cytokine, (3) apolipoprotein E or (4) other SNPs, largely related to cardiovascular physiology/pathophysiology and the functioning of the immune system. Of the studies identified, cohorts were usually small, without adequate control and ethnically diverse, making direct comparison between studies difficult. The most promising candidate genes include factor V Leiden, methylenetetrahydrofolate reductase, lymphotoxin-alpha, tumour necrosis factor-alpha, eNOS and mannose binding lectin. Large case-control studies are needed to confirm these candidates with attention given to cohort ethnicity, cerebral palsy subtype analysis and possible multiple gene and gene-environment interactions.

Factor V Leiden and Antiphospholipid Antibodies in Either Mothers or Infants Increase the Risk for Perinatal Arterial Ischemic Stroke

Background and Purpose— The objective was to investigate the role of infant and maternal thrombophilia in a cohort of mothers and infants presenting with perinatal arterial ischemic stroke.

Methods— Forty-seven infants with clinically and radiologically confirmed perinatal arterial ischemic stroke underwent thrombophilia workup: factor V Leiden (FVL), PII20210A mutation, Methylene-tetrahydrofolate reductase 677T polymorphism, protein C, protein S, antithrombin, FVIII, and antiphospholipid antibodies. Thrombophilia data were available for 23 mother–infant pairs and compared with control populations to evaluate the risk for PAS.

Results— Thirty of 47 (64%) infants and 15 of 22 mothers (68%) had evidence of thrombophilia. In 18 of 23 (78%) mother–infant pairs, there was at least 1 thrombophilic risk factor, but 15 pairs were mismatched in pathology. Among infants, FVL, protein C deficiency, and presence of antiphospholipid antibodies prevailed (OR, 4.2; 95% CI, 1.5–11.3; OR, 12.2; 95% CI, 2.5–59.9; OR, 4.1; 95% CI, 1.4–12.2, respectively). Interestingly FVL prevailed in almost one-third of mothers (OR, 8.5; 95% CI, 4.1–17.5) and 18% of mothers had antiphospholipid antibodies (OR, 3.8l; 95% CI, 1.5–10.0).

Conclusions— Maternal and neonatal thrombophilia, especially presence of FVL or antiphospholipid antibodies, may be important in the pathogenesis of perinatal arterial ischemic stroke. The nature of thrombophilic mother–infant risk potential interactions warrants further investigation.

Neonatal abstinence syndrome and cerebral infarction following maternal codeine use during pregnancy

Neonatal withdrawal from maternal drugs and medications is common in some NICUs. Codeine-containing cough preparations given to pregnant mothers have been identified as a cause of neonatal abstinence syndrome. However, many women do not consider prescription cough syrups when asked about drug use. Maternal medication or illicit drug use has been identified as a cause of perinatal arterial stroke. Since codeine is an opiate with similar pharmacodynamic effects to morphine, it is reasonable to investigate if maternal codeine use has effects on the fetus that are similar to other opiates. The authors present 2 cases of newborn infants with perinatal arterial stroke that may have been associated with in utero exposure to codeine. Physicians should ask about maternal medication use, including codeine-containing cough preparations, when evaluating newborn infants with evidence of cerebral infarction.

Fetal and Neonatal Thrombophilia

Thrombophilia of the fetus and neonate may contribute to higher prevalence of perinatal thrombosis. Due to the potential interaction between thrombophilic risk factors of the neonate and maternal thrombophilia and placental vasculopathy, we recommend thrombophilia assessment be performed in any child and in the mother in case of perinatal thrombosis. Further attention and larger prospective studies are required to establish the role of thrombophilic risk factors in the pathogenesis of any other perinatal complications.

The epidemiology of cerebral palsy: incidence, impairments and risk factors

PURPOSE

Describing the epidemiology of cerebral palsy (CP), its impairments and risk factors.

METHOD

Literature review 1965-2004. Search terms: Cerebral palsy, incidence, prevalence, impairments, risk factors.

RESULTS

In the last 40 years the prevalence of CP has risen to well above 2.0 per 1000 life births. In this time span the proportion of low-birthweight infants rose, the proportion of diplegia decreased, while the proportion of hemiplegia increased. CP is more prevalent in more deprived socio-economic populations. The majority of people with CP have the spastic syndrome of which the diplegic group is the smallest. Dependent on the subgroup of CP, 25-80% have additional impairments. A large proportion has some kind of cognitive impairment; the prevalence varies with the type of CP and especially increases when epilepsy is present. Epilepsy is present in 20-40%; it is most common among the hemi- and tetraplegics. Sensibility of the hands is impaired in about half. Chronic pain is reported by more than a quarter of the adults. Up to 80% have at least some impairment of speech. Low visual acuity is reported in almost three-quarters of all children. Half of all children have gastrointestinal and feeding problems. Stunted growth occurs in a quarter, while under- or overweight problems are present in half of the children. Almost 70% of people with spastic CP have abnormal brain CT findings; abnormal cranial ultrasounds is most strongly associated with hemiplegia, normal cranial ultrasounds with diplegia. The most important risk factors for CP are low birthweight, intrauterine infections and multiple gestation.

Associations between inherited thrombophilias, gestational age, and cerebral palsy

OBJECTIVE

This study was undertaken to investigate associations between inherited thrombophilic polymorphisms and cerebral palsy (CP) in a large case-control study.

STUDY DESIGN

This is a population-based case-control study. Genomic DNA from newborn screening cards of 443 white CP cases and 883 white controls was tested for factor V Leiden (FVL, G1691A), prothrombin gene mutation (PGM, G20210A), and methylenetetrahydrofolate reductase (MTHFR) C677T and MTHFR A1298C.

RESULTS

MTHFR C677T was associated with an increased risk of developing any CP (32-36 weeks' gestation, homozygous odds ratio [OR] 2.55, 95% CI 1.12-5.74; heterozygous OR 1.91, 95% CI 1.01-3.66). MTHFR C677T was also associated with diplegia at both less than 32 weeks' gestation (homozygous OR 2.76, 95% CI 1.21-6.12) and all gestations (heterozygous OR 1.58 95%, CI 1.02-2.45). For children less than 32 weeks, FVL homozygosity may be associated with an increase in the risk of developing quadriplegia (OR 9.12, 95% CI 0.86-53.71). MTHFR A1298C (heterozygous) was associated with a reduced risk of diplegia developing at 32 to 36 weeks' gestation (OR 0.16, 95% CI 0.02-0.70). There were no associations between any type of CP and thrombophilia for children born 37 weeks or greater. Heterozygous PGM and homozygous MTHFR C677T combined were associated with quadriplegia at all gestational ages (OR 5.33, 95% CI 1.06-23.25).

CONCLUSION

MTHFR C677T approximately doubles the risk of CP in preterm infants. A combination of homozygous MTHFR C677T and heterozygous PGM increases the risk of quadriplegia 5-fold at all gestational ages.

Perinatal stroke--risk factors and management

Stroke is an uncommon but increasingly recognised cause of mortality and long-term neurological morbidity in children. A significant number of these events appear to be caused by thromboembolic disease and, as with other childhood thrombotic problems, the incidence of central nervous system events appears highest during the neonatal period. In contrast to peripheral arterial and venous thrombotic problems, it is likely that a proportion of cerebral thromboembolic events occur either in utero or perinatally and reflect different risk factors from those occurring in older infants and children. The pathophysiology of perinatal stroke is complex and in many cases is likely to be multifactorial. It is now recognised that risk factors may relate to both maternal and placental problems as well as fetal and neonatal disorders. Large prospective studies of perinatal stroke are currently lacking and efforts to define the relative contribution from each of these areas are at an early stage. The complex nature of these disorders requires collaboration between a number of different disciplines including obstetrics, fetal medicine, pathology, neonatology and neurology. Of particular interest to haematologists is the possible impact of prothrombotic abnormalities in the pathophysiology of these events and also the potential for the use of antithrombotic agents in both management and prevention.

Role of thrombophilic risk factors in children with non-stroke cerebral palsy

BACKGROUND

Thrombophilic risk factors play an important role in the pathogenesis of perinatal stroke and resultant cerebral palsy (CP). The association between thrombophilia and CP caused by etiologies other than stroke is undetermined.

METHODS

We assessed three genetic thrombophilic markers (mutation of Factor V Leiden [FV G1691A], 677T polymorphism of thermolabile methylenetetrahydrofolate reductase [MTHFR] and G20210A mutation of the prothrombin gene) in 49 pediatric patients with non-stroke CP and compared the findings with 118 apparently healthy controls. CP in the study group was due to periventricular leukomalacia (n=27), intraventricular hemorrhage (n=9), hypoxic ischemic encephalopathy (n=4), prematurity with no apparent complication (n=8) and intrauterine growth retardation (n=1). Twenty-five children had spastic diplegia, 20 had spastic quadriplegia and 4 had spastic hemiplegia. CP was graded as being severe in 26 children (53%).

RESULTS

No significant difference in the prevalence of thrombophilic risk factors was found between the study and control groups. Twelve study children (24.5%) had at least one of the three thrombophilic mutations compared with 27 controls (23%). There was no significant difference in the prevalence of each thrombophilic risk factor in the various etiologic groups and in the subgroups of mild/severe CP and the control group.

CONCLUSION

These findings support the notion that thrombophilia neither contributes to the occurrence nor affects the clinical outcome and severity of non-stroke CP.

Perinatal stroke in children with motor impairment: a population-based study

OBJECTIVE

Risk factors for perinatal arterial stroke (PAS) are poorly understood. Most previous studies lack an appropriate control group and include only infants with symptoms in the newborn period. We set out to determine prenatal and perinatal risk factors for PAS.

METHODS

In a population-based, case-control study nested within the cohort of 231 582 singleton infants who were born at >or=36 weeks' gestation in Northern California Kaiser hospitals from 1991 to 1998, we searched electronically for children with motor impairment and reviewed their medical records to identify diagnoses of PAS. Control subjects were randomly selected from the study population. A medical record abstractor reviewed delivery records without knowledge of case status.

RESULTS

The prevalence of PAS with motor impairment was 17/100,000 live births. Of 38 cases, 26 (68%) presented after 3 months of age with hemiparesis or seizures. All 12 newborns with acute stroke symptoms had seizures. A delayed presentation was more common in children with moderate to severe motor impairment than among infants with only mild motor abnormalities (24 of 31 vs 2 of 7). Prepartum risk factors significantly associated with PAS in multivariate analysis were preeclampsia (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.1-11.4) and intrauterine growth restriction (OR: 5.3; 95% CI: 1.5-18.6). Newborns with PAS were also at higher risk of delivery complications, such as emergency cesarean section (OR: 6.8; 95% CI: 2.7-16.6), 5-minute Apgar <7 (OR: 23.6; 95% CI: 4.1-237), and resuscitation at birth (OR: 4.5; 95% CI: 1.6-12.3).

CONCLUSIONS

Preeclampsia and intrauterine growth restriction (IUGR) may be independent risk factors for perinatal stroke resulting in motor impairment. Large multicenter studies that include all children with perinatal stroke are needed to determine further the risk factors and outcome of perinatal stroke.

Neuroimaging in spasticity and movement disorders

Advances in neuroimaging provide unique opportunities to evaluate brain structure, biochemistry, and function. Although a number of imaging techniques have been used in newborns, cranial ultrasonography in premature infants and nuclear magnetic resonance modalities, including magnetic resonance imaging and diffusion-weighted imaging, in high-risk term infants are of foremost benefit. Interpretation is based on knowledge of characteristic imaging findings in specific childhood neurologic disorders and an understanding of differential diagnosis in cerebral palsy syndromes, such as spastic diplegia and various subtypes of extrapyramidal cerebral palsy. This review focuses on imaging studies that can be effectively used in at-risk infants and in children with spasticity and movement disorders to refine diagnosis and guide therapeutic interventions.

Fetal neurologic consultations

The pediatric neurologist can fulfill a useful role as a subspecialty consultant concerning the fetus with a suspected brain disorder, given that neurologic disease may occur before the intrapartum period. Brain disorders detected in the neonatal period may also reflect fetal brain damage before dysfunction is first documented. Medical conditions during the antepartum or intrapartum periods can alternatively predispose the fetus or neonate to express brain dysfunction at a later period, with either de novo or compounded brain injury. The pediatric neurologist must, therefore, consider maternal, placental, and fetal diseases on which a neonatal encephalopathy may be superimposed. This review article provides the neurologist with an integrative approach to fetal neurology, emphasizing perspectives from other subspecialties concerning maternal-fetal medicine, pathology, and neonatology, as well as other pediatric subspecialties. Evaluation of future strategies for either fetal or neonatal brain resuscitation will need to consider the developmental context in which a suspected brain injury occurred during the antepartum, intrapartum, and neonatal periods.

Antenatal causes of cerebral palsy: associations between inherited thrombophilias, viral and bacterial infection, and inherited susceptibility to infection

Cerebral palsy rates of 2 in every 1,000 births have varied little over the last 40 years, despite improvements in obstetric care. In the past, cerebral palsy was thought to be due to poor obstetric care and management; however, epidemiological studies have refuted this, suggesting that there is usually an antenatal timing to the neuropathology of cerebral palsy. There are many known risk factors for cerebral palsy, including multiple gestation, prematurity, and low birth weight. Recently, intrauterine infection, maternal pyrexia, and the presence of thrombophilic disorders (thrombophilia) have been identified as major risk factors for subsequent cerebral palsy. This review examines the links between intrauterine infection, the fetal inflammatory response, and thrombophilia as possible causes of cerebral palsy. The interactions of viral or bacterial infections during pregnancy, normal or abnormal fetal cytokine responses, and hereditary fetal thrombophilias as antenatal causes of the neuropathology of cerebral palsy are now areas of research priority.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to describe the condition cerebral palsy, list the risk factors for the development of cerebral palsy, outline the ultrasound findings associated with cerebral palsy, and point out other conditions associated with cerebral palsy.

Cerebral infarctions in the fetus and neonate: maternal-placental-fetal considerations

Historical data, clinical examination findings, and laboratory information must be integrated along a variable timeline that includes antepartum, intrapartum, and postnatal time periods when cerebral infarction can occur, in the context of the neonates genetic endowment. Genetic susceptibility or prenatal acquired vulnerabilities regarding stroke syndromes may set in motion a cascade of molecular pathways that ultimately cause or exacerbate brain injury when the vulnerable child experiences adverse medical conditions. The clinician must consider maternal, placental, and fetal conditions on which a stroke syndrome may be superimposed, with or without additional brain injury from other pathogenic mechanisms. Evaluation of fetal and neonatal cerebral infarction requires knowledge of mechanisms of brain injury that cross medical disciplines and may involve consultation with maternal/fetal specialists, placental and pediatric pathologists, neonatologists, geneticists, and other pediatric subspecialties. Comprehensive evaluations of survivors of cerebral infarction are needed to better understand structural and functional plasticity of the developing brain after a cerebrovascular event in the fetal and neonatal periods.