Presumed pre‐ or perinatal arterial ischemic stroke: Risk factors and outcomes

Abstract

A subgroup of children with arterial ischemic stroke in the pre- or perinatal period present with delayed diagnosis. We identified 22 children who met the following criteria: (1) normal neonatal neurological history, (2) hemiparesis and/or seizures first recognized after two months of age, and (3) computed tomography or magnetic resonance imaging showing remote cerebral infarct. Laboratory evaluations included protein C, protein S, antithrombin, activated protein C resistance screen (APCR), Factor V Leiden (FVL), prothrombin gene defect, methylene tetrahydrofolate reductase variant (MTHFR), anticardiolipin antibody (ACLA), and lupus anticoagulant. Not all children received all tests. Age at last visit ranged from 8 months to 16.5 years (median 4 years). Twelve were boys. Fourteen had left hemisphere infarcts. Median age at presentation was 6 months. Eighteen had gestational complications. Fourteen children had at least transient coagulation abnormalities (ACLA = 11, ACLA + APCR = 1, APCR = 2 with FVL + MTHFR = 1); six of these children had family histories suggestive of thrombosis. Cardiac echocardiogram was unremarkable in the 15 tested. Outcomes included persistent hemiparesis in 22; speech, behavior, or learning problems in 12; and persistent seizures in five, with no evidence of further stroke in any patient. The persistence and importance of coagulation abnormalities in this group need further study.

Association of Cerebral Palsy With Other Disabilities in Children With Perinatal Arterial Ischemic Stroke

“…Further ICD-9 searches covering additional years were not performed after we discovered the limitations of these searches; the methodology and rationale behind these searches has been previously described [2]. Inclusion criteria for this study were: 36 weeks or greater gestational age at birth, age of at least 12 months at last neurology clinic visit, presentation with neurological symptoms in the neonatal period with cranial imaging confirming arterial territory ischemic infarction ("neonatal presentation"), or presentation with neurological symptoms past the neonatal period with cranial imaging suggesting remote infarct and no events or risk factors past the perinatal period that may have precipitated infarction, and at least 6 months of neurological follow up ("delayed presentation"; known in previous publications as "presumed perinatal stroke" [3]). Children with radiographic evidence of generalized hypoxic ischemic injury or dysmorphic features that suggested a genetic syndrome were excluded because hypoxic-ischemic injury and genetic syndromes can cause cerebral palsy in the absence of focal arterial ischemic stroke.…”

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

“…The delayed presentation group consisted of infants and children who had been considered neurologically normal before 2 months of age and whose PAS was diagnosed after 2 months of age with an old arterial distribution infarct. 14 Of note, all infants who had a diagnosis of PAS became symptomatic either before 2 weeks of life or after 3 months of age.…”

“…Newborns with arterial infarction either may present acutely during the neonatal period with neurologic symptoms such as seizures 7,13 or may be clinically asymptomatic until several months of age, when pathologic handedness or seizures are first noted. 14 How the acute and delayed presentation groups differ in timing of injury, underlying pathogenesis, and neurologic outcome is unknown.…”

“…1,9,22,29 The majority of reports include only newborns who present acutely with stroke, whereas children with delayed presentation of PAS have been less studied. 14 The clinical diagnosis of "birth asphyxia" has been considered a risk factor for PAS 6 but may in fact refer to clinical signs that are consequences of cerebral infarction and thus may be unrelated to the underlying causal mechanism.…”

Therapeutic approaches and advances in pediatric stroke

“…3,6,8 In older infants and children, risk factors are identified in 70 to 90% of children. 3,9,10,11 About half of children have no prior significant medical history.…”