Prognosis of Neonatal Arterial Ischemic Stroke.

Investigators from University Children's Hospitals in Bern, Zurich, Aarau, and multiple other centers in Switzerland evaluated prospectively the epidemiology, manifestations, and treatment of all full-term neonates with neonatal arterial ischemic stroke (NAIS) and born 2000-2010.

Investigators from University Children's Hospitals in Bern, Zurich, Aarau, and multiple other centers in Switzerland evaluated prospectively the epidemiology, manifestations, and treatment of all full-term neonates with neonatal arterial ischemic stroke (NAIS) and born 2000-2010. The NAIS incidence in Switzerland was 13 per 100,000 live births. Median age was 2.0 days (range 1-26 days); median birth weight 3380 g (range 2370-4520 g). Of 100 neonates (67 boys) with NAIS all but 3 (97%) presented with seizures, and 50 (52%) had seizures as the only presenting symptom. Increased or decreased tone abnormalities were present in 32% and movement abnormalities in 11%; 81% had unilateral (80% left-sided) infarcts and 19% had bilateral lesions. The anterior circulation only (internal carotid, anterior cerebral, and middle cerebral arteries) was affected in 89%. Risk factors for NAIS were maternal risk conditions (32%), birth complications (68%), and neonatal comorbidities (54%). Genetic testing abnormalities included factor V Leiden mutation in 5%, heterozygous prothrombin mutation in 11%, and heterozygous methylene tetrahydrofolate reductase mutation in 36%. Seventeen percent received antithrombotic and antiplatelet therapy without serious side effects. At aged 2 years follow-up, 39% were diagnosed with cerebral palsy, 7 (9%) were treated for epilepsy (4 had infantile spasms), and 31% had delayed motor development. Children with normal mental performance at 2 years after birth may develop deficits later in life. [1]

COMMENTARY. A comparison of the incidence of NAIS in this population-based, prospective study with that in 9 previously published studies, 5 of which were population-based and 4 were hospital-based [1], the incidence varied widely from a low of 5 per 100,000 live births (a population-based study) to a high of 43 per 100,000 (a hospital-based study). The greater susceptibility of boys to NAIS is unexplained; boys and men have a higher incidence of stroke through life, and elevated testosterone levels increase the risk of cerebral thromboembolism [2].

Neonatal seizures are most commonly the clinical finding that triggers assessment in neonates with stroke. In children with NAIS without early-onset seizures, perinatal stroke is recognized retrospectively, with emerging hemiparesis or late-onset seizures presenting >14 days after the stroke. Risk factors for perinatal stroke include hereditary or acquired thrombophilia and environmental factors [3].