Neonatal Stroke Involving the Middle Cerebral Artery in Term Infants: Clinical Presentation, Eeg and Imaging Studies, and Outcome

Abstract

SUMMARY Six children with neonatal cerebral infarction of the middle cerebral artery are reported. Seizures or respiratory distress were the initial symptoms. In some cases abnormal findings appeared earlier on EEG than on ultrasound. The EEG changes were concordant with the localization of the lesion. Ultrasound examinations revealed an echodense structure within the vascular territory, after a phase of appearing to be normal, highly suggestive of cerebral infarction. The diagnosis was confirmed by CT scan. Findings on EEG, cranial ultrasound and CT suggested that the stroke represented a late intra‐uterine event. At long‐term follow‐up, six children had failed to develop normally for age and had become obviously hemiplegic as gross motor development proceeded. Four of the patients had developed epilepsy. These data indicate that the outcome of neonatal stroke may not be as positive as previously reported. RÉSUMÉ Attaque sylvienne chez le nourrisson à terme: description clinique. EEG. imagerie et devenir L'article décrit six nourrissons après un infarctus sylvien à la naissance. Une crise comitiale ou une détresse respiratoire ont constitué le symptôme initial. Dans quelques cas, les données anormales sont apparues plus tôt à l'EEG qu'a l'échographie. Les modifications EEG étaient en accord avec la localisation de la lésion, l'échographie révélait un signal dense dans le territoire vasculaire, après une période de normalité, ce qui est hautement suggestif d'un infarctus cérébral. Le diagnostic fut confirmé par le scanner. Les données de l'EEG, de l'échographie transcranienne et du scanner suggéraient une attaque survenant à la période intra‐utérine tardive. Au suivi à long terme, les six enfants ne se développerent pas normalement pour l'âge, devinrent de plus en plus manifestemcnt hémiplégiques au cours de développement moteur global. Une épilepsie apparut chez quatre enfants au suivi. Ces données indiquent que le devenir d'une attaque sylvienne á la naissance peut ne pas être aussi favorable que cela avait été rapporte. ZUSAMMENFASSUNG Apoplex der A. cerebri media beim reifen Neugeborenen: klinisches Bild, EEC‐ und bildgebende Unsuchungsbefunde und Outcome Es werden sechs Kinder mit neonatalem Apoplex der A. cerebri media vorgestellt. Die lnitialsymptome waren Anfälle oder Atemnot. Bei einigen Fällen erschienen die Befunde im EEG früher als Ultraschall. Die EEG‐Veränderungen stimmten mit der Lokalisation der Läsion überein. Die Ultraschalluntersuchungen ergaben–nach anfänglich normal erscheinendem Befund–einen echodichten Bereich im Gefäßgebiet, was sehr für einen cerebralen Infarct sprach. Die Diagnose wurde durch CT‐Befunde bestätigt. EEG‐, Ultraschalund CT‐Befunde lassen vermuten, daß sich der Apoplex in der späten intra‐uterinen Phase ereignet hat. Im Verlauf der Langzeitbeobachtung entwickelten sich sechs Kinder nicht altersentsprechend und wurden mit fortschreitender grobmotorischer Entwicklung hemiplegisch. Vier der Patienten entwickelten im Beobachtungszeiiraum cine Epilepsie. Diese Daten zeigen, daß d...

Management of Stroke in Infants and Children

“…36 Several studies of children with unilateral prenatal or perinatal strokes have described increased difficulty with facial recognition 37 and other visuospatial tasks in small cohorts. 38 -40 Estimates of the incidence of cerebral palsy after perinatal stroke vary widely: 9% to 88% after perinatal AIS 26,29,[41][42][43][44][45][46][47] and 6% to 67% after perinatal CVST. 4,30,32,44 Outcome of children with perinatal stroke ranges from normal to subtle hemiplegia to severe quadriplegia.…”

Neurogenesis and neuronal commitment following ischemia in a new mouse model for neonatal stroke

“…Although the majority of children survive their stroke, about 75% have sequelae including cerebral palsy, epilepsy, and a range of cognitive impairments, including learning and memory problems (Delsing et al, 2001;Koelfen et al, 1995). Stroke in the developing brain is therefore an important cause of cognitive impairment that often persists into adulthood.…”

Cognitive Outcome at Early School Age in Term-Born Children With Perinatally Acquired Middle Cerebral Artery Territory Infarction

“…The wider availability of neonatal imaging has allowed the detection of acutely evolving lesions in the first postnatal days, usually in infants with neurological symptoms, and this has given insights into their timing and into identification of risk factors. [1][2][3][4] It is now recognized that arterial territory infarction in neonates is not usually associated with evidence of intrapartum asphyxia or neurological signs other than convulsions or evidence for the antenatal onset of lesions in symptomatic neonates. 2,4 -9 Not all infants with arterial territory infarction of perinatal onset have an abnormal outcome.…”

“…Studies that have investigated cognitive development and some aspects of verbal development in infants and children with focal lesions are, in the main, retrospective, 9 have included different types of focal lesions, 4,[12][13][14] imaging with CT, 4 do not differentiate between lesions occurring pre-and postnatally, 9 -12 and have not always given the results of specific and appropriate testing. [3][4][5][6]9 The aim of this study was to assess the cognitive outcome at early school age of a cohort of term born children, with an acutely evolving arterial territory cerebral infarction detected on early neonatal MRI brain scan, who were prospectively followed. We also wished to establish the correlation between cognitive abilities and the side and extent of lesions on neonatal MRI and other clinical signs such as epilepsy and hemiplegia.…”