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Cavicchiolo ME, Brigiari G, Nosadini M, Pin JN, Vincenti A, Toldo I, Ancona C, Simioni P, D Errico I, Baraldi E, Sartori S. Cerebral venous thrombosis and deep medullary vein thrombosis: Padua experience over the last two decades. Eur J Pediatr 2024; 183:3461-3470. [PMID: 38780653 DOI: 10.1007/s00431-024-05602-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Cerebral venous thrombosis (CVT) is a cerebrovascular disorder that accounts for 20% of perinatal strokes. CVT incidence ranges from 0.67 to 1.12 per 100,000 newborns, while the incidence of "deep medullary vein thrombosis" (DMVT), a subtype of CVT, cannot be accurately estimated. This study aims to analyze the case history of CVT in the neonatal period, with a specific focus on DMVT. MATERIALS AND METHODS Newborns diagnosed with CVT, with or without DMVT, between January 2002 and April 2023, were collected using the Italian Registry of Infantile Thrombosis (RITI). Cerebral MRIs were reviewed by an expert neuroradiologist following a standardized protocol. RESULTS Forty-two newborns with CVT were identified, of which 27/42 (64%) had CVT, and the remaining 15/42 (36%) had DMVT (isolated DMVT in 9/15). Symptom onset occurred in the first week of life (median 8 days, IQR 4-14) with a male prevalence of 59%. The most common risk factors for CVT were complicated delivery (38%), prematurity (40%), congenital heart diseases (48%), and infections (40%). Seizures were the predominant presenting symptom in 52% of all cases. Hemorrhagic infarction was higher in cases with isolated DMVT (77%) compared to patients with CVT without DMVT (p = 0.013). Antithrombotic treatment was initiated in 36% of patients. Neurological impairment was observed in 48% of cases at discharge, while 18 out of 31 infants (58%) presented one or more neurological deficits at long term follow up. Conclusion: DMVT occurs in over a third of neonates with CVT. Multicentric studies are essential to establish standardized protocols for therapy, neuroimaging, and follow-up in these patients.
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Affiliation(s)
- Maria Elena Cavicchiolo
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Margherita Nosadini
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Jacopo Norberto Pin
- Division of Neuropediatrics, Institute of Pediatrics of Southern Switzerland, Bellinzona, Switzerland
| | - Arianna Vincenti
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Irene Toldo
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Claudio Ancona
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
| | - Paolo Simioni
- General Internal Medicine and Thrombotic and Haemorrhagic Unit, Department of Medicine, University Hospital of Padova, Padova, Italy
| | - Ignazio D Errico
- Neuroradiology Unit, Department of Neuroscience, University Hospital of Padua, Padova, Italy
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padua, Via Giustiniani 3, 35128, Padua, Italy
| | - Stefano Sartori
- Pediatric Neurology and Neurophysiology Unit, Department of Women's and Children's Health, University Hospital of Padua, Padova, Italy
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Bektaş Ö, Göktaş ÖA, Atasay B, Teber S. Investigating the Impact on Long-Term Outcomes and the Necessity of Hereditary Thrombophilia Screening in Presumed or Perinatal Arterial Ischemic Stroke. Clin Appl Thromb Hemost 2024; 30:10760296241231944. [PMID: 38327150 PMCID: PMC10851766 DOI: 10.1177/10760296241231944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/16/2024] [Accepted: 01/25/2024] [Indexed: 02/09/2024] Open
Abstract
This study aimed to investigate the influence of prothrombotic risk factors on long-term outcomes of patients with perinatal arterial ischemic stroke. The study was conducted through an analysis of monitoring results that were regularly maintained for approximately 20 years at a tertiary stroke-monitoring center. The study assessed prothrombotic risk factors, radiological area of involvement, clinical presentation, treatments, clinical outcomes, and long-term outcomes of the 48 patients included in the study, with a mean monitoring time of 77.6 ± 45.7 months (range: 6-204). Our results showed that the presence of prothrombotic risk factors did not affect long-term outcomes. However, patients with middle cerebral artery infarction had the highest risk of developing cerebral palsy, whereas those with presumed stroke had the highest risk of developing epilepsy. This study suggests that prothrombotic risk factors should not be evaluated during the acute stage unless there is a strong suspicion of the patient's history, and prevention or early diagnosis of presumed stroke patients will positively impact their long-term prognosis.
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Affiliation(s)
- Ömer Bektaş
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Özben Akıncı Göktaş
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
| | - Begüm Atasay
- Department of Neonatology, Ankara University Medical School, Ankara, Turkey
| | - Serap Teber
- Department of Pediatric Neurology, Ankara University Medical School, Ankara, Turkey
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3
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Williams TB, Kapoor S, Bryan C. Periventricular Leukomalacia Following Bowel Resection for Necrotizing Enterocolitis in a Premature Neonate. Cureus 2023; 15:e45865. [PMID: 37885550 PMCID: PMC10597751 DOI: 10.7759/cureus.45865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 10/28/2023] Open
Abstract
Necrotizing enterocolitis (NEC) and periventricular leukomalacia (PVL) are relatively common conditions in premature infants with low birth weight (VLBW). However, in the current literature, there are limited case reports of patients with concomitant NEC and PVL. We report a case of a premature female born at a gestational age of 25 weeks and five days who developed cystic intracranial lesions after emergent bowel resection due to NEC. Transcranial ultrasound and magnetic resonance imaging confirmed the presence of cystic PVL in the right middle cerebral artery distribution. Several observational studies note the association between spontaneous intestinal perforation, surgical NEC, and the presence of cystic PVL. When infants are unresponsive to medical management for NEC, exploratory laparotomy with resection of the necrotic or perforated intestine is indicated. However, infants treated surgically have poorer neurodevelopmental outcomes than those with medical therapy. Pathogenesis of neurodevelopmental impairment in preterm infants undergoing surgery involves dysfunctional cerebrovascular autoregulation (CAR), which is associated with harmful changes in cerebral perfusion that lead to neuronal injury. Ill preterm infants, such as those with NEC, cannot regulate cerebral perfusion appropriately, and impaired CAR may be present in more than half the preterm infants during laparotomy. Impaired CAR leads to poor cerebral perfusion that potentiates neuronal injury, such as PVL. This case also brings awareness to the need for adherence to screening practices for white matter injury in critical NICU patients through cost-effective transcranial ultrasound.
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Affiliation(s)
- Timothy B Williams
- Osteopathic Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Sonia Kapoor
- Osteopathic Medicine, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | - Carleene Bryan
- Neonatology, Wellington Regional Medical Center, Wellington, USA
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Krleza JL, Coen Herak D, Đakovic I, Vulin K, Roic G, Tripalo Batoš A, Čeri A, Zadro R, Đuranovic V. Inherited Thrombophilia Associated With Ischemic Pediatric Stroke in Parent-Child Pairs. Pediatr Neurol 2023; 146:119-128. [PMID: 37480820 DOI: 10.1016/j.pediatrneurol.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 04/16/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
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.
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Affiliation(s)
- Jasna Lenicek Krleza
- Department of Laboratory Diagnostcs, Children's Hospital Zagreb, Zagreb, Croatia; Universitas Studiorum Catholica Croatica, Zagreb, Croatia; University of Applied Health Sciences Zagreb, Zagreb, Croatia.
| | - Desiree Coen Herak
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia; Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Ivana Đakovic
- Department of Neuropediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Katarina Vulin
- Department of Medical Genetics and Reproductive Health, Children's Hospital Zagreb, Zagreb, Croatia
| | - Goran Roic
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Pediatric Radiology, Children's Hospital Zagreb, Zagreb, Croatia; Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
| | - Ana Tripalo Batoš
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Pediatric Radiology, Children's Hospital Zagreb, Zagreb, Croatia
| | - Andrea Čeri
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Renata Zadro
- Medical Biochemistry Laboratory, St Catherine Specialty Hospital, Zagreb, Croatia
| | - Vlasta Đuranovic
- University of Applied Health Sciences Zagreb, Zagreb, Croatia; Department of Neuropediatrics, Children's Hospital Zagreb, Zagreb, Croatia; Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
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Shahid J, Kashif A, Shahid MK. A Comprehensive Review of Physical Therapy Interventions for Stroke Rehabilitation: Impairment-Based Approaches and Functional Goals. Brain Sci 2023; 13:brainsci13050717. [PMID: 37239189 DOI: 10.3390/brainsci13050717] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
Stroke is the fourth leading cause of mortality and is estimated to be one of the major reasons for long-lasting disability worldwide. There are limited studies that describe the application of physical therapy interventions to prevent disabilities in stroke survivors and promote recovery after a stroke. In this review, we have described a wide range of interventions based on impairments, activity limitations, and goals in recovery during different stages of a stroke. This article mainly focuses on stroke rehabilitation tactics, including those for sensory function impairments, motor learning programs, hemianopia and unilateral neglect, flexibility and joint integrity, strength training, hypertonicity, postural control, and gait training. We conclude that, aside from medicine, stroke rehabilitation must address specific functional limitations to allow for group activities and superior use of a hemiparetic extremity. Medical doctors are often surprised by the variety of physiotherapeutic techniques available; they are unfamiliar with the approaches of researchers such as Bobath, Coulter, and Brunnstrom, among others, as well as the scientific reasoning behind these techniques.
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Affiliation(s)
- Jawaria Shahid
- Department of Physical Therapy, Ikram Hospital, Gujrat 50700, Pakistan
- Center of Physical Therapy, Rayan Medical Center, Gujrat 50700, Pakistan
| | - Ayesha Kashif
- Department of Senior Health Care, Eulji University, Uijeongbu 11759, Republic of Korea
| | - Muhammad Kashif Shahid
- Research Institute of Environment & Biosystem, Chungnam National University, Daejeon 34134, Republic of Korea
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Munster CB, El-Shibiny H, Szakmar E, Yang E, Walsh BH, Inder TE, El-Dib M. Magnetic resonance venography to evaluate cerebral sinovenous thrombosis in infants receiving therapeutic hypothermia. Pediatr Res 2023; 93:985-989. [PMID: 35854084 DOI: 10.1038/s41390-022-02195-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 06/14/2022] [Accepted: 06/28/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The incidence of cerebral sinovenous thrombosis (CSVT) in infants receiving therapeutic hypothermia for neonatal encephalopathy remains controversial. The aim of this study was to identify if the routine use of magnetic resonance venography (MRV) in term-born infants receiving hypothermia is associated with diagnostic identification of CSVT. METHODS We performed a retrospective review of 291 infants who received therapeutic hypothermia from January 2014 to March 2020. Demographic and clinical data, as well as the incidence of CSVT, were compared between infants born before and after adding routine MRV to post-rewarming magnetic resonance imaging (MRI). RESULTS Before routine inclusion of MRV, 209 babies were cooled, and 25 (12%) underwent MRV. Only one baby (0.5%) was diagnosed with CSVT in that period, and it was detected by structural MRI, then confirmed with MRV. After the inclusion of routine MRV, 82 infants were cooled. Of these, 74 (90%) had MRV and none were diagnosed with CSVT. CONCLUSION CSVT is uncommon in our cohort of infants receiving therapeutic hypothermia for neonatal encephalopathy. Inclusion of routine MRV in the post-rewarming imaging protocol was not associated with increased detection of CSVT in this population. IMPACT Cerebral sinovenous thrombosis (CSVT) in infants with NE receiving TH may not be as common as previously indicated. The addition of MRV to routine post-rewarming imaging protocol did not lead to increased detection of CSVT in infants with NE. Asymmetry on MRV of the transverse sinus is a common anatomic variant. MRI alone may be sufficient in indicating the presence of CSVT.
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Affiliation(s)
- Chelsea B Munster
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Hoda El-Shibiny
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Eniko Szakmar
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Brian H Walsh
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neonatology, Cork University Maternity Hospital, Cork, Ireland
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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An exploratory study to identify neonatal arterial ischemic stroke: A single-center study. Brain Dev 2022; 44:672-680. [PMID: 36058756 DOI: 10.1016/j.braindev.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neonatal arterial ischemic stroke (NAIS) presents as seizures, including convulsions, subtle seizures, and apnea, and most patients experience neurological sequelae. Diagnosis is often delayed owing to low test sensitivity. The present study aimed to identify the early clinical diagnostic factors for NAIS in neonates with seizures. METHODS The present study included 54 patients born at ≥36 weeks of gestation during the last 15 years who presented to the neonatal intensive care unit with neonatal seizures and underwent brain magnetic resonance imaging (MRI), 6 of whom were diagnosed with NAIS. Maternal background, clinical characteristics, and transcranial pulsed Doppler sonography results were retrospectively reviewed. RESULTS Of the 24 patients who presented with convulsions or subtle seizures, 3 (13%) were diagnosed with NAIS and 3 of 30 patients (10%) presented with apnea. Maternal premature ventricular contraction complications were higher in the NAIS group than in the non-NAIS group (p = 0.01). NAIS group showed lower mean middle cerebral artery (MCA) resistance index (RI) was lower the non-NAIS group (p = 0.009), while the left-right RI difference (p = 0.019), mean MCA blood velocity (MnV; p = 0.04), and left-right MnV difference (p < 0.001) in cerebral blood flow velocities (CBFVs) were higher in the NAIS group. CONCLUSIONS Our results revealed that maternal arrhythmia may be a diagnostic factor for NAIS in neonates with seizures. Early brain MRI is essential in neonates with seizures and findings of low MCA-RI, high MCA-MnV, or high left-right difference in CBFVs to distinguish between NAIS and non-NAIS.
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Marchi V, Rizzi R, Nevalainen P, Melani F, Lori S, Antonelli C, Vanhatalo S, Guzzetta A. Asymmetry in sleep spindles and motor outcome in infants with unilateral brain injury. Dev Med Child Neurol 2022; 64:1375-1382. [PMID: 35445398 PMCID: PMC9790667 DOI: 10.1111/dmcn.15244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/17/2022] [Accepted: 03/22/2022] [Indexed: 12/30/2022]
Abstract
AIM To determine whether interhemispheric difference in sleep spindles in infants with perinatal unilateral brain injury could link to a pathological network reorganization that underpins the development of unilateral cerebral palsy (CP). METHOD This was a multicentre retrospective study of 40 infants (19 females, 21 males) with unilateral brain injury. Sleep spindles were detected and quantified with an automated algorithm from electroencephalograph records performed at 2 months to 5 months of age. The clinical outcomes after 18 months were compared to spindle power asymmetry (SPA) between hemispheres in different brain regions. RESULTS We found a significantly increased SPA in infants who later developed unilateral CP (n=13, with the most robust interhemispheric difference seen in the central spindles. The best individual-level prediction of unilateral CP was seen in the centro-occipital spindles with an overall accuracy of 93%. An empiric cut-off level for SPA at 0.65 gave a positive predictive value of 100% and a negative predictive value of 93% for later development of unilateral CP. INTERPRETATION Our data suggest that automated analysis of interhemispheric SPA provides a potential biomarker of unilateral CP at a very early age. This holds promise for guiding the early diagnostic process in infants with a perinatally identified brain injury. WHAT THIS PAPER ADDS Unilateral perinatal brain injury may affect the development of electroencephalogram (EEG) sleep spindles. Interhemispheric asymmetry in sleep spindles can be quantified with automated EEG analysis. Spindle power asymmetry can be a potential biomarker of unilateral cerebral palsy.
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Affiliation(s)
- Viviana Marchi
- Department of Developmental NeuroscienceIRCCS Stella Maris FoundationPisaItaly
| | - Riccardo Rizzi
- Department of Developmental NeuroscienceIRCCS Stella Maris FoundationPisaItaly,Department of Neuroscience, PsychologyDrug Research and Child Health NEUROFARBA, University of FlorenceFlorenceItaly
| | - Päivi Nevalainen
- Department of Clinical NeurophysiologyChildren's Hospital, HUS Diagnostic Center, Clinical Neurosciences, Helsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Federico Melani
- Neuroscience Department, Children's Hospital MeyerUniversity of FlorenceFlorence
| | - Silvia Lori
- Neurophysiology Unit, Neuro‐Musculo‐Skeletal DepartmentUniversity Hospital CareggiFlorenceItaly
| | - Camilla Antonelli
- Department of Developmental NeuroscienceIRCCS Stella Maris FoundationPisaItaly,Department of Neuroscience, PsychologyDrug Research and Child Health NEUROFARBA, University of FlorenceFlorenceItaly
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, BABA CenterChildren's Hospital, Neuroscience Center, HiLIFE, Helsinki University Hospital and University of HelsinkiHelsinkiFinland
| | - Andrea Guzzetta
- Department of Developmental NeuroscienceIRCCS Stella Maris FoundationPisaItaly,Department of Clinical and Experimental MedicineUniversity of PisaPisaItaly
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Kwok TC, Dineen RA, Whitehouse W, Lynn RM, McSweeney N, Sharkey D. Neonatal stroke surveillance study protocol in the United Kingdom and Republic of Ireland. Open Med (Wars) 2022; 17:1417-1424. [PMID: 36128449 PMCID: PMC9449691 DOI: 10.1515/med-2022-0554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/20/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Neonatal stroke is a devastating condition that causes brain injury in babies and often leads to lifelong neurological impairment. Recent prospective population studies of neonatal stroke are lacking. Neonatal strokes are different from those in older children and adults. A better understanding of its aetiology, current management, and outcomes could reduce the burden of this rare condition. The study aims to explore the incidence and 2 year outcomes of neonatal stroke across an entire population in the UK and Republic of Ireland. This is an active national surveillance study using a purpose-built integrated case notification-data collection online platform. Over a 13 month period, with a potential 6 month extension, clinicians will notify neonatal stroke cases presenting in the first 90 days of life electronically via the online platform monthly. Clinicians will complete a primary questionnaire via the platform detailing clinical information, including neuroimaging, for analysis and classification. An outcome questionnaire will be sent at 2 years of age via the platform. Appropriate ethics and regulatory approvals have been received. The neonatal stroke study represents the first multinational population surveillance study delivered via a purpose-built integrated case notification-data collection online platform and data safe haven, overcoming the challenges of setting up the study.
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Affiliation(s)
- T’ng Chang Kwok
- Centre for Perinatal Research, Population and Lifespan Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre , Nottingham , NG7 2UH , United Kingdom
| | - Robert A. Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, Queen’s Medical Centre , Nottingham , NG7 2UH , United Kingdom
- NIHR Nottingham Biomedical Research Centre , Nottingham , United Kingdom
| | - William Whitehouse
- Centre for Perinatal Research, Population and Lifespan Sciences, School of Medicine, University of Nottingham, Queen’s Medical Centre , Nottingham , NG7 2UH , United Kingdom
| | - Richard M. Lynn
- Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health , London , WC1N 1EH , England
| | - Niamh McSweeney
- Department of Paediatrics and Child Health, Cork University Hospital, Wilton , Cork , T12 DC4A , Ireland
| | - Don Sharkey
- Centre for Perinatal Research, Population and Lifespan Sciences, School of Medicine, University of Nottingham, E floor, East Block, Queen’s Medical Centre , Nottingham , NG7 2UH , United Kingdom
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Abstract
Perinatal ischemic stroke is a common cause of lifelong disability.
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Affiliation(s)
- Nicholas V Stence
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 125, Aurora, CO 80045, USA.
| | - David M Mirsky
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 125, Aurora, CO 80045, USA
| | - Ilana Neuberger
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 125, Aurora, CO 80045, USA
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11
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Vojcek E, Gráf R, László AM, Gyebnar G, Seri I. Long-term neurodevelopmental outcome of neonates born at term with perinatal haemorrhagic stroke: A population-based study. Dev Med Child Neurol 2022; 64:971-978. [PMID: 35137402 PMCID: PMC9305871 DOI: 10.1111/dmcn.15149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/30/2022]
Abstract
AIM To assess the long-term neurodevelopmental outcome of neonates born at term diagnosed with perinatal haemorrhagic stroke (PHS) and investigate the associations among brain territorial involvement, clinical risk factors, and neurodevelopmental outcomes. METHOD We conducted a population-based study enrolling 55 neonates born at term with PHS confirmed by magnetic resonance imaging born between 2007 and 2017. Long-term neurodevelopmental outcome was assessed using the Bayley Scales of Infant Development, Second Edition, the Brunet-Lézine test, and the Stanford-Binet Intelligence Scales, Fifth Edition. RESULTS Follow-up was available in 50 (91%) of the infants, at a median age of 60 months (interquartile range 35-88). Forty per cent of the infants developed according to population norms, and developmental disabilities were diagnosed less frequently among neonates with frontal lobe PHS. In a multivariable model, parietal lobe PHS increased the risk for cerebral palsy (odds ratio [OR] 6.7; 95% confidence interval [CI] 1.1-41.4) and cognitive impairment (OR: 23.6; 95% CI: 2.9-194.9), while the involvement of the thalamus and/or basal ganglia was associated with epilepsy (OR: 7.0; 95% CI: 1.3-37.7). Seizures on admission were associated with epilepsy (OR: 10.8; 95% CI: 1.8-64.3). Patients with PHS affecting multiple lobes had poor prognosis. INTERPRETATION Parietal lobe haemorrhage, the involvement of the thalamus/basal ganglia, PHS affecting multiple lobes, and seizures were independent predictors of chronic neurodevelopmental sequelae, suggesting that the stroke territorial involvement and clinical risk factors influence the outcome of PHS.
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Affiliation(s)
- Eszter Vojcek
- First Department of PediatricsSemmelweis UniversityBudapestHungary,Department of PediatricsSzent János Hospital and North Buda United HospitalsBudapestHungary
| | - Rózsa Gráf
- Department of RehabilitationSzent János Hospital and North Buda United HospitalsBudapestHungary
| | - Anna M. László
- Department of Applied StatisticsInstitute of Mathematics and Basic SciencesHungarian University of Agriculture and Life SciencesBudapestHungary
| | - Gyula Gyebnar
- Department of NeuroradiologyMedical Imaging CenterSemmelweis UniversityBudapestHungary
| | - Istvan Seri
- First Department of PediatricsSemmelweis UniversityBudapestHungary,Department of PediatricsChildren’s Hospital Los AngelesUniversity of Southern CaliforniaLos AngelesCAUSA
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Cruciat G, Nemeti GI, Popa-Stanila R, Florian A, Goidescu IG. Imaging diagnosis and legal implications of brain injury in survivors following single intrauterine fetal demise from monochorionic twins - a review of the literature. J Perinat Med 2021; 49:837-846. [PMID: 33882202 DOI: 10.1515/jpm-2020-0566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/18/2021] [Indexed: 12/28/2022]
Abstract
Brain injury of the surviving twin from monochorionic pregnancies following intrauterine fetal demise during the second and third trimesters is a rare but severe complication. Monochorionicity and gestational age at the time of stillbirth seem to be decisive factors in terms of long-term neurologic outcome prediction for the survivor. Magnetic resonance imaging (MRI), diffusion weighted imaging (DWI) in particular, seem to bring the earliest and most accurate diagnosis. Ultrasound detection of brain damage is possible in later stages of fetal brain injury. It is essential to provide early diagnosis and multidisciplinary counsel to the parents to ensure informed decision making. For couples who choose to terminate pregnancy legislation related to late abortion might lead to further distress. Our paper aims to stress the importance of MRI DWI in the evaluation of surviving twins following single intrauterine fetal demise in monochorionic pregnancies and the delicate context of the medical professionals and parents facing this clinical situation, sometimes complicated by legal constraints.
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Affiliation(s)
- Gheorghe Cruciat
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Georgiana Irina Nemeti
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Roxana Popa-Stanila
- Department of Radiology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Andreea Florian
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Iulian Gabriel Goidescu
- Obstetrics and Gynecology I, Mother and Child Department, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Vojcek E, Jermendy A, Laszlo AM, Graf R, Rudas G, Berenyi M, Seri I. The role of brain territorial involvement and infection/inflammation in the long-term outcome of neonates with arterial ischemic stroke: A population-based cohort study. Early Hum Dev 2021; 158:105393. [PMID: 34034089 DOI: 10.1016/j.earlhumdev.2021.105393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Neonatal arterial ischemic stroke (NAIS) carries the risk of significant long-term neurodevelopmental burden on survivors. AIMS To assess the long-term neurodevelopmental outcome of term neonates diagnosed with NAIS and investigate the associations among brain territorial involvement on MRI, clinical risk factors and neurodevelopmental outcomes. STUDY DESIGN Population-based cohort study. SUBJECTS Seventy-nine term neonates with NAIS confirmed by MRI born between 2007 and 2017. OUTCOME MEASURES Long-term neurodevelopmental outcome assessed using the Bayley Scales of Infant Development-II, the Brunet-Lézine test and the Binet Intelligence scales-V. RESULTS Follow-up was available in 70 (89%) of the subjects enrolled, at a median age of 60 months [IQR: 35-84]. Normal neurodevelopmental outcome was found in 43% of the patients. In a multivariable model, infants with main MCA stroke had an increased risk for overall adverse outcome (OR: 9.1, 95% CI: 1.7-48.0) and a particularly high risk for cerebral palsy (OR: 55.9, 95% CI: 7.8-399.2). The involvement of the corticospinal tract without extensive stroke also increased the risk for cerebral palsy/fine motor impairment (OR: 13.5, 95% CI: 2.4-76.3). Multiple strokes were associated with epilepsy (OR: 9.5, 95% CI: 1.0-88.9) and behavioral problems (OR: 4.4, 95% CI: 1.1-17.5) and inflammation/infection was associated with cerebral palsy (OR: 9.8, 95% CI: 1.4-66.9), cognitive impairment (OR: 9.2, 95% CI: 1.8-47.8) and epilepsy (OR: 10.3, 95% CI: 1.6-67.9). CONCLUSIONS Main MCA stroke, involvement of the corticospinal tract, multiple strokes and inflammation/infection were independent predictors of adverse outcome, suggesting that the interplay of stroke territorial involvement and clinical risk factors influence the outcome of NAIS.
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Affiliation(s)
- Eszter Vojcek
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Saint John Hospital and North-Buda Unified Hospitals, Budapest, Hungary.
| | - Agnes Jermendy
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna M Laszlo
- Institute of Mathematics and Base Sciences, Szent István University, Budapest, Hungary
| | - Rozsa Graf
- Department of Rehabilitation, Szent János Hospital and North Buda United Hospitals, Budapest, Hungary
| | - Gabor Rudas
- Department of Neuroradiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Marianne Berenyi
- Department of Developmental Neurology, Saint Margaret Hospital, Budapest, Hungary
| | - Istvan Seri
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Department of Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, United States
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14
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Verrall CE, Yang JYM, Chen J, Schembri A, d'Udekem Y, Zannino D, Kasparian NA, du Plessis K, Grieve SM, Welton T, Barton B, Gentles TL, Celermajer DS, Attard C, Rice K, Ayer J, Mandelstam S, Winlaw DS, Mackay MT, Cordina R. Neurocognitive Dysfunction and Smaller Brain Volumes in Adolescents and Adults With a Fontan Circulation. Circulation 2020; 143:878-891. [PMID: 33231097 DOI: 10.1161/circulationaha.120.048202] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Neurocognitive outcomes beyond childhood in people with a Fontan circulation are not well defined. This study aimed to investigate neurocognitive functioning in adolescents and adults with a Fontan circulation and associations with structural brain injury, brain volumetry, and postnatal clinical factors. METHODS In a binational study, participants with a Fontan circulation without a preexisting major neurological disability were prospectively recruited from the Australia and New Zealand Fontan Registry. Neurocognitive function was assessed by using Cogstate software in 107 participants with a Fontan circulation and compared with control groups with transposition of the great arteries (n=50) and a normal circulation (n=41). Brain MRI with volumetric analysis was performed in the participants with a Fontan circulation and compared with healthy control data from the ABIDE I and II (Autism Brain Imaging Data Exchange) and PING (Pediatric Imaging, Neurocognition, and Genetics) data repositories. Clinical data were retrospectively collected. RESULTS Of the participants with a Fontan circulation who had a neurocognitive assessment, 55% were male and the mean age was 22.6 years (SD 7.8). Participants with a Fontan circulation performed worse in several areas of neurocognitive function compared with those with transposition of the great arteries and healthy controls (P<0.05). Clinical factors associated with worse neurocognitive outcomes included more inpatient days during childhood, younger age at Fontan surgery, and longer time since Fontan procedure (P<0.05). Adults with a Fontan circulation had more marked neurocognitive dysfunction than adolescents with a Fontan circulation in 2 domains (psychomotor function, P=0.01 and working memory, P=0.02). Structural brain injury was present in the entire Fontan cohort; the presence of white matter injury was associated with worse paired associate learning (P<0.001), but neither the presence nor severity of infarct, subcortical gray matter injury, and microhemorrhage was associated with neurocognitive outcomes. Compared with healthy controls, people with a Fontan circulation had smaller global brain volumes (P<0.001 in all regions) and smaller regional brain volumes in most cerebral cortical regions (P<0.05). Smaller global brain volumes were associated with worse neurocognitive functioning in several domains (P<0.05). A significant positive association was also identified between global brain volumes and resting oxygen saturations (P≤0.04). CONCLUSIONS Neurocognitive impairment is common in adolescents and adults with a Fontan circulation and is associated with smaller gray and white matter brain volume. Understanding modifiable factors that contribute to brain injury to optimize neurocognitive function is paramount.
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Affiliation(s)
- Charlotte E Verrall
- Heart Centre for Children (C.E.V., J.A., D.S.W.), The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health (C.E.V., D.S.C., J.A., D.S.W., R.C.), University of Sydney, New South Wales, Australia
| | - Joseph Y M Yang
- Neuroscience Advanced Clinical Imaging Suite (NACIS), Department of Neurosurgery (J.Y.M.Y.), The Royal Children's Hospital, Melbourne, Victoria, Australia.,Developmental Imaging (J.Y.M.Y., J.C.), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jian Chen
- Developmental Imaging (J.Y.M.Y., J.C.), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | | | | | | | | | - Stuart M Grieve
- Sydney Translational Imaging Laboratory, Charles Perkins Centre, Faculty of Medicine and Health (S.M.G., T.W.), University of Sydney, New South Wales, Australia
| | - Thomas Welton
- Sydney Translational Imaging Laboratory, Charles Perkins Centre, Faculty of Medicine and Health (S.M.G., T.W.), University of Sydney, New South Wales, Australia
| | - Belinda Barton
- Children's Hospital Education Research Institute and Kids Neuroscience Centre (B.B.), The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | | | - David S Celermajer
- Sydney Medical School, Faculty of Medicine and Health (C.E.V., D.S.C., J.A., D.S.W., R.C.), University of Sydney, New South Wales, Australia
| | | | | | - Julian Ayer
- Heart Centre for Children (C.E.V., J.A., D.S.W.), The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health (C.E.V., D.S.C., J.A., D.S.W., R.C.), University of Sydney, New South Wales, Australia
| | - Simone Mandelstam
- Department of Cardiac Surgery (Y.d'U.), Medical Imaging (S.M.), The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - David S Winlaw
- Heart Centre for Children (C.E.V., J.A., D.S.W.), The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Sydney Medical School, Faculty of Medicine and Health (C.E.V., D.S.C., J.A., D.S.W., R.C.), University of Sydney, New South Wales, Australia
| | - Mark T Mackay
- Department of Neurology (M.T.M.), The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rachael Cordina
- Sydney Medical School, Faculty of Medicine and Health (C.E.V., D.S.C., J.A., D.S.W., R.C.), University of Sydney, New South Wales, Australia
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Motor outcome after perinatal stroke and early prediction of unilateral spastic cerebral palsy. Eur J Paediatr Neurol 2020; 29:54-61. [PMID: 32988734 DOI: 10.1016/j.ejpn.2020.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 08/11/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Unilateral spastic cerebral palsy (USCP) occurs in 30%-68% of infants with perinatal stroke. Early detection of USCP is essential for referring infants to early intervention. The aims of this study were to report motor outcomes after perinatal stroke, and to determine the predictive value of the General Movements Assessment (GMA) and Hand Assessment for Infants (HAI) for detection of USCP. MATERIALS AND METHODS This was a prospective observational study involving infants with perinatal stroke. GMA was conducted between 10 and 15 weeks post term-age (PTA). The HAI was performed between 3 and 5 months PTA. Motor outcome was collected between 12 and 36 months PTA. RESULTS The sample consisted of 46 infants. Fifteen children (32.6%) were diagnosed with CP, two children with bilateral CP and 13 with USCP. Abnormal GMA had a sensitivity of 85% (95% confidence interval [CI] 55-98%) and a specificity of 52% (95% CI 33-71%) to predict USCP. When asymmetrically presented FMs were also considered as abnormal, sensitivity increased to 100%, hence the specificity declined to 43%. A HAI asymmetry index cut-off of 23, had both a sensitivity and a specificity of 100% to detect USCP. CONCLUSION Using GMA and HAI can enable prediction of USCP before the age of 5 months in infants with perinatal stroke. Nevertheless, GMA must be interpreted with caution in this particular population. The HAI was found to be a very accurate screening tool for early detection of asymmetry and prediction of USCP.
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Mineyko A, Nettel-Aguirre A, de Jesus P, Benseler S, Yusuf K, Narendran A, Kirton A. Association of neonatal inflammatory markers and perinatal stroke subtypes. Neurology 2020; 95:e1163-e1173. [PMID: 32727836 DOI: 10.1212/wnl.0000000000010309] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 03/30/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To examine the relationship between neonatal inflammatory cytokines and perinatal stroke using a systems biology approach analyzing serum and blood-spot cytokines from 47 patients. METHODS This was a population-based, controlled cohort study with prospective and retrospective case ascertainment. Participants were recruited through the Alberta Perinatal Stroke Project. Stroke was classified as neonatal arterial ischemic stroke (NAIS), arterial presumed perinatal ischemic stroke (APPIS), or periventricular venous infarction (PVI). Biosamples were stored blood spots (retrospective) and acute serum (prospective). Controls had comparable gestational and maternal ages. Sixty-five cytokines were measured (Luminex). Hierarchical clustering analysis was performed to create heat maps. The Fisher linear discriminant analysis was used to create projection models to determine discriminatory boundaries between stroke types and controls. RESULTS A total of 197 participants were analyzed (27 with NAIS, 8 with APPIS, 12 with PVI, 150 controls). Cytokines were quantifiable with quality control measures satisfied (standards testing, decay analysis). Linear discriminant analysis had high accuracy in using cytokine profiles to separate groups. Profiles in participants with PVI and controls were similar. NAIS separation was accurate (sensitivity 77%, specificity 97%). APPIS mapping was also distinguishable from NAIS (sensitivity 86%, specificity 99%). Classification tree analysis generated similar diagnostic accuracy. CONCLUSIONS Unique inflammatory biomarker signatures are associated with specific perinatal stroke diseases. Findings support an acquired pathophysiology and suggest the possibility that at-risk pregnancies might be identified to develop prevention strategies. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that differences in acute neonatal serum cytokine profiles can discriminate between patients with specific perinatal stroke diseases and controls.
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Affiliation(s)
- Aleksandra Mineyko
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada.
| | - Alberto Nettel-Aguirre
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Pauline de Jesus
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Susanne Benseler
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Kamran Yusuf
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aru Narendran
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Adam Kirton
- From the Departments of Pediatrics (A.M., A.N.-A., S.B., K.Y., A.N., A.K.), Clinical Neurosciences (A.M., P.d.J., A.K.), and Community Health Sciences (A.N.-A.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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Torres ER, Tumey TA, Dean DC, Kassahun-Yimer W, Lopez-Lambert ED, Hitchcock ME. Non-pharmacological strategies to obtain usable magnetic resonance images in non-sedated infants: Systematic review and meta-analysis. Int J Nurs Stud 2020; 106:103551. [PMID: 32294563 DOI: 10.1016/j.ijnurstu.2020.103551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 02/12/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although the use of sedation is commonly practiced to keep infants still while receiving magnetic resonance imaging, non-pharmacological strategies are a potential alternative. OBJECTIVES The purpose of this study was to determine the success rate of obtaining usable magnetic resonance images in infants with the sole use of non-pharmacological strategies. DESIGN Systematic literature review and meta-analysis SETTING: A search was conducted in PubMed, CINAHL and Cochrane Library. PARTICIPANTS Human infants from birth to 24 months of age who did not receive any sedation or anesthesia during magnetic resonance imaging METHOD: Articles that reported the success rate of obtaining usable images were included. RESULTS Of the 521 non-duplicate articles found, 58 articles were included in the systematic review with sample sizes ranging from 2-457, an average success rate of 87.8%, and an average scan time of 30 min. The most common non-pharmacological technique included feeding and swaddling infants before imaging to encourage infants to sleep during the scan. Meta-analysis performed on 53 articles comprising 3,410 infants found a success rate of 87%, but significant heterogeneity was found (I2 = 98.30%). It was more difficult to obtain usable images solely with non-pharmacological techniques if infants were critically ill or a structural magnetic resonance imaging of the brain was required. CONCLUSION Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most but not all infants. Tweetable abstract: Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most infants.
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Affiliation(s)
- Elisa R Torres
- School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson 39216, MS, United States.
| | - Tyler A Tumey
- Burrell College of Osteopathic Medicine, 3501 Arrowhead Dr Las Cruces, NM 88001, United States.
| | - Douglas C Dean
- Waisman Center, University of Wisconsin-Madison, 1500 Highland Ave, Madison WI 53705, United States.
| | - Wondwosen Kassahun-Yimer
- Department of Data Science, University of Mississippi Medical Center, School of Population Health,2500 North State Street, Jackson, MS 39216, United States.
| | - Eloise D Lopez-Lambert
- School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson 39216, MS, United States
| | - Mary E Hitchcock
- Ebling Library, University of Wisconsin-Madison, 750 Highland Ave, Madison WI 53705, United States.
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Sorg AL, von Kries R, Klemme M, Gerstl L, Weinberger R, Beyerlein A, Lack N, Felderhoff-Müser U, Dzietko M. Risk factors for perinatal arterial ischaemic stroke: a large case-control study. Dev Med Child Neurol 2020; 62:513-520. [PMID: 31489622 DOI: 10.1111/dmcn.14347] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Abstract
AIM To identify maternal, obstetric, and neonatal risk factors related to perinatal arterial ischaemic stroke (PAIS) diagnosed within 28 days after birth and to understand the underlying pathophysiology. METHOD For case and control ascertainment, we used active surveillance in 345 paediatric hospitals and a population-based perinatal database for quality assurance of hospital care. We analysed complete cases of PAIS using logistic regression. Multivariate analysis was guided by a directed acyclic graph. RESULTS After exclusion of records with missing data, we analysed 134 individuals with PAIS and 576 comparison individuals. In univariate analysis, male sex, preterm birth (<37wks gestational age), small for gestational age (SGA), low umbilical artery pH (<7.1), low 5-minute-Apgar score (<7), multiple pregnancies, hypoxia, intubation/mask ventilation, nulliparity, Caesarean section, vaginal-operative delivery, chorioamnionitis, and oligohydramnios were associated with an increased risk. Mutual adjustment yielded male sex (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.20-2.73), multiple birth (OR 3.22; 95% CI 1.21-8.58), chorioamnionitis (OR 9.89; 95% CI 2.88-33.94), preterm birth (OR 1.86; 95% CI 1.01-3.43), and SGA (OR 3.05; 95% CI 1.76-5.28) as independent risk factors. INTERPRETATION We confirmed the increased risk in males and the role of chorioamnionitis and SGA for PAIS, pointing to the importance of inflammatory processes and fetal-placental insufficiency. Multiple birth and preterm birth were additional risk factors. WHAT THIS PAPER ADDS Chorioamnionitis and small for gestational age (SGA) precede perinatal arterial ischaemic stroke (PAIS). Chorioamnionitis and SGA are independent risk factors for PAIS. Inflammatory processes and fetal-placental insufficiency are the likely underlying mechanisms. Multiple birth and preterm birth are additional risk factors.
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Affiliation(s)
- Anna-Lisa Sorg
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Rüdiger von Kries
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Mathias Klemme
- Department of Neonatology, University Children's Hospital and Perinatal Center, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Lucia Gerstl
- Department of Pediatric Neurology, University Children's Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Raphael Weinberger
- Division of Pediatric Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andreas Beyerlein
- Institute of Computational Biology, Helmholtz Zentrum München, Neuherberg, Germany
| | - Nicholas Lack
- Bavarian Quality Assurance for In-Patient Medical Care, Munich, Germany
| | | | - Mark Dzietko
- Department of Pediatrics I, Neonatology, University of Duisburg-Essen, Essen, Germany
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Abstract
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.
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Affiliation(s)
- Emmett E Whitaker
- Department of Anesthesiology, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States.
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Obstetrics, Gynecology & Reproductive Sciences, University of Vermont Larner College of Medicine, Burlington, VT, United States; Department of Pharmacology, University of Vermont Larner College of Medicine, Burlington, VT, United States
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20
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Nevalainen P, Metsäranta M, Toiviainen-Salo S, Lönnqvist T, Vanhatalo S, Lauronen L. Bedside neurophysiological tests can identify neonates with stroke leading to cerebral palsy. Clin Neurophysiol 2019; 130:759-766. [PMID: 30904770 DOI: 10.1016/j.clinph.2019.02.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/30/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The unspecific symptoms of neonatal stroke still challenge its bedside diagnosis. We studied the accuracy of routine electroencephalography (EEG) and simultaneously recorded somatosensory evoked potentials (EEG-SEP) for diagnosis and outcome prediction of neonatal stroke. METHODS We evaluated EEG and EEG-SEPs from a hospital cohort of 174 near-term neonates with suspected seizures or encephalopathy, 32 of whom were diagnosed with acute ischemic or hemorrhagic stroke in MRI. EEG was scored for background activity and seizures. SEPs were classified as present or absent. Developmental outcome of stroke survivors was evaluated from medical records at 8- to 18-months age. RESULTS The combination of continuous EEG and uni- or bilaterally absent SEP (n = 10) was exclusively seen in neonates with a middle cerebral artery (MCA) stroke (specificity 100%). Moreover, 80% of the neonates with this finding developed with cerebral palsy. Bilaterally present SEPs did not exclude stroke, but predicted favorable neuromotor outcome in stroke survivors (positive predictive value 95%). CONCLUSIONS Absent SEP combined with continuous EEG background in near-term neonates indicates an MCA stroke and a high risk for cerebral palsy. SIGNIFICANCE EEG-SEP offers a bedside method for diagnostic screening and a reliable prediction of neuromotor outcome in neonates suspected of having a stroke.
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Affiliation(s)
- Päivi Nevalainen
- Department of Clinical Neurophysiology, Children's Hospital, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital (HUH), Helsinki, Finland.
| | - Marjo Metsäranta
- Department of Pediatrics, Children's Hospital, University of Helsinki and HUH, Helsinki, Finland
| | - Sanna Toiviainen-Salo
- Department of Pediatric Radiology, Children's Hospital, HUS Medical Imaging Center, Radiology, University of Helsinki and HUH, Helsinki, Finland
| | - Tuula Lönnqvist
- Department of Child Neurology, Children's Hospital, University of Helsinki and HUH, Helsinki, Finland
| | - Sampsa Vanhatalo
- Department of Clinical Neurophysiology, Children's Hospital, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital (HUH), Helsinki, Finland
| | - Leena Lauronen
- Department of Clinical Neurophysiology, Children's Hospital, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital (HUH), Helsinki, Finland
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Abstract
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.
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Gano D, Ferriero DM. Focal Cerebral Infarction. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Cerebral sinovenous thrombosis (CSVT) is a focal or diffuse disruption of cerebral blood flow secondary to occlusion of cerebral veins and/or sinuses. The challenge of CSVT during the neonatal age has led to a great interest in this condition among neonatologists, child neurologists, and pediatric neuroradiologists. The highly variable clinical spectra, etiologies, and prognosis require fine medical skills and a high level of suspicion. Nevertheless, the diagnosis is often delayed or missed altogether. Differences in brain vulnerability at different stages of maturation may explain the spectrum of associated brain lesions, which varies with gestational age. Treatment is controversial and reported clinical outcomes vary widely. The controversial treatment of CSVT with anticoagulant therapy is based only on case series and expert consensus, there is lack of safety data.
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Affiliation(s)
- Luca A Ramenghi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy.
| | - Valentina Cardiello
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
| | - Andrea Rossi
- Neonatal Intensive Care Unit, Giannina Gaslini Children's Hospital, Genova, Italy
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24
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Faustino-Mendes T, Machado-Pereira M, Castelo-Branco M, Ferreira R. The Ischemic Immature Brain: Views on Current Experimental Models. Front Cell Neurosci 2018; 12:277. [PMID: 30210301 PMCID: PMC6123378 DOI: 10.3389/fncel.2018.00277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 08/08/2018] [Indexed: 01/13/2023] Open
Affiliation(s)
| | - Marta Machado-Pereira
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Covilhã, Portugal
| | - Miguel Castelo-Branco
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Covilhã, Portugal.,Hospital Center of Cova da Beira, Covilhã, Portugal
| | - Raquel Ferreira
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Covilhã, Portugal
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25
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Munoz D, Hidalgo MJ, Balut F, Troncoso M, Lara S, Barrios A, Parra P. Risk Factors for Perinatal Arterial Ischemic Stroke: A Case-Control Study. CELL MEDICINE 2018; 10:2155179018785341. [PMID: 32634191 PMCID: PMC6172995 DOI: 10.1177/2155179018785341] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Arterial ischemic stroke in newborns is an important cause of neonatal morbidity and mortality. Its pathophysiology and associated risk factors are not yet clearly understood and defined. Objective The aim of this retrospective study was to investigate possible risk factors in diagnosed cases of PAIS (perinatal arterial ischemic stroke). Materials and methods Case-control study. Clinical data of patients with PAIS diagnosis were analyzed. Two healthy controls were selected for each PAIS case, matched for gestational age. Risk factors were explored using univariable and multivariable analysis. Outcome 40 patients were included in the study, 24 males and 16 females; 52.5% of cases were diagnosed within the first month of birth, and 47.5% were retrospectively diagnosed. The results showed a male predominance (66.7%). The distribution of cerebral ischemic injury was predominantly medial cerebral artery (87.5%) and occurred more commonly in the left cerebral hemisphere (62.5%). Significant risk factors in the univariate analysis (P < 0.05) were primiparity, stillbirth, neonatal sepsis, asphyxia, twin pregnancy, placenta abruption, emergency cesarean section, Apgar score ≤7 after 5 min, breech presentation, and hyperbilirubinemia. In the multivariate analysis, primiparity (OR 11.74; CI 3.28-42.02), emergency cesarean section (OR 13.79; CI 3.51-54.13), birth asphyxia (OR 40.55; CI 3.08-532.94) and Apgar score ≤7 after 5 min (OR 13.75; CI 1.03-364.03) were significantly associated factors with PAIS. Only five (16.6%) patients had an abnormal thrombophilia study. Conclusion Risk factors of primiparity, emergency cesarean section, birth asphyxia, and Apgar score ≤7 after 5 min were significantly associated with perinatal stroke. More studies with a larger number of patients and with prolonged follow up are required to establish more clearly the associated risk factors involved in this pathology.
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Affiliation(s)
- Daniela Munoz
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
- Daniela Munoz, Department of Pediatric Neurology and
Psychiatry, San Borja Arriarán Hospital, University of Chile, Región Metropolitana, Santa
Rosa Avenue, 1234, Santiago, Chile.
| | - María José Hidalgo
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Fernanda Balut
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Mónica Troncoso
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Susana Lara
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Andrés Barrios
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
| | - Patricia Parra
- Department of Pediatric Neurology and Psychiatry, San Borja Arriarán
Hospital, University of Chile, Santiago, Chile
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26
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Kouri I, Mathews K, Joshi C. Facial Weakness and Ophthalmoplegia in a 4-Day-Old Infant. Semin Pediatr Neurol 2018; 26:63-66. [PMID: 29961523 DOI: 10.1016/j.spen.2017.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We present a neonate with neurologic deficits recognized at 4 days of age. A male infant was born at term via emergency cesarian section due to failure to progress and fetal decelerations. He underwent therapeutic hypothermia for hypoxic ischemic encephalopathy. Upon completion of rewarming, he was noted to have left facial palsy, abduction deficit on the left eye past the midline, and nystagmus involving the right eye. Brain magnetic resonance imaging showed a pontine stroke, and computed tomography angiogram revealed basilar artery thrombosis. He was treated with enoxaparin for 3 months, followed by low-dose aspirin. The mechanism of the stroke remains unclear, and there is limited evidence to guide management.
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Affiliation(s)
- Ioanna Kouri
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA.
| | - Katherine Mathews
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Charuta Joshi
- Department of Pediatrics and Neurology, University of Iowa Stead Family Children's Hospital, Iowa City, IA
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27
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Abstract
Perinatal brain injury may lead to long-term morbidity and neurodevelopmental impairment. Improvements in perinatal care have resulted in the survival of more infants with perinatal brain injury. The effects of hypoxia-ischemia, inflammation, and infection during critical periods of development can lead to a common pathway of perinatal brain injury marked by neuronal excitotoxicity, cellular apoptosis, and microglial activation. Various interventions can prevent or improve the outcomes of different types of perinatal brain injury. The objective of this article is to review the mechanisms of perinatal brain injury, approaches to prevention, and outcomes among children with perinatal brain injury.
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28
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Pulver M, Juhkami K, Loorits D, Ilves P, Kuld J, Õiglane-Šlik E, Metsvaht T, Laugesaar R. Symptomatic Neonatal Arterial Ischemic Stroke With Prenatal and Postnatal Neuroimaging. Child Neurol Open 2017; 4:2329048X17730460. [PMID: 28959702 PMCID: PMC5593205 DOI: 10.1177/2329048x17730460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/11/2017] [Accepted: 07/23/2017] [Indexed: 11/17/2022] Open
Abstract
The authors report a girl born at term via planned cesarean delivery. Three days earlier, an antenatal magnetic resonance imaging study, showing no cerebral lesions in the fetus, was performed. Ten minutes after delivery, signs of progressive respiratory failure developed and the infant was transferred to the intensive care unit. On the next day, a computed tomography (CT) scan showed acute ischemic lesions in the areas of the left middle and posterior cerebral arteries. The exact mechanism of stroke remained unidentified. It is possible that emboli occluded the left middle cerebral artery and left posterior cerebral artery. At the age of 1 year and 4 months, the patient demonstrated a slight right-sided hemiparesis more pronounced in the hand. To our knowledge, there are no prior published case studies reporting a healthy fetal brain, which then undergoes an acute neonatal arterial infarction near or during birth following an elective cesarean delivery.
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Affiliation(s)
- Mati Pulver
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | | | - Dagmar Loorits
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Pilvi Ilves
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia.,Department of Radiology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jaanika Kuld
- Children's Clinic of Tartu University Hospital, Tartu, Estonia
| | - Eve Õiglane-Šlik
- Children's Clinic of Tartu University Hospital, Tartu, Estonia.,Faculty of Medicine, Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Tuuli Metsvaht
- Children's Clinic of Tartu University Hospital, Tartu, Estonia.,Faculty of Medicine, Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Rael Laugesaar
- Children's Clinic of Tartu University Hospital, Tartu, Estonia.,Faculty of Medicine, Department of Pediatrics, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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29
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Siddiq I, Armstrong D, Surmava AM, Dlamini N, MacGregor D, Moharir M, Askalan R. Utility of Neurovascular Imaging in Acute Neonatal Arterial Ischemic Stroke. J Pediatr 2017. [PMID: 28624098 DOI: 10.1016/j.jpeds.2017.05.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the prevalence of magnetic resonance angiography (MRA) findings and clinically characterize neonates with arterial ischemic stroke (AIS) who have abnormal or variable vasculature. STUDY DESIGN This was a single-center, retrospective study of patients with neonatal stroke from 1991 to 2012. We reviewed charts and neuroimaging, including MRA, in neonates with AIS. Clinical data of patients with MRA findings were compared with the control group of neonates with AIS and a normal MRA. RESULTS We identified 142 cases of neonatal AIS, of which 81 patients had magnetic resonance imaging and MRA. Among the neonates with arterial neuroimaging, 29 had arterial findings (for a prevalence rate of 20%-35%). The majority of the findings were stenotic or hypoplastic branches. Two patients had presumed carotid artery dissection. Low Apgar scores and the presence of sepsis were significantly (P <.05) more common in neonates with MRA findings. CONCLUSION The prevalence of arterial abnormalities or variations in neonatal AIS has been underestimated because neurovascular imaging is often not performed. We recommend an MRA for neonates with AIS, particularly those who have low Apgar scores and/or sepsis, to rule out a vasculopathy that may warrant therapeutic intervention.
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Affiliation(s)
- Ishita Siddiq
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Derek Armstrong
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ann-Marie Surmava
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nomazulu Dlamini
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Daune MacGregor
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Rand Askalan
- Division of Neurology, Hospital for Sick Children, Toronto, Ontario, Canada.
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30
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Lee CC, Lin JJ, Lin KL, Lim WH, Hsu KH, Hsu JF, Fu RH, Chiang MC, Chu SM, Lien R. 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. Pediatr Neonatol 2017; 58:270-277. [PMID: 28087259 DOI: 10.1016/j.pedneo.2016.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/02/2016] [Accepted: 07/08/2016] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Chien-Chung Lee
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Jainn-Jim Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Kuang-Lin Lin
- Division of Pediatric Neurology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Wai-Ho Lim
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC
| | - Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, No. 5, Fu-Shing Street, Kwei-Shan, Taoyuan, Taiwan, ROC.
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31
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Resting-State Functional Connectivity and Cognitive Impairment in Children with Perinatal Stroke. Neural Plast 2016; 2016:2306406. [PMID: 28074160 PMCID: PMC5198182 DOI: 10.1155/2016/2306406] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/25/2016] [Accepted: 11/01/2016] [Indexed: 01/08/2023] Open
Abstract
Perinatal stroke is a leading cause of congenital hemiparesis and neurocognitive deficits in children. Dysfunctions in the large-scale resting-state functional networks may underlie cognitive and behavioral disability in these children. We studied resting-state functional connectivity in patients with perinatal stroke collected from the Estonian Pediatric Stroke Database. Neurodevelopment of children was assessed by the Pediatric Stroke Outcome Measurement and the Kaufman Assessment Battery. The study included 36 children (age range 7.6–17.9 years): 10 with periventricular venous infarction (PVI), 7 with arterial ischemic stroke (AIS), and 19 controls. There were no differences in severity of hemiparesis between the PVI and AIS groups. A significant increase in default mode network connectivity (FDR 0.1) and lower cognitive functions (p < 0.05) were found in children with AIS compared to the controls and the PVI group. The children with PVI had no significant differences in the resting-state networks compared to the controls and their cognitive functions were normal. Our findings demonstrate impairment in cognitive functions and neural network profile in hemiparetic children with AIS compared to children with PVI and controls. Changes in the resting-state networks found in children with AIS could possibly serve as the underlying derangements of cognitive brain functions in these children.
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32
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Martinez-Biarge M, Cheong JLY, Diez-Sebastian J, Mercuri E, Dubowitz LMS, Cowan FM. Risk Factors for Neonatal Arterial Ischemic Stroke: The Importance of the Intrapartum Period. J Pediatr 2016; 173:62-68.e1. [PMID: 27049002 DOI: 10.1016/j.jpeds.2016.02.064] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/22/2016] [Accepted: 02/25/2016] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
| | - Jeanie L Y Cheong
- Department of Pediatrics, Imperial College London, London, United Kingdom; Departments of Newborn Research and Neonatal Services, Royal Women's Hospital, Melbourne, Australia
| | | | - Eugenio Mercuri
- Department of Pediatrics, Imperial College London, London, United Kingdom; Pediatric Neurology Unit, Catholic University, Rome, Italy
| | - Lilly M S Dubowitz
- Department of Pediatrics, Imperial College London, London, United Kingdom
| | - Frances M Cowan
- Department of Pediatrics, Imperial College London, London, United Kingdom
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33
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Ilves P, Laugesaar R, Loorits D, Kolk A, Tomberg T, Lõo S, Talvik I, Kahre T, Talvik T. Presumed Perinatal Stroke: Risk Factors, Clinical and Radiological Findings. J Child Neurol 2016; 31:621-8. [PMID: 26446909 DOI: 10.1177/0883073815609149] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 08/22/2015] [Indexed: 12/28/2022]
Abstract
It is unknown why some infants with perinatal stroke present clinical symptoms late during infancy and will be identified as infants with presumed perinatal stroke. The risk factors and clinical and radiological data of 42 infants with presumed perinatal stroke (69% with periventricular venous infarction and 31% with arterial ischemic stroke) from the Estonian Pediatric Stroke Database were reviewed. Children with presumed perinatal stroke were born at term in 95% of the cases and had had no risk factors during pregnancy in 43% of the cases. Children with periventricular venous infarction were born significantly more often (82%) vaginally (P = .0213) compared to children with arterial stroke (42%); nor did they require resuscitation (P = .0212) or had any neurological symptoms after birth (P = .0249). Periventricular venous infarction is the most common type of lesion among infants with the presumed perinatal stroke. Data suggest that the disease is of prenatal origin.
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Affiliation(s)
- Pilvi Ilves
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia Department of Radiology, University of Tartu, Tartu, Estonia
| | - Rael Laugesaar
- Department of Pediatrics, University of Tartu, Tartu, Estonia Children's Clinic of Tartu University Hospital, Tartu, Estonia
| | - Dagmar Loorits
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Anneli Kolk
- Department of Pediatrics, University of Tartu, Tartu, Estonia Department of Neurology and Neurorehabilitation, Children's Clinic of Tartu University Hospital, Tartu, Estonia
| | - Tiiu Tomberg
- Radiology Clinic of Tartu University Hospital, Tartu, Estonia
| | - Silva Lõo
- Department of Pediatrics, University of Tartu, Tartu, Estonia
| | - Inga Talvik
- Department of Pediatrics, University of Tartu, Tartu, Estonia Department of Neurology and Neurorehabilitation, Children's Clinic of Tartu University Hospital, Tartu, Estonia
| | - Tiina Kahre
- Department of Genetics, United Laboratories of Tartu University Hospital, Tartu, Estonia
| | - Tiina Talvik
- Department of Pediatrics, University of Tartu, Tartu, Estonia Children's Clinic of Tartu University Hospital, Tartu, Estonia
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34
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Machado V, Pimentel S, Pinto F, Nona J. Perinatal ischemic stroke: a five-year retrospective study in a level-III maternity. EINSTEIN-SAO PAULO 2015; 13:65-71. [PMID: 25993071 PMCID: PMC4946814 DOI: 10.1590/s1679-45082015ao3056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 01/07/2015] [Indexed: 12/04/2022] Open
Abstract
Objective To study the incidence, clinical presentation, risk factors, imaging diagnosis, and clinical outcome of perinatal stroke. Methods Data was retrospectively collected from full-term newborns admitted to the neonatal unit of a level III maternity in Lisbon with cerebral stroke, from January 2007 to December 2011. Results There were 11 cases of stroke: nine were arterial ischemic stroke and two were cerebral venous sinus thrombosis. We estimated an incidence of arterial ischemic stroke of 1.6/5,000 births and of cerebral venous sinus thrombosis of 7.2/100,000 births. There were two cases of recurrent stroke. Eight patients presented with symptoms while the remaining three were asymptomatic and incidentally diagnosed. The most frequently registered symptoms (8/11) were seizures; in that, generalized clonic (3/8) and focal clonic (5/8). Strokes were more commonly left-sided (9/11), and the most affected artery was the left middle cerebral artery (8/11). Transfontanelle ultrasound was positive in most of the patients (10/11), and stroke was confirmed by cerebral magnetic resonance in all patients. Electroencephalographic recordings were carried out in five patients and were abnormal in three (focal abnormalities n=2, burst-suppression pattern n=1). Eight patients had previously identified risk factors for neonatal stroke which included obstetric and neonatal causes. Ten patients were followed up at outpatients setting; four patients developed motor deficits and one presented with epilepsy. Conclusions Although a modest and heterogeneous sample, this study emphasizes the need for a high level of suspicion when it comes to neonatal stroke, primarily in the presence of risk factors. The prevalence of neurological sequelae in our series supports the need of long-term follow-up and early intervention strategies.
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Affiliation(s)
| | | | | | - José Nona
- Maternidade Dr. Alfredo da Costa, Lisboa, Portugal
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35
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Plaisier A, Raets MMA, Ecury-Goossen GM, Govaert P, Feijen-Roon M, Reiss IKM, Smit LS, Lequin MH, Dudink J. Serial cranial ultrasonography or early MRI for detecting preterm brain injury? Arch Dis Child Fetal Neonatal Ed 2015; 100:F293-300. [PMID: 25637006 DOI: 10.1136/archdischild-2014-306129] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 01/10/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To investigate detection ability and feasibility of serial cranial ultrasonography (CUS) and early MRI in preterm brain injury. DESIGN Prospective cohort study. SETTING Level III neonatal intensive care unit. PATIENTS 307 infants, born below 29 weeks of gestation. METHODS Serial CUS and MRI were performed according to standard clinical protocol. In case of instability, MRI was postponed or cancelled. Brain images were assessed by independent experts and compared between modalities. MAIN OUTCOME MEASURES Presence of preterm brain injury on either CUS or MRI and discrepant imaging findings on CUS and MRI. RESULTS Serial CUS was performed in all infants; early MRI was often postponed (n=59) or cancelled (n=126). Injury was found in 146 infants (47.6%). Clinical characteristics differed significantly between groups that were subdivided according to timing of MRI. 61 discrepant imaging findings were found. MRI was superior in identifying cerebellar haemorrhage; CUS in detection of acute intraventricular haemorrhage, perforator stroke and cerebral sinovenous thrombosis. CONCLUSIONS Advanced serial CUS seems highly effective in diagnosing preterm brain injury, but may miss cerebellar abnormalities. Although MRI does identify these lesions, feasibility is limited. Improved safety, better availability and tailored procedures are essential for MRI to increase its value in clinical care.
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Affiliation(s)
- Annemarie Plaisier
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marlou M A Raets
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands
| | - Ginette M Ecury-Goossen
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands
| | - Paul Govaert
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands Department of Pediatrics, Koningin Paola Children's Hospital, Antwerp, Belgium
| | - Monique Feijen-Roon
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands
| | - Liesbeth S Smit
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands Division of Pediatric Neurology, Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Maarten H Lequin
- Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jeroen Dudink
- Division of Neonatology, Department of Pediatrics, Erasmus Medical Center-Sophia, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
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Lehman LL, Rivkin MJ. Perinatal arterial ischemic stroke: presentation, risk factors, evaluation, and outcome. Pediatr Neurol 2014; 51:760-8. [PMID: 25444092 DOI: 10.1016/j.pediatrneurol.2014.07.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 07/24/2014] [Accepted: 07/25/2014] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Michael J Rivkin
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts; Department of Psychiatry, Boston Children's Hospital, Boston, Massachusetts; Department of and Radiology, Boston Children's Hospital, Boston, Massachusetts.
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Dai Y, Dong S, Zhu M, Wu D, Zhong Y. Visualizing cerebral veins in fetal brain using susceptibility-weighted MRI. Clin Radiol 2014; 69:e392-7. [PMID: 25060932 DOI: 10.1016/j.crad.2014.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 01/12/2023]
Abstract
AIM To explore the feasibility of two-dimensional (2D) susceptibility-weighted imaging (SWI) in the visualization of cerebral veins in the foetal brain. MATERIALS AND METHODS Forty-two pregnant healthy women (gestational age: 19-37 weeks, mean: 28.5 ± 7.1 weeks) underwent SWI examination using a 1.5 T MRI system. Two neurologists independently analysed all magnetic resonance imaging (MRI) studies. The relationship between the veins detected and the gestational age was investigated. The prominence of veins was assessed using a categorical score. RESULTS In total, 167 veins were detected by SWI in 29 subjects with a symmetric hemisphere distribution (p > 0.05). An additional vein was detected by SWI biweekly from 24 weeks of gestation. Most veins of Galen and internal cerebral veins on SWI images were prominent, whereas others were faint or moderate. CONCLUSION SWI appears to be a feasible method of detecting cerebral veins in the foetal brain.
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Affiliation(s)
- Y Dai
- Philips Healthcare, People's Republic of China
| | - S Dong
- Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, People's Republic of China
| | - M Zhu
- Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, People's Republic of China.
| | - D Wu
- Shanghai Key Laboratory of Magnetic Resonance, Department of Physics, East China Normal University, People's Republic of China
| | - Y Zhong
- Shanghai Children's Medical Center Affiliated to Shanghai Jiaotong University School of Medicine, People's Republic of China
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Brain injury associated with neonatal extracorporeal membrane oxygenation in the Netherlands: a nationwide evaluation spanning two decades. Pediatr Crit Care Med 2013; 14:884-92. [PMID: 24121484 DOI: 10.1097/pcc.0b013e3182a555ac] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine the prevalence of and to classify ultrasound-proven brain injury during neonatal extracorporeal membrane oxygenation in The Netherlands. DESIGN Retrospective nationwide study (Rotterdam and Nijmegen), spanning two decades. SETTING Level III university hospitals. SUBJECTS All neonates who underwent neonatal extracorporeal membrane oxygenation from 1989 to 2010. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cranial ultrasound images were reviewed independently by two investigators without knowledge of primary diagnosis, outcome, type of extracorporeal membrane oxygenation, or statistics. The scans were reviewed for lesion type and timing, with the use of a refined classification method for focal brain injury. Extracorporeal membrane oxygenation type was venoarterial in 88%. Brain abnormalities were detected in 17.3%: primary hemorrhage was most frequent (8.8%). Stroke was identified in 5% of the total group, with a notable significant preference for the left hemisphere (in 70%). Lobar hematoma (prevalence 2.2 %) was also significantly left predominant. CONCLUSION The incidence of brain injury found with cranial ultrasound in The Netherlands of the patients treated with extracorporeal membrane oxygenation during the neonatal period was 17.3%. Primary hemorrhage was the largest group of lesions, not clearly side-specific except for lobar bleeding, most probably related to changes in venous flow. Arterial ischemic stroke occurred predominant in the left hemisphere.
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Sannia A, Natalizia AR, Parodi A, Malova M, Fumagalli M, Rossi A, Ramenghi LA. Different gestational ages and changing vulnerability of the premature brain. J Matern Fetal Neonatal Med 2013; 28 Suppl 1:2268-72. [PMID: 23968292 DOI: 10.3109/14767058.2013.796166] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In recent decades, there has been a general increase in survival rates of preterm and low birth weight infants, but this overall decrease in perinatal mortality has not been accompanied by a decrease in long-term physical and mental disability. In order to reduce the long-term sequelae of prematurity and to establish preventive measures, it is important to identify risk factors since the main determinant of specific vulnerability to different types of lesions is gestational age. The regional tissue vulnerability at a given gestational age is probably determined by the local metabolic requirements together with specific cell characteristics and their level of maturation. In this article, we discuss the most common neonatal cerebral lesions (cerebellar haemorrhage, germinal matrix intraventricular haemorrhage, periventricular leukomalacia, arterial ischaemic stroke, cerebral vein sinus thrombosis and hypoxic-ischaemic encephalopathy) related to the gestational age-dependent vulnerability of the premature brain.
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Affiliation(s)
- Andrea Sannia
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Anna R Natalizia
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Alessandro Parodi
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Mariya Malova
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Monica Fumagalli
- b NICU, Department of Clinical Sciences and Community Health , Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano , Milan , Italy , and
| | - Andrea Rossi
- c Pediatric Neuroradiology Unit , Istituto Giannina Gaslini , Genova , Italy
| | - Luca A Ramenghi
- a Neonatal Intensive Care Unit , Istituto Giannina Gaslini , Genova , Italy
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Piro E, Piccione M, Marrone G, Giuffrè M, Corsello G. Dyke-Davidoff-Masson syndrome: case report of fetal unilateral ventriculomegaly and hypoplastic left middle cerebral artery. Ital J Pediatr 2013; 39:32. [PMID: 23672850 PMCID: PMC3666998 DOI: 10.1186/1824-7288-39-32] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 05/03/2013] [Indexed: 02/01/2023] Open
Abstract
Prenatal ultrasonographic detection of unilateral cerebral ventriculomegaly arises suspicion of pathological condition related to cerebrospinal fluid flow obstruction or cerebral parenchimal pathology. Dyke-Davidoff-Masson syndrome is a rare condition characterized by cerebral hemiatrophy, calvarial thickening, skull and facial asymmetry, contralateral hemiparesis, cognitive impairment and seizures. Congenital and acquired types are recognized and have been described, mainly in late childhood, adolescence and adult ages. We describe a female infant with prenatal diagnosis of unilateral left ventriculomegaly in which early brain MRI and contrast enhanced-MRI angiography, showed cerebral left hemiatrophy associated with reduced caliber of the left middle cerebral artery revealing the characteristic findings of the Dyke-Davidoff-Masson syndrome. Prenatal imaging, cerebral vascular anomaly responsible for the cerebral hemiatrophy and the early clinical evolution have never been described before in such a young child and complete the acquired clinical descriptions in older children. Differential diagnosis, genetic investigations, neurophysiologic assessments, short term clinical and developmental follow up are described. Dyke-Davidoff-Masson syndrome must be ruled out in differential diagnosis of fetal unilateral ventriculomegaly. Early clinical assessment, differential diagnosis and cerebral imaging including cerebral MRI angiography allow the clinicians to diagnose also in early infancy this rare condition.
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Affiliation(s)
- Ettore Piro
- Department of Sciences for Health Promotion and Mother and Child Care "Giuseppe D'Alessandro", University of Palermo, Palermo, Italy.
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van der Aa NE, Dudink J, Benders MJNL, Govaert P, van Straaten HLM, Porro GL, Groenendaal F, de Vries LS. Neonatal posterior cerebral artery stroke: clinical presentation, MRI findings, and outcome. Dev Med Child Neurol 2013; 55:283-90. [PMID: 23336217 DOI: 10.1111/dmcn.12055] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2012] [Indexed: 12/25/2022]
Abstract
AIM To report the clinical presentation, magnetic resonance imaging (MRI) findings, and follow-up data of newborn infants with perinatal arterial ischemic stroke in the territory of the posterior cerebral artery (PCA). METHOD Data on 18 newborn infants from three neonatal intensive care units (11 males, seven females) with an MRI-confirmed PCA stroke were analysed and reported. Infants were born at a mean gestational age of 38.7 weeks (SD 3.4) with a mean birthweight of 3244g (SD 850). RESULTS Fourteen infants presented with clinical seizures. Five of these had associated hypoxic-ischemic encephalopathy, four had hypoglycaemia, and five had neither hypoxic-ischemic encephalopathy nor hypoglycaemia. Subclinical seizures were present in one infant with hypoxic-ischemic encephalopathy and one with meningitis. One preterm infant presented with apnoeas and one had hypoxic-ischemic encephalopathy without seizures. Neurodevelopmental follow-up of 17 children at a median age of 36 months (SD 28, range 12-120mo) showed five with a global delay. Two children with additional injury developed postneonatal epilepsy and one child with extensive injury developed hemiplegia. A visual field defect was observed in nine children (six hemianopia, three quadrantanopia). In the 11 children with a second MRI at 3 months, the asymmetry of the optic radiation correlated with the development of a visual field deficit. INTERPRETATION Outcome after PCA stroke is fairly good, depending on additional brain injury. Follow-up is required, as subsequent visual field defects are frequently observed. Further research will be needed to clarify the role of hypoglycaemia in perinatal arterial ischemic stroke.
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Affiliation(s)
- Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Scher MS. Normal and abnormal cerebrovascular development. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1021-42. [DOI: 10.1016/b978-0-444-52910-7.00021-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Meoded A, Poretti A, Northington FJ, Tekes A, Intrapiromkul J, Huisman TAGM. Susceptibility weighted imaging of the neonatal brain. Clin Radiol 2012; 67:793-801. [PMID: 22341186 DOI: 10.1016/j.crad.2011.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/12/2011] [Accepted: 12/19/2011] [Indexed: 01/28/2023]
Abstract
Susceptibility weighted imaging (SWI) is a well-established magnetic resonance technique, which is highly sensitive for blood, iron, and calcium depositions in the brain and has been implemented in the routine clinical use in both children and neonates. SWI in neonates might provide valuable additional diagnostic and prognostic information for a wide spectrum of neonatal neurological disorders. To date, there are few articles available on the application of SWI in neonatal neurological disorders. The purpose of this article is to illustrate and describe the characteristic SWI findings in various typical neonatal neurological disorders.
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Affiliation(s)
- A Meoded
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Scher MS. Developmental origins of cerebrovascular disease II: considering gene-environment interactions when developing neuroprotective strategies. J Child Neurol 2012; 27:238-50. [PMID: 22180566 DOI: 10.1177/0883073811417715] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Mark S Scher
- School of Medicine, Case Western Reserve University, and Division of Pediatric Neurology, Fetal/Neonatal Neurology Program, Rainbow Babies and Children's Hospital, Case Medical Center, University Hospitals of Cleveland, OH, USA.
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Abstract
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.
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Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's, Melbourne, Australia.
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Davies ESS, Volk HA, Behr S, Summers B, de Lahunta A, Syme H, Jull P, Garosi L. Porencephaly and hydranencephaly in six dogs. Vet Rec 2011; 170:179. [PMID: 22186380 DOI: 10.1136/vr.100109] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A retrospective study was performed to identify dogs with cerebrospinal fluid-filled cavitatory lesions on MRI. Six dogs were included and the lesions were classified. In the three dogs in the present study with hydranencephaly, unilateral but complete loss of the temporal and parietal lobes was noted and had almost complete loss of the occipital and frontal lobes of a cerebral hemisphere. In the three dogs with porencephaly, there was unilateral incomplete loss of the parietal lobe and one dog had additional partial loss of the temporal and frontal lobes. Two of the dogs with porencephaly had seizures; the third showed no associated clinical signs. The dogs with hydranencephaly had mentation changes and circled compulsively. The two porencephalic dogs with seizures were treated with phenobarbitone. One of the dogs with hydranencephaly showed increased frequency and duration of circling; one dog's clinical signs did not progress and the third dog was euthanased due to increasing aggression. The dog with increased circling had ventriculoperitoneal shunt placement and the circling frequency reduced.
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Affiliation(s)
- E S S Davies
- Willows Veterinary Centre, Highlands Road, Shirley, Solihull, West Midlands B90 4NH, UK.
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Kirton A, Armstrong-Wells J, Chang T, Deveber G, Rivkin MJ, Hernandez M, Carpenter J, Yager JY, Lynch JK, Ferriero DM. Symptomatic neonatal arterial ischemic stroke: the International Pediatric Stroke Study. Pediatrics 2011; 128:e1402-10. [PMID: 22123886 DOI: 10.1542/peds.2011-1148] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Adam Kirton
- Alberta Children's Hospital, Calgary, Alberta, Canada.
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Wintermark P, Warfield SK. New insights in perinatal arterial ischemic stroke by assessing brain perfusion. Transl Stroke Res 2011; 3:255-62. [PMID: 24323781 DOI: 10.1007/s12975-011-0122-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 10/17/2011] [Accepted: 10/20/2011] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Pia Wintermark
- Division of Newborn Medicine, Montreal Children's Hospital, McGill University, 2300 rue Tupper, C-920, Montreal, QC, H3H 1P3, Canada,
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Thordstein M, Hallböök T, Lundgren J, van Westen D, Elam M. Transfer of cortical motor representation after a perinatal cerebral insult. Pediatr Neurol 2011; 44:131-4. [PMID: 21215913 DOI: 10.1016/j.pediatrneurol.2010.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 06/29/2010] [Accepted: 08/18/2010] [Indexed: 01/26/2023]
Abstract
In a 16-year-old boy with hemiplegia and severe, intractable epilepsy after a neonatal cerebral ischemic insult, cortical motor control was only equivocally assessed by functional magnetic resonance imaging. Therefore, high-precision navigated transcranial magnetic stimulation was performed, which demonstrated that cortical control of muscles on the paretic side was selectively affected. Leg muscle control was located in the contralateral hemisphere, as expected in healthy individuals, whereas forearm muscles were controlled from both hemispheres, and hand muscles were controlled only from the hemisphere ipsilateral to the paresis.
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Affiliation(s)
- Magnus Thordstein
- Department of Clinical Neurophysiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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