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Song Y, Li S, Hao L, Han Y, Wu W, Fan Y, Gao X, Li X, Ren C, Chen Y. Risk factors of neonatal stroke from different origins: a systematic review and meta-analysis. Eur J Pediatr 2024; 183:3073-3083. [PMID: 38661815 DOI: 10.1007/s00431-024-05531-5] [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: 01/24/2024] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/26/2024]
Abstract
Given the persistent ambiguity regarding the etiology of neonatal stroke across diverse origins, our objective was to conduct a comprehensive evaluation of both qualitative and quantitative risk factors. An exhaustive search of eight databases was executed to amass all pertinent observational studies concerning risk factors for neonatal stroke from various origins. Subsequent to independent screening, data extraction, and bias assessment by two researchers, a meta-analysis was conducted utilizing RevMan and Stata software. Nineteen studies, encompassing a total of 30 factors, were incorporated into this analysis. Beyond established risk factors, our investigation unveiled gestational diabetes (OR, 5.51; P < 0.00001), a history of infertility (OR, 2.44; P < 0.05), placenta previa (OR, 3.92; P = 0.02), postdates (OR, 2.07; P = 0.01), preterm labor (OR, 2.32; P < 0.00001), premature rupture of membranes (OR, 3.02; P = 0.007), a prolonged second stage of labor (OR, 3.94; P < 0.00001), and chorioamnionitis (OR, 4.35; P < 0.00001) as potential risk factors for neonatal cerebral arterial ischemic stroke. Additionally, postdates (OR, 4.31; P = 0.003), preterm labor (OR, 1.60; P < 0.00001), an abnormal CTG tracing (OR, 9.32; P < 0.0001), cesarean section (OR, 4.29; P = 0.0004), male gender (OR, 1.73; P = 0.02), and vaginal delivery (OR, 1.39; P < 0.00001) were associated with an elevated risk for neonatal hemorrhagic stroke. CONCLUSIONS This study provides a succinct overview and comparative analysis of maternal, perinatal, and additional risk factors associated with neonatal cerebral artery ischemic stroke and neonatal hemorrhagic stroke, furnishing critical insights for healthcare practitioners involved in the diagnosis and prevention of neonatal stroke. This research also broadens the conceptual framework for future investigations. WHAT IS KNOWN • Research indicates that prenatal, perinatal, and neonatal risk factors can elevate the risk of neonatal arterial ischemic stroke (NAIS). However, the risk factors for neonatal cerebral arterial ischemic stroke remain contentious, and those for neonatal hemorrhagic stroke (NHS) and neonatal cerebral venous sinus thrombosis (CVST) are still not well-defined. WHAT IS NEW • This study is the inaugural comprehensive review and meta-analysis encompassing 19 studies that explore maternal, perinatal, and various risk factors linked to neonatal stroke of differing etiologies. Notably, our analysis elucidates eight risk factors associated with NAIS: gestational diabetes mellitus, a history of infertility, placenta previa, postdates, preterm birth, premature rupture of membranes, a prolonged second stage of labor, and chorioamnionitis. Furthermore, we identify six risk factors correlated with NHS: postdates, preterm birth, an abnormal CTG, the method of delivery, male gender, and vaginal delivery. Additionally, our systematic review delineates risk factors associated with CVST.
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Affiliation(s)
- Yankun Song
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Shangbin Li
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Ling Hao
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Yiwei Han
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Wenhui Wu
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Yuqing Fan
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Xiong Gao
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Xueying Li
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China
| | - Changjun Ren
- Department of Pediatrics, First Affifiliated Hospital of Hebei Medical University, Hebei Medical University, Shijiazhuang, 050000, China.
| | - Yuan Chen
- Department of Pediatrics, the Second Hospital of Hebei medical university, Hebei Medical University, Shijiazhuang, 050000, China.
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Giraud A, Dinomais M, Garel P, Chevin M, Thébault G, Renaud C, Presles É, Raia-Barjat T, Sébire G, Chabrier S. Perinatal inflammation exposure and developmental outcomes 7 years after neonatal arterial ischaemic stroke. Dev Med Child Neurol 2023; 65:1073-1080. [PMID: 36700522 DOI: 10.1111/dmcn.15522] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 12/19/2022] [Accepted: 12/26/2022] [Indexed: 01/27/2023]
Abstract
AIM To test the association between perinatal inflammation exposure and Full-Scale IQ (FSIQ) score 7 years after neonatal arterial ischaemic stroke (NAIS). METHOD We conducted a cross-sectional ancillary study nested in a multicentric longitudinal French cohort of infants born at term with NAIS between November 2003 and October 2006. Seventy-three children were included (45 males, 28 females). The a priori defined primary outcome measure was the FSIQ score assessed with the Wechsler Intelligence Scale for Children, Fourth Edition at 7 years of age. RESULTS Seventeen (23%) of the included children were exposed to perinatal inflammation. Exposure to perinatal inflammation was independently associated with an increase of FSIQ score (coefficient 13.4, 95% confidence interval 1.3-25.4; p = 0.03). Children exposed to perinatal inflammation had a higher median cerebral volume, a lower median lesion volume, and less extensive lesion distributions compared to non-exposed children. INTERPRETATION We propose the existence of two NAIS categories: arteritis-associated NAIS in children exposed to perinatal inflammation and embolism-associated NAIS in children non-exposed to perinatal inflammation. Identifying these two NAIS categories would open the possibility for specific curative strategies: anti-inflammatory strategy in arteritis-associated NAIS and recanalization strategy in embolism-associated NAIS.
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Affiliation(s)
- Antoine Giraud
- INSERM, U1059 SAINBIOSE, Université Jean Monnet, Saint-Étienne, France
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Mickaël Dinomais
- Département de Médecine Physique et de Réadaptation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Pauline Garel
- Centre National de Référence de l'AVC de l'Enfant, Médecine Physique et Réadaptation Pédiatrique, INSERM CIC1408, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Mathilde Chevin
- Child Neurology Division, Department of Paediatrics, McGill University, QC, Canada
| | - Guillaume Thébault
- Département de Médecine Physique et de Réadaptation, Centre Hospitalier Paul Coste Floret, France
| | - Cyrille Renaud
- Centre National de Référence de l'AVC de l'Enfant, Médecine Physique et Réadaptation Pédiatrique, INSERM CIC1408, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | - Émilie Presles
- INSERM, U1059 SAINBIOSE, Université Jean Monnet, Saint-Étienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
| | | | - Guillaume Sébire
- Child Neurology Division, Department of Paediatrics, McGill University, QC, Canada
| | - Stéphane Chabrier
- INSERM, U1059 SAINBIOSE, Université Jean Monnet, Saint-Étienne, France
- Centre National de Référence de l'AVC de l'Enfant, Médecine Physique et Réadaptation Pédiatrique, INSERM CIC1408, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
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Cornet MC, Grose C, Vexler Z, Wu YW, Fullerton HJ. The Role of Infection and Inflammation in the Pathogenesis of Pediatric Arterial Ischemic Stroke. Semin Pediatr Neurol 2022; 44:100995. [PMID: 36456035 DOI: 10.1016/j.spen.2022.100995] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022]
Abstract
Infections play an important role in the pathogenesis of acute ischemic stroke (AIS) in neonates and children. In neonates, chorioamnionitis or intrauterine inflammation has been implicated as a common risk factor for AIS. In infants and children, recent investigations demonstrated that even minor childhood infections are associated with subsequent increased risk for AIS. Post-infectious inflammatory mechanisms following infections with herpesviruses may lead to focal cerebral arteriopathy (FCA), one of the most common causes of AIS in a previously healthy child. Other agents such as parvovirus B19, dengue virus, and SARS-CoV-2 have recently been implicated as other potential triggers. Infections are compelling treatable stroke risk factors, with available therapies for both pathogens and downstream inflammatory effects. However, infections are common in childhood, while stroke is uncommon. The ongoing VIPS II (Vascular effects of Infection in Pediatric Stroke) study aims to identify the array of pathogens that may lead to childhood AIS and whether either unusual strains or unusual combinations of pathogens explain this paradox. Immune modulation with corticosteroids for FCA is another active area of research, with European and U.S. trials launching soon. The results of these new pediatric stroke studies combined with findings emerging from the larger field of immune-mediated post-infectious diseases will likely lead to new approaches to the prevention and treatment of pediatric stroke. This review highlights recent developments from both clinical and animal model research enhancing our understanding of this relationship between infection, inflammation, and stroke in neonates and children.
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Affiliation(s)
- Marie-Coralie Cornet
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
| | - Charles Grose
- Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Zinaida Vexler
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Yvonne W Wu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Heather J Fullerton
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA; Department of Neurology, University of California San Francisco, San Francisco, California, USA
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He Y, Ying J, Tang J, Zhou R, Qu H, Qu Y, Mu D. Neonatal Arterial Ischaemic Stroke: Advances in Pathologic Neural Death, Diagnosis, Treatment, and Prognosis. Curr Neuropharmacol 2022; 20:2248-2266. [PMID: 35193484 PMCID: PMC9890291 DOI: 10.2174/1570159x20666220222144744] [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: 11/29/2021] [Revised: 02/04/2022] [Accepted: 02/18/2022] [Indexed: 12/29/2022] Open
Abstract
Neonatal arterial ischaemic stroke (NAIS) is caused by focal arterial occlusion and often leads to severe neurological sequelae. Neural deaths after NAIS mainly include necrosis, apoptosis, necroptosis, autophagy, ferroptosis, and pyroptosis. These neural deaths are mainly caused by upstream stimulations, including excitotoxicity, oxidative stress, inflammation, and death receptor pathways. The current clinical approaches to managing NAIS mainly focus on supportive treatments, including seizure control and anticoagulation. In recent years, research on the pathology, early diagnosis, and potential therapeutic targets of NAIS has progressed. In this review, we summarise the latest progress of research on the pathology, diagnosis, treatment, and prognosis of NAIS and highlight newly potential diagnostic and treatment approaches.
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Affiliation(s)
- Yang He
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Junjie Ying
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Jun Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Ruixi Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Haibo Qu
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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5
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Xia Q, Yang Z, Xie Y, Zhu Y, Yang Z, Hei M, Ding Y, Kong W, Kang L, Yang S, Mei Y, Feng Z, Zhang L, Lei Y, Wang P, Dong J, Yang L, Ju J, Chang H, Zhan S, Yu J, Zhang P, Wang R, Guo H, Liu X, Tan H, Liu Y, Zhang Z, Zhen L, Yan J, Liu Z, Yang C, Wang Q, Wang J, Sun L, Zeng H, Li J, Qu W, Wang X, Liu G, Yang X, Liu X, Zhang X, Xu X, Gu Y, Long H, Zhang L, Liu L, Tang Z, Hou X. The Incidence and Characteristics of Perinatal Stroke in Beijing: A Multicenter Study. Front Public Health 2022; 10:783153. [PMID: 35400054 PMCID: PMC8987304 DOI: 10.3389/fpubh.2022.783153] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/31/2022] [Indexed: 02/05/2023] Open
Abstract
ObjectiveTo assess the incidence, risk factors, and clinical characteristics of perinatal stroke in Beijing.MethodsThis multicenter prospective study included all the live births from 17 representative maternal delivery hospitals in Beijing from March 1, 2019 to February 29, 2020. Neonates with a stroke were assigned to the study group. Clinical data, including general information, clinical manifestations, and risk factors, were collected. Up until 18 months after birth, neonates were routinely assessed according to the Ages and Stages Questionnaire (ASQ) and/or the Bayley scale. Statistical analysis was done using the chi-squared, t-tests, and logistic regression analysis using SPSS version 26.0.OutcomesIn total, 27 cases were identified and the incidence of perinatal stroke in Beijing was 1/2,660 live births, including 1/5,985 for ischemic stroke and 1/4,788 for hemorrhagic stroke. Seventeen cases (62.96%) of acute symptomatic stroke and convulsions within 72 h (10 cases, 37.04%) were the most common presentations. Ten patients showed no neurological symptoms and were found to have had a stroke through routine cranial ultrasonography after being hospitalized for non-neurological diseases. The risk factors include primiparity, placental or uterine abruption/acute chorioamnionitis, intrauterine distress, asphyxia, and severe infection. In the study group, 11.1% (3/27) of patients had adverse neurodevelopmental outcomes. The patients in the study group had lower scores for the ASQ than those in the control group in the communication, gross, and fine motor dimensions.ConclusionThe incidence of perinatal stroke in Beijing was consistent with that in other countries. Routine neuroimaging of infants with risk factors may enable identification of asymptomatic strokes in more patients. Patients who have suffered from a stroke may have neurological sequelae; therefore, early detection, treatment, and regular follow-ups are beneficial for improving their recovery outcomes.
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Affiliation(s)
- Qianqian Xia
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Zhao Yang
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Yao Xie
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Ying Zhu
- Pediatric Department, Peking University First Hospital, Beijing, China
| | - Zixin Yang
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Mingyan Hei
- Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yingxue Ding
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Weijing Kong
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Limin Kang
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Shengnan Yang
- Department of Neonatology, Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Yabo Mei
- Neonatal Intensive Care Unit of Faculty of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Zhichun Feng
- Neonatal Intensive Care Unit of Faculty of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zhang
- Pediatric Department, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Yanzhe Lei
- Pediatric Department, Haidian Maternal and Child Health Hospital, Beijing, China
| | - Ping Wang
- Department of Neonatology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Jingyu Dong
- Pediatric Department, Tongzhou Maternal and Child Health Hospital, Beijing, China
| | - Li Yang
- Pediatric Department, Tongzhou Maternal and Child Health Hospital, Beijing, China
| | - Jun Ju
- Pediatric Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hesheng Chang
- Pediatric Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Shina Zhan
- Pediatric Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Jinqian Yu
- Pediatric Department, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Peng Zhang
- Pediatric Department, Beijing Miyun Maternal and Child Health Hospital, Beijing, China
| | - Ran Wang
- Pediatric Department, Beijing Miyun Maternal and Child Health Hospital, Beijing, China
| | - Hui Guo
- Pediatric Department, Fengtai Maternal and Child Health Hospital, Beijing, China
| | - Xinli Liu
- Pediatric Department, Fengtai Maternal and Child Health Hospital, Beijing, China
| | - Huaqing Tan
- Pediatric Department, Beijing Daxing Maternal and Child Care Hospital, Beijing, China
| | - Yakun Liu
- Pediatric Department, Beijing Daxing Maternal and Child Care Hospital, Beijing, China
| | - Zhenzong Zhang
- Pediatric Department, The First Hospital of Fangshan, Beijing, China
| | - Lixia Zhen
- Pediatric Department, The First Hospital of Fangshan, Beijing, China
| | - Jinting Yan
- Pediatric Department, Beijing Mentougou Hospital, Beijing, China
| | - Zhan Liu
- Pediatric Department, Beijing Mentougou Hospital, Beijing, China
| | - Chunxia Yang
- Pediatric Department, Changping Women and Children Health Care Hospital, Beijing, China
| | - Qingqing Wang
- Pediatric Department, Changping Women and Children Health Care Hospital, Beijing, China
| | - Jinfeng Wang
- Beijing Pinggu Maternal and Child Health Hospital, Beijing, China
| | - Lifang Sun
- Beijing Pinggu Maternal and Child Health Hospital, Beijing, China
| | - Huihui Zeng
- Pediatric Department, Huairou Maternal and Child Health Care Hospital, Beijing, China
| | - Jing Li
- Pediatric Department, Huairou Maternal and Child Health Care Hospital, Beijing, China
| | - Wenwen Qu
- Department of Pediatrics, Peking University Shougang Hospital and Capital Medical University, Beijing, China
| | - Xuemei Wang
- Department of Pediatrics, Peking University Shougang Hospital and Capital Medical University, Beijing, China
- General Respiratory Department of Beijing Jingdu Children's Hospital, Beijing, China
| | - Guiying Liu
- Department of Pediatrics, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xi Yang
- Department of Pediatrics, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xinxin Liu
- Pediatric Department, Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xuefeng Zhang
- Pediatric Department, Fifth Medical Center of Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaojing Xu
- Pediatric Department, The First Hospital of Tsinghua University, Beijing, China
| | - Yanan Gu
- Pediatric Department, The First Hospital of Tsinghua University, Beijing, China
| | - Hui Long
- Department of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Li Zhang
- Department of Pediatrics, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Lili Liu
- Pediatric Department, Peking University First Hospital, Beijing, China
- *Correspondence: Lili Liu
| | - Zezhong Tang
- Pediatric Department, Peking University First Hospital, Beijing, China
- Zezhong Tang
| | - Xinlin Hou
- Pediatric Department, Peking University First Hospital, Beijing, China
- Xinlin Hou
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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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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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Haddad FL, Patel SV, Schmid S. Maternal Immune Activation by Poly I:C as a preclinical Model for Neurodevelopmental Disorders: A focus on Autism and Schizophrenia. Neurosci Biobehav Rev 2020; 113:546-567. [PMID: 32320814 DOI: 10.1016/j.neubiorev.2020.04.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 01/28/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
Maternal immune activation (MIA) in response to a viral infection during early and mid-gestation has been linked through various epidemiological studies to a higher risk for the child to develop autism or schizophrenia-related symptoms.. This has led to the establishment of the pathogen-free poly I:C-induced MIA animal model for neurodevelopmental disorders, which shows relatively high construct and face validity. Depending on the experimental variables, particularly the timing of poly I:C administration, different behavioural and molecular phenotypes have been described that relate to specific symptoms of neurodevelopmental disorders such as autism spectrum disorder and/or schizophrenia. We here review and summarize epidemiological evidence for the effects of maternal infection and immune activation, as well as major findings in different poly I:C MIA models with a focus on poly I:C exposure timing, behavioural and molecular changes in the offspring, and characteristics of the model that relate it to autism spectrum disorder and schizophrenia.
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Affiliation(s)
- Faraj L Haddad
- Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada.
| | - Salonee V Patel
- Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada.
| | - Susanne Schmid
- Anatomy & Cell Biology, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, ON, Canada.
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Abstract
Perinatal strokes are a diverse but specific group of focal cerebrovascular injuries that occur early in brain development and affect an estimated 5 million people worldwide. The objective of this review is to describe the epidemiology, clinical presentations, pathophysiology, outcomes, and management for the 6 subtypes of perinatal stroke. Some perinatal strokes are symptomatic in the first days of life, typically with seizures, including neonatal arterial ischemic stroke, neonatal hemorrhagic stroke, and cerebral sinovenous thrombosis. The remaining subtypes present in the first year of life or later, usually with motor asymmetry and include arterial presumed perinatal ischemic stroke, presumed perinatal hemorrhagic stroke, and in utero periventricular venous infarction. The consequences of these injuries include cerebral palsy, epilepsy, and cognitive and behavioral challenges, in addition to the psychosocial impact on families. While there have been significant advances in understanding mechanisms of both injury and recovery, there is still a great deal to learn regarding causation and the optimization of outcomes.
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Affiliation(s)
- Mary Dunbar
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada
| | - Adam Kirton
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, AB, Canada.
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10
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Fluss J, Dinomais M, Chabrier S. Perinatal stroke syndromes: Similarities and diversities in aetiology, outcome and management. Eur J Paediatr Neurol 2019; 23:368-383. [PMID: 30879961 DOI: 10.1016/j.ejpn.2019.02.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/04/2019] [Accepted: 02/24/2019] [Indexed: 01/09/2023]
Abstract
With a birth-prevalence of 37-67/100,000 (mostly term-born), perinatal stroke encompasses distinct disease-states with diverse causality, mechanism, time of onset, mode of presentation and outcome. Neonatal primary haemorrhagic stroke and ischemic events (also divided into neonatal arterial ischemic stroke and neonatal cerebral sinus venous thrombosis) that manifest soon after birth are distinguished from presumed perinatal - ischemic or haemorrhagic - stroke. Signs of the latter become apparent only beyond the neonatal period, most often with motor asymmetry or milestones delay, and occasionally with seizures. Acute or remote MRI defines the type of stroke and is useful for prognosis. Acute care relies on homeostatic maintenance. Seizures are often self-limited and anticonvulsant agents might be discontinued before discharge. Prolonged anticoagulation for a few weeks is an option in some cases of sinovenous thrombosis. Although the risk of severe impairment is low, many children develop mild to moderate multimodal developmental issues that require a multidisciplinary approach.
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Affiliation(s)
- Joel Fluss
- Pediatric Neurology Unit, Geneva Children's Hospital, 6 rue Willy-Donzé, 1211 Genève 4, Switzerland
| | - Mickaël Dinomais
- CHU Angers, Département de Médecine Physique et de Réadaptation, CHU Angers-Capucins, F-49933, Angers, France; Université d'Angers, Laboratoire Angevin de Recherche en Ingénierie des Systèmes (LARIS) EA7315, F-49000, Angers, France
| | - Stéphane Chabrier
- CHU Saint-Étienne, French Centre for Paediatric Stroke, Paediatric Physical and Rehabilitation Medicine Department, INSERM, CIC 1408, F-42055, Saint-Étienne, France; INSERM, U1059 Sainbiose, Univ Saint-Étienne, Univ Lyon, F-42023, Saint-Étienne, France.
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11
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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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Dunbar M, Kirton A. Perinatal stroke: mechanisms, management, and outcomes of early cerebrovascular brain injury. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:666-676. [PMID: 30119760 DOI: 10.1016/s2352-4642(18)30173-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 12/24/2022]
Abstract
Perinatal stroke encompasses a heterogeneous group of focal neurological injuries early in brain development that probably affects more than 5 million people worldwide. Many such injuries are symptomatic in the first days of life, including neonatal arterial ischaemic stroke, cerebral sinovenous thrombosis, and neonatal haemorrhagic stroke. The remaining focal neurological injuries usually present later in the first year with motor asymmetry, such as arterial presumed perinatal ischaemic stroke, periventricular venous infarction, and presumed perinatal haemorrhagic stroke. The numerous sequelae of these injuries include hemiparesis (cerebral palsy), epilepsy, and cognitive, language, and behavioural challenges. In this Review we summarise each perinatal stroke disease, examining the epidemiology, pathophysiology, acute management, and outcomes, including the effect on parents and families, and emerging therapies to mitigate these lifelong morbidities.
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Affiliation(s)
- Mary Dunbar
- Department of Community Health Services, University of Calgary, Calgary, Alberta, Canada; Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Adam Kirton
- Calgary Pediatric Stroke Program, University of Calgary, Calgary, Alberta, Canada; Department of Radiology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada; Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; Hotchkiss Brain Institute, Calgary, AB, Canada.
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Cytokine production pattern of T lymphocytes in neonatal arterial ischemic stroke during the first month of life-a case study. J Neuroinflammation 2018; 15:191. [PMID: 29933753 PMCID: PMC6015463 DOI: 10.1186/s12974-018-1229-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/15/2018] [Indexed: 12/21/2022] Open
Abstract
Background The perinatal period carries the highest risk for stroke in childhood; however, the pathophysiology is poorly understood and preventive, prognostic, and therapeutic strategies are not available. A new pathophysiological model describes the development of neonatal arterial ischemic stroke (NAIS) as the combined result of prenatal inflammation and hypoxic–ischemic insult. Neuroinflammation and a systemic inflammatory response are also important features of NAIS. Identifying key players of the inflammatory system is in the limelight of current research. Case presentation We present four NAIS cases, in whom detailed analysis of intracellular and plasma cytokine levels are available from the first month of life. All neonates were admitted with the initial diagnosis of hypoxic ischemic encephalopathy (HIE); however, early MRI examination revealed NAIS. Blood samples were collected between 3 and 6 h of life, at 24 h, 72 h, 1 week, and 1 month of life. Peripheral blood mononuclear cells were assessed with flow cytometry and plasma cytokine levels were measured. Pooled data from the cohort of four NAIS patients were compared to infants with HIE. At 6 and 72 h of age, the prevalence of IL10+ CD8+ lymphocytes remained lower in NAIS. At 6 h, CD8+ lymphocytes in NAIS produced more IL-17. At 72 h, CD8+ cells produced more IL-6 in severe HIE than in NAIS, but IL-6 production remained elevated in CD8 cells at 1 month in NAIS, while it decreased in HIE. At 1 week, the prevalence of TGF-β + lymphocytes prone to enter the CNS was elevated in NAIS. On the other hand, by 1 month of age, the prevalence of TGF-β + CD4+ lymphocytes decreased in NAIS compared to HIE. At 72 h, we found elevated plasma levels of IL-5, MCP-1, and IL-17 in NAIS. By 1 month, plasma levels of IL-4, IL-12, and IL-17 decreased in NAIS but remained elevated in HIE. Conclusions Differences in the cytokine network are present between NAIS and HIE. CD8 lymphocytes appear to shift towards the pro-inflammatory direction in NAIS. The inflammatory response appears to be more pronounced at 72 h in NAIS but decreases faster, reaching lower plasma levels of inflammatory markers at 1 month.
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Giraud A, Guiraut C, Chevin M, Chabrier S, Sébire G. Role of Perinatal Inflammation in Neonatal Arterial Ischemic Stroke. Front Neurol 2017; 8:612. [PMID: 29201015 PMCID: PMC5696351 DOI: 10.3389/fneur.2017.00612] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/02/2017] [Indexed: 12/19/2022] Open
Abstract
Based on the review of the literature, perinatal inflammation often induced by infection is the only consistent independent risk factor of neonatal arterial ischemic stroke (NAIS). Preclinical studies show that acute inflammatory processes take place in placenta, cerebral arterial wall of NAIS-susceptible arteries and neonatal brain. A top research priority in NAIS is to further characterize the nature and spatiotemporal features of the inflammatory processes involved in multiple levels of the pathophysiology of NAIS, to adequately design randomized control trials using targeted anti-inflammatory vasculo- and neuroprotective agents.
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Affiliation(s)
- Antoine Giraud
- EA 4607 SNA EPIS, Jean Monnet University, Saint-Etienne, France.,Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Clémence Guiraut
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Mathilde Chevin
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Stéphane Chabrier
- French Center for Pediatric Stroke and Pediatric Rehabilitation Unit, Department of Pediatrics, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Guillaume Sébire
- Child Neurology Division, Department of Pediatrics, McGill University, Montréal, QC, Canada
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15
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Abstract
Over the last decades, the importance of inflammatory processes in pediatric stroke have become increasingly evident. Ischemia launches a cascade of events: activation and inhibition of inflammation by a large network of cytokines, adhesion and small molecules, protease, and chemokines. There are major differences in the neonatal brain compared to adult brain, but developmental trajectories of the process during childhood are not yet well known. In neonatal stroke ischemia is the leading pathophysiology, but infectious and inflammatory processes have a significant input into the course and degree of tissue damage. In childhood, beside inflammation lanced by ischemia itself, the event of ischemia might be provoked by an underlying inflammatory pathophysiology: transient focal arteriopathy, dissection, sickle cell anemia, Moyamoya and more generalized in meningitides, generalized vasculitis or genetic arteriopathies (as in ADA2). Focal inflammatory reactions tend to be located in the distal part of the carotid artery or the proximal medial arteries, but generalized processes rather tend to affect the small arteries.
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