Left brachial artery thrombus, left axillary vein thrombus, and stroke in a neonate with factor V Leiden mutation

Skin Necrosis in a Patient with Factor V Leiden Mutation following Nipple Sparing Mastectomy

Nipple-sparing mastectomy (NSM) and immediate breast reconstruction have replaced radical surgical interventions for the treatment of selected patients with breast cancer undergoing prophylactic mastectomy. NSM is technically a difficult procedure. After dissection, the remaining breast skin and nipple-areola complex (NAC) must be thin enough to be free of tumor tissue and thick enough to preserve tissue perfusion. Factor V Leiden mutation is the most common cause of hereditary thrombophilia; thrombosis almost always develops in the venous system. The literature includes only a few case series of arterial thrombosis. The present study aimed to describe for the first time a patient with Factor V Leiden mutation that developed nipple-areola complex and skin necrosis, and multiple embolisms in the upper extremity arteries following NSM.

[Intrauterine upper limb ischemia due to a heterozygous mutation (677C>T) of the methylene-tetrahydrofolatereductase gene]

Limb ischemia rarely occurs in utero. The diagnosis can be made by clinical observation at birth or a few hours later. Color duplex ultrasound is the first imaging test used to confirm the diagnosis. The etiology appears to be complex and multifactorial. We report 2 cases of intrauterine limb ischemia involving the upper limb in 2 newborns. Both children were heterozygous for the 5,10-methylenetetrahydrofolate reductase 677C>T gene variant. The first patient was born by caesarean section at 34 weeks of gestation. At delivery, the infant presented with pallor in his right upper limb and weak radial arterial pulsation. Doppler ultrasound and computed tomography angiography demonstrated a totally occlusive thrombus within the right brachial artery. The newborn underwent systemic thrombolysis with good recovery. The second patient was born via cesarean section at 37 weeks of gestation. At delivery, the infant presented with a motionless, cold, and gangrenous right upper limb. The demarcation line was just below the right elbow. Doppler ultrasound revealed a complete occlusion of the right subclavian artery. After failure of antithrombotic therapy, the limb was amputated with no further complication. We discuss the epidemiology, etiology, and clinical features of this rare pathology.

Two children with both arm ischemia and arterial ischemic stroke during the perinatal period

It is rare for both limb ischemia and arterial ischemic stroke to occur in the same child during the perinatal period. Two children who appear to have had perinatal emboli to both an arm and a middle cerebral artery territory are presented here. One child required amputation of the ischemic limb below the shoulder, and the other required skin grafts to the distal ischemic fingers. Each of these children later received cerebral magnetic resonance imaging for evaluation of developmental delay and was found to have what appeared to be old perinatal arterial ischemic stroke. Both children were homozygous for the methylenetetrahydrofolate reductase C677T gene variant. Eight other children with perinatal limb ischemia and stroke were found on literature review; several also had delayed diagnosis of perinatal stroke. This report examines the approach to diagnosis and treatment in each of these and makes suggestions for the similar cases in the future.

Diagnostic management of neonatal stroke

In this paper the clinical presentation of neonatal arterial ischaemic stroke (NAIS) and neonatal cerebral sinovenous thrombosis (NCSVT) is briefly summarised; then a structured hierarchical diagnostic flow is proposed to discern clinical phenotypes underlying neonatal (ischaemic as well as haemorrhagic) stroke. The diagnostic flow proposed following clinical detection or chance imaging finding is an initial step towards standardisation of the mechanisms leading to stroke. For NAIS the sequence is: infection, trauma, embolism, arteriopathy, other, primary thrombosis and unclassified; for NCSVT the sequence is: infection, trauma, venopathy, other, primary thrombosis and unclassified. Such standardisation should guide attempts at prevention and treatment. The analysis of a retrospective personal cohort of 134 newborn infants with stroke, suggest that-for stroke in general-embolism is the most common identifiable mechanism (25%), preceding trauma (10%) and infection (8%). For NAIS the presence of an embolic phenotype is 33% in this cohort. The designation unclassifiable scored 34% for the entire stroke group, 25% for neonatal arterial ischaemic stroke. Complex arterial stroke, with multiple arteries involved-is regularly seen following embolism, infection and cranial trauma.

Liver transplantation as definitive treatment for a factor V Leiden mutation

Liver transplantation (LT) was achieved for factor V Leiden-induced thrombophilia in a neonate with hepatic veno-occlusive disease. Initial LT was performed with a liver segment removed from a child with primary oxalosis. Four months later, a second, definitive LT was performed. The child remains well without recurrent thrombosis.

Leiden mutation, bed rest and infection: simultaneous triggers for maternal deep-vein thrombosis and neonatal intracranial hemorrhage?

The possible etiologic roles of infection and bed rest are discussed in connection with a case of maternal homozygous Leiden mutation leading to prematurity, maternal deep-vein thrombosis and neonatal intracranial hemorrhage in a heterozygous premature baby. Maternal bacterial infection and bed rest may trigger deep-vein femoral thrombosis in women with a homozygous Leiden mutation on tocolytic therapy for the treatment of premature labor. The neonate carrying at least one mutated allele of factor V Leiden might be at risk for the development of intracranial hemorrhage.

Cerebrovascular disorders in children with the factor V Leiden mutation

Since 1995, at least 128 children with a cerebrovascular disorder, cerebral palsy, or both and the factor V Leiden mutation have been reported. The majority of these strokes were in the first year of life, many of them in the perinatal period. Two thirds had an additional exogenous risk factor for thrombosis, and 42% had another recognized endogenous prothrombotic risk factor in combination with the mutation. We review the association of the factor V Leiden mutation and a cerebrovascular disorder in children younger than 16 years of age and describe the clinical features of 8 children with cerebral palsy and the Leiden mutation. This mutation should be considered in the evaluation of children with a stroke or its sequelae, including infants with perinatal stroke.