Perinatal Stroke in Children With Motor Impairment: A Population-Based Study

Abstract

ABSTRACT. Objective. Risk factors for perinatal arterial stroke (PAS) are poorly understood. Most previous studies lack an appropriate control group and include only infants with symptoms in the newborn period. We set out to determine prenatal and perinatal risk factors for PAS.Methods. In a population-based, case-control study nested within the cohort of 231 582 singleton infants who were born at >36 weeks' gestation in Northern California Kaiser hospitals from 1991 to 1998, we searched electronically for children with motor impairment and reviewed their medical records to identify diagnoses of PAS. Control subjects were randomly selected from the study population. A medical record abstractor reviewed delivery records without knowledge of case status.Results. The prevalence of PAS with motor impairment was 17/100 000 live births. Of 38 cases, 26 (68%) presented after 3 months of age with hemiparesis or seizures. All 12 newborns with acute stroke symptoms had seizures. A delayed presentation was more common in children with moderate to severe motor impairment than among infants with only mild motor abnormalities (24 of 31 vs 2 of 7). Prepartum risk factors significantly associated with PAS in multivariate analysis were preeclampsia (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.1-11.4) and intrauterine growth restriction (OR: 5.3; 95% CI: 1.5-18.6). Newborns with PAS were also at higher risk of delivery complications, such as emergency cesarean section (OR: 6.8; 95% CI: 2.7-16.6), 5-minute Apgar <7 (OR: 23.6; 95% CI: 4.1-237), and resuscitation at birth (OR: 4.5; 95% CI: 1.6 -12.3).Conclusions. Preeclampsia and intrauterine growth restriction (IUGR) may be independent risk factors for perinatal stroke resulting in motor impairment. Large multicenter studies that include all children with perinatal stroke are needed to determine further the risk factors and outcome of perinatal stroke. Pediatrics 2004;114:612-619; perinatal stroke, epidemiology, neonate, infarction, cerebral palsy.

Incidence and Outcomes of Symptomatic Neonatal Arterial Ischemic Stroke

“…When it occurs during the perinatal period, arterial ischemic stroke is associated with considerable lifetime burden such as cerebral palsy (CP), cognitive impairment, and epilepsy. [1][2][3][4][5][6][7] Various terms have been used to describe arterial ischemic stroke during the perinatal period. Because of a lack of consistency among studies, its terms were defined in a workshop of the National Institute of Child Health and Human Development and the National Institute of Neurologic Disorders and Stroke.…”

“…Hospital-and population-based studies in North America and Europe have provided epidemiologic data suggesting that the incidence of ischemic perinatal stroke is between 5 and 43 per 100 000 live births. 2,[10][11][12][13][14][15][16][17][18] Studies have shown that about half of patients become symptomatic during the neonatal period. 14 A summary of epidemiologic studies on NAIS and PPIS is presented in Table 1.…”

Perinatal stroke – risk factors and management

“…low apgar scores or the presence of seizures and, particularly where data is based on the presence of relatively subtle findings, it may be difficult to conclude whether these abnormalities are causal or have occurred as a consequence of an underlying cerebral abnormality. This is highlighted in the case-control study where, although there was an increased incidence of non-specific perinatal abnormalities in the affected group, there was no significant difference between cases and controls in those diagnosed with significant birth asphyxia (Wu et al, 2004). Similarly, documented no cases with evidence of severe birth asphyxia in a series of 24-term infants with stroke, however, 14/24 had abnormal perinatal findings including abnormal CTG recordings and 11/24 had meconium-stained liquor.…”

“…On multivariate analysis, antenatal risk factors significantly associated with stroke were pre-eclampsia [odds ratio (OR): 3AE6; 95% confidence interval (CI): 1AE1-11AE4] and intrauterine growth retardation (IUGR) (OR: 5AE3; 95% CI: 1AE5-18AE6). Other significantly associated perinatal factors were emergency Caesarean section, 5-min apgar scores <7, and resuscitation at birth (Wu et al, 2004).…”

“…In a second retrospective case-control study, Wu et al (2004) reported data from a cohort of singleton term, or nearterm infants, with focal motor impairment. Thirty-eight cases were identified, 26 of whom presented at more than 3 months of age.…”