Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 15-1997. Respiratory distress and seizure in a neonate

Neonatal Head Ultrasound: A Review and Update-Part 2: The Term Neonate and Analysis of Brain Anomalies

Neonatal head ultrasound has a key role in triaging neonates with antenatal imaging or postnatal clinical concerns. This article will discuss key features of various intracranial pathologies of concern in term infants. It will also illustrate various congenital malformations.

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.

Genetic risk factors for perinatal arterial ischemic stroke

The cause of perinatal arterial ischemic stroke is unknown in most cases. We explored whether genetic polymorphisms modify the risk of perinatal arterial ischemic stroke. In a population-based case-control study of 1997-2002 births at Kaiser Permanente Northern California, we identified 13 white infants with perinatal arterial ischemic stroke. Control subjects included 86 randomly selected white infants. We genotyped polymorphisms in nine genes involved in inflammation, thrombosis, or lipid metabolism previously linked with stroke, and compared genotype frequencies in case and control individuals. We tested several polymorphisms: tumor necrosis factor-α -308, interleukin-6, lymphotoxin A, factor V Leiden, methyltetrahydrofolate reductase 1298 and 667, prothrombin 20210, and apolipoprotein E ε2 and ε4 alleles. Patients with perinatal arterial ischemic stroke were more likely than control subjects to demonstrate at least one apolipoprotein E ε4 allele (54% vs 25%, P = 0.03). More patients with perinatal arterial ischemic stroke carried two ε4 alleles than did control subjects (15% vs 2%, P = 0.09), although this finding lacked statistical significance. Proinflammatory and prothrombotic polymorphisms were not associated with perinatal arterial ischemic stroke. The apolipoprotein E polymorphism may confer genetic susceptibility for perinatal arterial ischemic stroke. Larger population-based studies are required to confirm this finding.

Diagnosis of perinatal stroke I: definitions, differential diagnosis and registration

INTRODUCTION

Perinatal stroke can be divided into three subtypes: ischaemic stroke, either arterial or sinovenous and haemorrhagic stroke. For the sake of universal registration and to perform intervention studies, we propose a detailed diagnostic registration system for perinatal stroke taking 10 variables into account. These variables are discussed here and in the accompanying article.

MATERIAL AND RESULTS

Differentiation is needed from focal brain changes as a result of disorders other than stroke, whereby accurate timing is possible only when early neonatal imaging is available. Detailed templates are presented for arterial and venous vascular classification. AIS is further subdivided into single territory and complex infarction and some stratification is proposed in the complicated stroke group. This registration system has been applied to a retrospective cohort of 134 newborns with stroke (single-centre observation from 1999 to 2007) and the results are compared with published data. By applying this registration system, intervention studies for one homogeneous stroke type (e.g. complete middle cerebral artery stroke) may be facilitated.

CONCLUSION

Ten variables may be sufficient to register a perinatal stroke. These include gestational age, birthweight, gender, delivery mode, time of detection, presentation, type of stroke, vessel affected or type of cavity, imaging method at detection and clinical context.

Fetal thrombotic vasculopathy in the placenta: cerebral thrombi and infarcts, coagulopathies, and cerebral palsy

Thrombi in the fetal circulation of the placenta cause a pattern of clustered fibrotic villi called fetal thrombotic vasculopathy (FTV), which has been associated with serious injuries to neonates, especially brain injuries. Correlation of FTV with visceral thrombi in autopsy specimens might lead to a more accurate estimate of the prevalence of somatic thrombi as a significant and underrecognized cause of prenatal injury or perinatal death, and show the potential validity of placental FTV as an indicator of thrombotic lesions in the fetus and newborns who survive. Clinicopathologic correlation was used to perform a 3-year retrospective autopsy review. We identified 16 cases (19%) among 84 perinatal autopsy specimens in which placental FTV was associated with stillbirth, intrapartum, or neonatal death. Two liveborn neonates survived 2.5 hours, and one for 24 hours; there was one intrapartum death, and the rest were stillborn. Clinical evidence of severe central nervous system (CNS) injury to two of the liveborn infants was evident at birth. Twelve stillborns died from 12 to 48 hours before delivery. Placental FTV had features of organization that clearly antedated the fetal death. Autopsy findings confirmed somatic thrombi in six cases (37.5%) of the 16 with FTV, including cerebral thrombi or infarcts (three cases), renal thromboemboli (three cases), and pulmonary thromboemboli (two cases). One mother had history of deep vein thrombosis, and four of eight tested had abnormal coagulation test results. Placental FTV indicates a significant probability of thrombi in the fetus and represents an important, possibly underrecognized cause of perinatal mortality and neonatal injury. Parental coagulopathy as a significant factor in prenatal injury and death deserves more comprehensive study. The placenta remains an undervalued and underutilized surgical specimen in the evaluation of perinatal injury, especially cerebral palsy.