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Roy B, Webb A, Walker K, Morgan C, Badawi N, Novak I. Clinical characteristics and outcomes of perinatal stroke in Australia: Population-based longitudinal study. J Paediatr Child Health 2024; 60:586-592. [PMID: 39162173 DOI: 10.1111/jpc.16640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/28/2024] [Accepted: 07/29/2024] [Indexed: 08/21/2024]
Abstract
AIM Perinatal stroke is one of the main causes of hemiplegia and seizure disorder. This study aimed to analyse the clinical characteristics and outcomes of perinatal stroke in a cohort of Australian children for its early detection. METHODS A population-based prospective longitudinal study on perinatal stroke up to 2 years of age, was conducted from 2017 to 2019. RESULTS Eighty-seven children with perinatal stroke included 79% (69/87) acute and 21% (18/87) presumed perinatal stroke. Seventy-four per cent (51/69) acute symptomatic perinatal strokes presented in the first 3 days of life and 78% (14/18) presumed perinatal strokes presented by 6 months of age. 62% had an arterial stroke, 29% had a venous stroke and 5% had a combined arterial and venous stroke. Unexpectedly, 35% (24/69) acute symptomatic perinatal stroke had only respiratory symptoms and 50% (9/18) presumed perinatal stroke were asymptomatic. The incidence of cerebral palsy was 29% (20/69) with acute symptomatic perinatal stroke and 72% (13/18) with presumed perinatal stroke. CONCLUSIONS The first week of a child's life is the most critical period in terms of lifelong disability from perinatal stroke. Recognising diverse clinical presentations will ensure early diagnosis and timely intervention treatments.
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Affiliation(s)
- Bithi Roy
- Children's Hospital Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- The Mater Hospital, Sydney, New South Wales, Australia
- The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Annabel Webb
- Discipline of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Karen Walker
- RPA Newborn Care, Sydney Local Health District, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Catherine Morgan
- Children's Hospital Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Nadia Badawi
- Children's Hospital Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, Australia
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Iona Novak
- Discipline of Child and Adolescent Health, Cerebral Palsy Alliance Research Institute, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Hirschel J, Barcos-Munoz F, Chalard F, Chiodini F, Epiney M, Fluss J, Rougemont AL. Perinatal arterial ischemic stroke: how informative is the placenta? Virchows Arch 2024; 484:815-825. [PMID: 38502326 PMCID: PMC11106178 DOI: 10.1007/s00428-024-03780-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/31/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
Neuroplacentology is an expanding field of interest that addresses the placental influence on fetal and neonatal brain lesions and on further neurodevelopment. The objective of this study was to clarify the link between placental pathology and perinatal arterial ischemic stroke (PAIS). Prior publications have reported different types of perinatal stroke with diverse methodologies precluding firm conclusions. We report here the histological placental findings in a series of 16 neonates with radiologically confirmed PAIS. Findings were grouped into 3 categories of lesions: (1) inflammation, (2) placental and fetal hypoxic lesions, and (3) placentas with a high birthweight/placenta weight ratio. Matched control placentas were compared to the pathological placentas when feasible. The eight term singleton placentas were compared to a series of 20 placentas from a highly controlled amniotic membrane donation program; in three twin pregnancies, the placental portions from the affected twin and unaffected co-twin were compared. Slightly more than half (9/16, 56%) had histopathological features belonging to more than one category, a feature shared by the singleton control placentas (13/20, 65%). More severe and extensive lesions were however observed in the pathological placentas. One case occurring in the context of SARS-CoV-2 placentitis further expands the spectrum of COVID-related perinatal disease. Our study supports the assumption that PAIS can result from various combinations and interplay of maternal and fetal factors and confirms the value of placenta examination. Yet, placental findings must be interpreted with caution given their prevalence in well-designed controls.
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Affiliation(s)
- Jessica Hirschel
- Division of Neonatal and Intensive Care, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Francisca Barcos-Munoz
- Division of Neonatal and Intensive Care, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals of Geneva, Geneva, Switzerland
| | - François Chalard
- Unit of Pediatric Radiology, Department of Radiology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Florence Chiodini
- Therapeutic Tissue Biobank, University Hospitals of Geneva, Geneva, Switzerland
| | - Manuella Epiney
- Obstetrics Unit Department of Obstetrics and Gynecology, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Joel Fluss
- Pediatric Neurology Unit, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Anne-Laure Rougemont
- Division of Clinical Pathology, Diagnostic Department, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland.
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Dunbar M, Norris A, Craig BT, Chaput K, Mohammad K, Cole L, Esser MJ, Caughey A, Carlson H, Kirton A. Relationship Between Neonatal Brain Injury and Objective Measures of Head Trauma: A Case-Control Study. Neurology 2023; 101:e2401-e2410. [PMID: 37848334 PMCID: PMC10752635 DOI: 10.1212/wnl.0000000000207766] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal brain injury is a common and devastating diagnosis conferring lifelong challenges for children and families. The role of mechanical forces applied to the head, often referred to as "birth trauma," are often considered although evidence for this association is lacking. The objective of this study was to investigate the association between common types of neonatal brain injury and scalp swelling using a novel method to quantify scalp swelling as an unbiased proxy for mechanical forces applied to the head. METHODS Case-control study using population-based, prospectively collected tertiary care center databases and healthy controls from the Human Connectome Development Project. Included were infants born 32-42 weeks gestational age and MRI in the first 9 days. Outcomes categories included healthy neonates, hypoxic ischemic encephalopathy (HIE) with or without brain injury, or stroke (ischemic or hemorrhagic). Volume of scalp swelling was objectively quantified by a novel imaging method blinded to brain injury. Variables included mode of delivery and use of instrumentation. Statistical tests included Kruskal-Wallis test, chi square, and multivariable and multinomial logistic regression. RESULTS There were 309 infants included (55% male): 72 healthy controls, 77 HIE without brain injury on MRI, 78 HIE with brain injury, and 82 with stroke (60 ischemic, 22 hemorrhagic). Scalp swelling was present in 126 (40.8%, 95% confidence interval [CI] 35.2%-46.5%) with no difference in proportions between outcome groups. Compared to healthy controls, median volume was higher in those with HIE without brain injury (17.5 mL, 95% CI 6.8-28.2), HIE with brain injury (12.1 mL, 95% CI 5.5-18.6), but not ischemic stroke (4.7 mL, 95% CI -1.2-10.6) nor hemorrhagic stroke (8.3 mL, 95% CI -2.2-18.8). Scalp swelling was associated with instrumented delivery (OR 2.1, 95% CI 1.0-4.1), but not associated with increased odds of brain injury in those with HIE (OR 1.5, 95% CI 0.76-3.30). Scalp swelling measures were highly reliable (ICC = 0.97). DISCUSSION "Birth trauma" quantified by scalp swelling volume was more common in infants with difficult deliveries, but not associated with greater odds of brain injury due to hypoxia or stroke. These results may help parents and practitioners to dissociate the appearance of trauma with the risk of brain injury.
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Affiliation(s)
- Mary Dunbar
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Abbey Norris
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Brandon T Craig
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Kathleen Chaput
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Khorshid Mohammad
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Lauran Cole
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Michael J Esser
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Aaron Caughey
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Helen Carlson
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada
| | - Adam Kirton
- From the Department of Pediatrics (M.D., B.T.C., H.C., A.K.), University of Calgary; Calgary Pediatric Stroke Program (M.D., B.T.C., H.C., A.K.); Alberta Children's Hospital Research Institute (M.D., B.T.C., H.C., A.K.); Hotchkiss Brain Institute (M.D., B.T.C., H.C., A.K.); Pediatric Stroke Program (A.N.); Department of Obstetrics and Gynecology (K.C.); Department of Pediatrics (K.M., M.J.E.), University of Calgary; Department of Pediatrics (L.C.), University of Alberta, Edmonton, Canada; Department of Obstetrics and Gynecology (A.C.), Oregon Health & Science University, Portland, OR; and Department of Clinical Neurosciences and Radiology (A.K.), University of Calgary, Alberta, Canada.
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Spinillo A, Dominoni M, Mas FD, Cesari S, Fiandrino G, Gardella B. Placental fetal vascular malperfusion, neonatal neurologic morbidity, and infant neurodevelopmental outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol 2023; 229:632-640.e2. [PMID: 37315755 DOI: 10.1016/j.ajog.2023.06.014] [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: 12/20/2022] [Revised: 06/02/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVE This study aimed to evaluate the association of placental fetal vascular malperfusion lesions with neonatal brain injury and adverse infant neurodevelopmental outcomes. DATA SOURCES PubMed and Medline, Scopus, and Cochrane databases were searched from inception to July 2022. STUDY ELIGIBILITY CRITERIA We included cohort and case-control studies reporting the associations of fetal vascular malperfusion lesions with neonatal encephalopathy, perinatal stroke, intracranial hemorrhage, periventricular leukomalacia, and infant neurodevelopmental and cognitive outcomes. METHODS Data were analyzed by including fetal vascular malperfusion lesions as an exposure variable and brain injuries or neurodevelopmental impairment as outcomes using random-effects models. The effect of moderators, such as gestational age or study type, was assessed by subgroup analysis. Study quality and risk of bias were assessed by applying the Observational Study Quality Evaluation method. RESULTS Out of the 1115 identified articles, 26 were selected for quantitative analysis. The rates of neonatal central nervous system injury (neonatal encephalopathy or perinatal stroke) in term or near-term infants were more common among fetal vascular malperfusion cases (n=145) than among controls (n=1623) (odds ratio, 4.00; 95% confidence interval, 2.72-5.90). In premature deliveries, fetal vascular malperfusion lesions did not influence the risk of intracranial hemorrhage or periventricular leukomalacia (odds ratio, 1.40; 95% confidence interval, 0.90-2.18). Fetal vascular malperfusion-associated risk of abnormal infant neurodevelopmental outcome (314 fetal vascular malperfusion cases and 1329 controls) was modulated by gestational age being higher in term infants (odds ratio, 5.02; 95% confidence interval, 1.59-15.91) than in preterm infants (odds ratio, 1.70; 95% confidence interval, 1.13-2.56). Abnormal infant cognitive development and mental development were more common among fetal vascular malperfusion cases (n=241) than among controls (n=2477) (odds ratio, 2.14; 95% confidence interval, 1.40-3.27). The type of study (cohort vs case-control) did not influence the association between fetal vascular malperfusion and subsequent infant brain injury or abnormal neurodevelopmental outcome. CONCLUSION The findings of cohort and case-control studies indicate a considerable association between fetal vascular malperfusion placental lesions and increased risk of brain injury in term neonates, and neurodevelopmental impairment in both term and preterm infants. A diagnosis of placental fetal vascular malperfusion should be taken into consideration by both pediatricians and neurologists during the follow-up of infants at risk of adverse neurodevelopmental outcomes.
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Affiliation(s)
- Arsenio Spinillo
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Departments of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Departments of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
| | - Stefania Cesari
- Department of Pathology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giacomo Fiandrino
- Department of Pathology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Departments of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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Roy B, Webb A, Walker K, Morgan C, Badawi N, Novak I. Risk factors for perinatal stroke in term infants: A case-control study in Australia. J Paediatr Child Health 2023; 59:673-679. [PMID: 36786434 DOI: 10.1111/jpc.16372] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/15/2023]
Abstract
AIM The aetiology of perinatal stroke is poorly understood. This study aimed to prospectively confirm the risk factors and identify any previously unknown variables. METHODS A prospective case-control study was conducted in Australia. Univariate odds ratios (ORs), associated 95% confidence intervals (CIs) and multivariable logistic regression models fitted with backwards stepwise variable selection were used. RESULTS Sixty perinatal stroke cases reported between 2017 and 2019 included 95% (57/60) with multiple risk factors. Univariate analysis identified emergency caesarean section rather than NVD (P < 0.01), low Apgar score (<7) at 1, 5 and 10 min of age (P < 0.01), resuscitation at birth (P < 0.01), abnormal cord blood gas (P < 0.01), neonatal infection/sepsis (P < 0.01), congenital heart disease (P < 0.01) and hypoglycaemia (P < 0.01) as significant risk factors. Multivariate analysis found smoking during pregnancy (OR: 1.48; 95% CI: 1.09-1.99), 1-min Apgar score < 7 (OR: 1.54; 95% CI: 1.15-2.08), 10-min Apgar score < 7 (OR: 1.26; 95% CI: 1.02-1.54) and hypoglycaemia (OR: 1.49; 95% CI: 1.07-2.06). CONCLUSIONS Perinatal stroke is associated with multiple risk factors. Exposure to smoking, 10-min Apgar score < 7, neonatal infection and hypoglycaemia were independent risk factors. Emergency caesarean section, resuscitation at birth and abnormal cord blood gas were additional risk factors.
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Affiliation(s)
- Bithi Roy
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,The University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Annabel Webb
- Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Karen Walker
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,RPA Newborn Care, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Catherine Morgan
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, New South Wales, Australia.,Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nadia Badawi
- The University of Sydney Children's Hospital Westmead Clinical School, Sydney, New South Wales, Australia.,Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia.,Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Iona Novak
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Cerebral Palsy Alliance Research Institute, Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
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Srivastava R, Dunbar M, Shevell M, Oskoui M, Basu A, Rivkin MJ, Shany E, de Vries LS, Dewey D, Letourneau N, Hill MD, Kirton A. Development and Validation of a Prediction Model for Perinatal Arterial Ischemic Stroke in Term Neonates. JAMA Netw Open 2022; 5:e2219203. [PMID: 35767262 PMCID: PMC9244611 DOI: 10.1001/jamanetworkopen.2022.19203] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Perinatal arterial ischemic stroke (PAIS) is a focal brain injury in term neonates that is identified postnatally but is presumed to occur near the time of birth. Many pregnancy, delivery, and fetal factors have been associated with PAIS, but early risk detection is lacking; thus, targeted treatment and prevention efforts are currently limited. OBJECTIVE To develop and validate a diagnostic risk prediction model that uses common clinical factors to predict the probability of PAIS in a term neonate. DESIGN, SETTING, AND PARTICIPANTS In this diagnostic study, a prediction model was developed using multivariable logistic regression with registry-based case data collected between January 2003, and March 2020, from the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and Alberta Pregnancy Outcomes and Nutrition study. Criteria for inclusion were term birth and no underlying medical conditions associated with stroke diagnosis. Records with more than 20% missing data were excluded. Variable selection was based on peer-reviewed literature. Data were analyzed in September 2021. EXPOSURES Clinical pregnancy, delivery, and neonatal factors associated with PAIS as common data elements across the 4 registries. MAIN OUTCOMES AND MEASURES The primary outcome was the discriminative accuracy of the model predicting PAIS, measured by the concordance statistic (C statistic). RESULTS Of 2571 term neonates in the initial analysis (527 [20%] case and 2044 [80%] control individuals; gestational age range, 37-42 weeks), 1389 (54%) were male, with a greater proportion of males among cases compared with controls (318 [60%] vs 1071 [52%]). The final model was developed using 1924 neonates, including 321 cases (17%) and 1603 controls (83%), and 9 clinical factors associated with risk of PAIS in term neonates: maternal age, tobacco exposure, recreational drug exposure, preeclampsia, chorioamnionitis, intrapartum maternal fever, emergency cesarean delivery, low 5-minute Apgar score, and male sex. The model demonstrated good discrimination between cases and controls (C statistic, 0.73; 95% CI, 0.69-0.76) and good model fit (Hosmer-Lemeshow P = .20). Internal validation techniques yielded similar C statistics (0.73 [95% CI, 0.69-0.77] with bootstrap resampling, 10-fold cross-validated area under the curve, 0.72 [bootstrap bias-corrected 95% CI, 0.69-0.76]), as did a sensitivity analysis using cases and controls from Alberta, Canada, only (C statistic, 0.71; 95% CI, 0.65-0.77). CONCLUSIONS AND RELEVANCE The findings suggest that clinical variables can be used to develop and internally validate a model to predict the risk of PAIS in term neonates, with good predictive performance and strong internal validity. Identifying neonates with a high probability of PAIS who could then be screened for early diagnosis and treatment may be associated with reductions in lifelong morbidity for affected individuals and their families.
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Affiliation(s)
- Ratika Srivastava
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mary Dunbar
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
- Department of Neurology/Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Maryam Oskoui
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada
- Department of Neurology/Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Anna Basu
- Newcastle upon Tyne Hospitals, National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michael John Rivkin
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Eilon Shany
- Department of Neonatology, Soroka University Medical Center, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Linda S. de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Deborah Dewey
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Owerko Centre at the Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicole Letourneau
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adam Kirton
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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Leon RL, Kalvacherla V, Andrews MM, Thomas JM, Mir IN, Chalak LF. Placental pathologic lesions associated with stroke in term neonates. Front Endocrinol (Lausanne) 2022; 13:920680. [PMID: 36157451 PMCID: PMC9492924 DOI: 10.3389/fendo.2022.920680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/17/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To determine the birth prevalence of perinatal stroke in term born infants at our high-volume delivery center and assess the frequency of both gross and histologic placental pathologies associated with perinatal stroke using the Amsterdam Placental Workshop Group Consensus Statement guidelines and definitions. STUDY DESIGN A single-center retrospective cohort study spanning 2010-2020. RESULTS There were 129,759 live births at Parkland Hospital during the study period and a total of 18 term born infants leading to a birth prevalence of 1 in 6,829 infants. Perinatal risk factors were found in all but one patient, and 74% presented with seizures. Pathologic placental examination was available in 56% of the cohort and only one patient had normal placental examination. Acute histologic chorioamnionitis was described in five placentas (50%) and an additional two had isolated umbilical and/or chorionic plate vasculitis with or without funisitis compared to a rate of 28% with acute inflammation in a Control group. Chronic inflammation in the form of villitis of unknown etiology was described in three of the acutely inflamed placentas and was high-grade in each of those while none of the placentas from our Control group showed evidence of any chronic lesion. CONCLUSION Both acute and chronic placental inflammation are common in perinatal stroke; placental examination should be considered an essential component to the diagnostic workup.
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Affiliation(s)
- Rachel L. Leon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- *Correspondence: Rachel L. Leon,
| | | | | | - Jennifer M. Thomas
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Imran N. Mir
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina F. Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Vitagliano M, Dunbar M, Dyck Holzinger S, Letourneau N, Dewey D, Oskoui M, Shevell M, Kirton A. Perinatal arterial ischemic stroke and periventricular venous infarction in infants with unilateral cerebral palsy. Dev Med Child Neurol 2022; 64:56-62. [PMID: 34374437 DOI: 10.1111/dmcn.15000] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2021] [Indexed: 01/12/2023]
Abstract
AIM To explore clinical factors associated with perinatal arterial ischemic stroke (AIS) and periventricular venous infarction (PVI) in infants who develop unilateral cerebral palsy (CP). METHOD This was a case-control study. Data current to 2019 was extracted from the Canadian Cerebral Palsy Registry (CCPR). Cases were infants born at term with confirmed unilateral CP. Magnetic resonance images were stratified by expert review of reports as definitive perinatal stroke (AIS or PVI). Controls with common data elements were recruited from a population-based study in Alberta. Multivariable regression analyses were performed to estimate associations expressed as odds ratios with 95% confidence intervals. RESULTS Of 2093 cases from the CCPR, 662 had unilateral CP, of whom 299 (45%) had perinatal stroke: AIS 169 (57%) and PVI 130 (43%). Median age at diagnosis for AIS was 11.9 months (interquartile range: 6.2-25.7mo; range 0.17-104.1mo), and 58.6% were male. Median age at diagnosis for PVI was 25.3 months (interquartile range: 14.5-38mo, range 0.7-114.7mo) and 57.7% were male. Independent associations for both AIS and PVI on multivariable analysis were chorioamnionitis, illicit drug exposure, diabetes, gestational age, and maternal age. Variables associated with AIS alone were low Apgar score and prolonged rupture of membranes. Variables associated with PVI alone were small for gestational age and primigravida. INTERPRETATION Controlled analysis of disease-specific unilateral CP may offer unique perspectives on its pathophysiology. Acute intrapartum factors are mainly associated with AIS, while in utero factors are associated with PVI.
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Affiliation(s)
| | - Mary Dunbar
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Sasha Dyck Holzinger
- Canadian Cerebral Palsy Registry, Research Institute of McGill Health Center, Montreal, Quebec, Canada
| | - Nicole Letourneau
- Departments of Pediatrics, Psychiatry and Community Health Sciences, Faculty of Nursing and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Deborah Dewey
- Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Maryam Oskoui
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Departments of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Shevell
- Department of Pediatrics, McGill University, Montreal, Quebec, Canada.,Departments of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Adam Kirton
- Department of Pediatrics and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
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Gardella B, Dominoni M, Scatigno AL, Cesari S, Fiandrino G, Orcesi S, Spinillo A. What is known about neuroplacentology in fetal growth restriction and in preterm infants: A narrative review of literature. Front Endocrinol (Lausanne) 2022; 13:936171. [PMID: 36060976 PMCID: PMC9437342 DOI: 10.3389/fendo.2022.936171] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
The placenta plays a fundamental role during pregnancy for fetal growth and development. A suboptimal placental function may result in severe consequences during the infant's first years of life. In recent years, a new field known as neuroplacentology has emerged and it focuses on the role of the placenta in fetal and neonatal brain development. Because of the limited data, our aim was to provide a narrative review of the most recent knowledge about the relation between placental lesions and fetal and newborn neurological development. Papers published online from 2000 until February 2022 were taken into consideration and particular attention was given to articles in which placental lesions were related to neonatal morbidity and short-term and long-term neurological outcome. Most research regarding the role of placental lesions in neurodevelopment has been conducted on fetal growth restriction and preterm infants. Principal neurological outcomes investigated were periventricular leukomalacia, intraventricular hemorrhages, neonatal encephalopathy and autism spectrum disorder. No consequences in motor development were found. All the considered studies agree about the crucial role played by placenta in fetal and neonatal neurological development and outcome. However, the causal mechanisms remain largely unknown. Knowledge on the pathophysiological mechanisms and on placenta-related risks for neurological problems may provide clues for early interventions aiming to improve neurological outcomes, especially among pediatricians and child psychiatrists.
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Affiliation(s)
- Barbara Gardella
- Department of Obstetrics and Gynecology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Obstetrics and Gynecology, University of Pavia, Pavia, Italy
- *Correspondence: Barbara Gardella,
| | - Mattia Dominoni
- Department of Obstetrics and Gynecology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Obstetrics and Gynecology, University of Pavia, Pavia, Italy
| | - Annachiara Licia Scatigno
- Department of Obstetrics and Gynecology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Obstetrics and Gynecology, University of Pavia, Pavia, Italy
| | - Stefania Cesari
- Department of Pathology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Giacomo Fiandrino
- Department of Pathology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Simona Orcesi
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy
- Child Neurology and Psychiatry Unit, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Mondino Foundation, Pavia, Italy
| | - Arsenio Spinillo
- Department of Obstetrics and Gynecology, Fondazione Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
- Department of Obstetrics and Gynecology, University of Pavia, Pavia, Italy
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Perinatal stroke: mapping and modulating developmental plasticity. Nat Rev Neurol 2021; 17:415-432. [PMID: 34127850 DOI: 10.1038/s41582-021-00503-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/04/2023]
Abstract
Most cases of hemiparetic cerebral palsy are caused by perinatal stroke, resulting in lifelong disability for millions of people. However, our understanding of how the motor system develops following such early unilateral brain injury is increasing. Tools such as neuroimaging and brain stimulation are generating informed maps of the unique motor networks that emerge following perinatal stroke. As a focal injury of defined timing in an otherwise healthy brain, perinatal stroke represents an ideal human model of developmental plasticity. Here, we provide an introduction to perinatal stroke epidemiology and outcomes, before reviewing models of developmental plasticity after perinatal stroke. We then examine existing therapeutic approaches, including constraint, bimanual and other occupational therapies, and their potential synergy with non-invasive neurostimulation. We end by discussing the promise of exciting new therapies, including novel neurostimulation, brain-computer interfaces and robotics, all focused on improving outcomes after perinatal stroke.
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Scher MS. "The First Thousand Days" Define a Fetal/Neonatal Neurology Program. Front Pediatr 2021; 9:683138. [PMID: 34408995 PMCID: PMC8365757 DOI: 10.3389/fped.2021.683138] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/27/2021] [Indexed: 01/11/2023] Open
Abstract
Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.
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Affiliation(s)
- Mark S Scher
- Division of Pediatric Neurology, Department of Pediatrics, Fetal/Neonatal Neurology Program, Emeritus Scholar Tenured Full Professor in Pediatrics and Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, United States
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