Perinatal cortical infarction within middle cerebral artery trunks

Abstract

Aim-To define neonatal pial middle cerebral artery infarction. Methods-A retrospective study was made of neonates in whom focal arterial infarction had been detected ultrasonographically. A detailed study was made of cortical middle cerebral artery infarction subtypes. Results-Forty infarctions, with the exception of those in a posterior cerebral artery, were detected ultrasonographically over a period of 10 years. Most were confirmed by computed tomography or magnetic resonance imaging. Factor V Leiden heterozygosity was documented in three. The onset was probably antepartum in three, and associated with fetal distress before labour in one. There were 19 cases of cortical middle cerebral artery stroke. The truncal type (n=13) was more common than complete (n = 5) middle cerebral artery infarction. Of six infarcts in the anterior trunk, four were in term infants and five aVected the right hemisphere. Clinical seizures were part of the anterior truncal presentation in three. One of these infants, with involvement of the primary motor area, developed a severe motor hemisyndrome. The Bayley Mental Developmental Index was above 80 in all of three infants tested with anterior truncal infarction. Of seven patients with posterior truncal infarction, six were at or near term. Six of these lesions were left sided. Clinical seizures were observed in three. A mild motor hemisyndrome developed in at least three of these infants due to involvement of parieto-temporal nonprimary cortex. Conclusions-Inability to diVerentiate between truncal and complete middle cerebral artery stroke is one of the explanations for the reported diVerent outcomes. Severe motor hemisyndrome can be predicted from neonatal ultrasonography on the basis of primary motor cortex involvement. Clinical seizures were recognised in less than half of the patients with truncal infarction; left sided presentation was present in the posterior, but not the anterior truncal type of infarction. Asphyxia is a rare cause of focal arterial infarction.

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

“…7,10,[37][38][39] None of the case children in our cohort received a diagnosis of recognized risk factors, including cardiac abnormalities, polycythemia, and neonatal infection. 16,22,23,40 Preeclampsia was associated with a 3.6-fold increased risk of PAS. Previous investigators have suggested an association between preeclampsia and a variety of adverse pregnancy outcomes, including IUGR, neonatal encephalopathy, neonatal sinovenous thrombosis, and fetal death.…”

“…Previous population- 35,36 and hospital-based 13,22,24 estimates range from 18 to 93 per 100 000 live births. These figures underestimate the true prevalence of PAS, given that they do not include infants and children who present outside the newborn period.…”

“…Investigators have reported a number of obstetric and neonatal complications in the setting of perinatal stroke, including birth asphyxia, preeclampsia, chorioamnionitis, cardiac anomalies, polycythemia, and systemic infection, 6,7,9,10,[15][16][17][18][19][20][21][22][23] although controlled studies have failed to find a significant difference in the frequency of perinatal complications between infants with PAS and control subjects. 24 Recently, genetic thrombophilias have received increasing attention as potential risk factors.…”

“…Most describe only a small number of children 6,7,10,15,24,28 or lack an adequate comparison group to assess the significance of potential risk factors. 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.…”

Perinatal stroke – risk factors and management

“…In older studies the diagnosis of stroke was based on autopsy findings, but more recently this has been replaced by imaging. In these studies the incidence of perinatal stroke has been estimated at between 24AE7-35/10 5 live births or approximately 1/3000-1/4000 live births (Perlman et al, 1994;Estan & Hope, 1997;Govaert et al, 2000). The incidence of perinatal stroke in these studies is lower than in the Canadian stroke registry, which may reflect a number of factors.…”