Dr Arameh Aghababaie, Dr Hesham El Sayed

Did you think you left strokes safely behind as you entered paediatric training? Unfortunately they don’t only affect adults – in fact, strokes can also occur in children and even newborn babies.

Here we are going to talk about perinatal strokes – they are rare BUT it is crucial not to miss the diagnosis or opportunity to intervene.

What is a perinatal stroke?

Similar to adults, perinatal strokes can be ischaemic or haemorrhagic and may be arterial or venous. To be defined as a perinatal stroke, the injury occurs between 20 weeks in-utero, up to 28 days of life. Although they are rare, perinatal strokes are the most common type of paediatric stroke.

Types of perinatal stroke

  • Arterial ischaemic stroke
  • Haemorrhagic stroke
  • Cerebral sinovenous thrombosis
  • Periventricular venous infarction

What causes a perinatal stroke?

It’s difficult to ascertain what causes perinatal strokes, and sadly they usually cannot be prevented, and there is nothing that the mother could have done differently – it is important for us as healthcare professionals to make this clear to the parents.

Perinatal strokes are often caused by the following neonatal risk factors:

  • Blood clots – formed in the placenta and entering foetal circulation and blocking cerebral vessels
  • Bacterial meningitis – leading to cerebral vessel inflammation
  • Congenital heart disease – blood clots can migrate via septal defects to cerebral vessels
  • Dehydration – newborns have a large surface-area to volume ratio and therefore lose heat very quickly. This can also lead to blood clot formation
  • Polycythaemia – same as in dehydration, thicker blood is more prone to clot formation
  • Birth trauma or HIE – any acute perinatal stress can cause a haemorrhagic stroke
  • Metabolic disorders such as glutaric acid-1 deficiency
  • Clotting disorders – clotting derangements can make the cerebral vessels more prone to bleeding or clot formations (depending on the type of clotting disorder)

There are some links to some maternal risk factors, such as pre-eclampsia, diabetes, placental abruption, chorioamnionitis, prolonged rupture of membranes, and smoking or cocaine abuse. But this is slightly controversial and not completely proven.

What are the symptoms and signs?

Signs are commonly recognised in the first few hours or days of life, however they can also be recognised later in childhood.

Early signs in the neonatal period will often be seizures, which can be subtle or very apparent, such as abnormal movements, gazing without blinking, apnoeas, bradycardias, and desaturations.

Late signs in childhood can be early hand preference, reduced power or sensation, poor coordination, speech delay, and seizures.

How is a perinatal stroke diagnosed?

Initial diagnosis of a perinatal stroke can be from cranial ultrasound (as that is what we can usually get our hands on ASAP without having to plead with radiologists for CTs/MRIs in the underground chambers of the hospital!). However, ultimately, we would need a CT and MRI. This is because a CT is more sensitive at detecting bleeds than the good ol’ cranial ultrasound, but the MRI helps discern what type of perinatal stroke it is and it may be possible to estimate the age of the bleed. You should then give a heads up to your local neurological/neurosurgical centre! They may ask for an MRA or MRV.

Once you’ve diagnosed a perinatal stroke, you need to do a panel of investigations to figure out the likely cause. The investigations will usually include:

Baby undergoing CFM – image from anserstudy.com/information-for-parents/tests-to-detect-seizures/
  • Full blood count, clotting profile, urea and electrolytes, bone profile, and liver function tests
  • Full septic screen, including a lumbar puncture if sepsis is suspected
  • Cerebral Function Monitoring (CFM) and later a formal EEG if there is any abnormality on CFM
  • Echocardiogram – to assess for any congenital cardiac disease

How are perinatal strokes managed?

Once the following investigations have been performed above, the acute management is as follows:

  • IV fluids! Always! Keep your baby hydrated
  • Broad spectrum IV antibiotics (in case the cause is meningitis)
  • If seizures are confirmed clinically or electrically via Cerebral Function Monitoring (CFM) then load the baby on phenobarbitone – and start a maintenance dose as prophylaxis
  • Blood transfusion might be needed if the haemoglobin has dropped as a result of the bleed
  • Supplement oxygen if required – if the baby is clinically unstable, you should consider intubation to secure the airway
  • Therapeutic hypothermia has been suggested as a possible intervention to protect the brain during this acute insult, however it has not been proven.

To manage the bleed itself, you should urgently contact your local neurosurgical centre as they may want to intervene surgically if it is a haemorrhagic stroke. If it’s an ischaemic stroke they may also suggest anticoagulants. You also may wish to speak to the local neurology team if the baby begins to have persistent seizures that are difficult to control.

Long-term, these babies need neurodevelopmental follow-up so that they can be continually assessed throughout childhood. They are at high risk of developing cerebral palsy, or epilepsy, or both.

Top Tips

If you notice a baby having any abnormal movements, gazing without blinking, or prolonged apnoeas, bradycardias, or desaturations, think seizures. Stabilise the baby then get cranial imaging ASAP to make sure you don’t miss a bleed!

Summary

Perinatal strokes can feel scary when you’re faced with them, so you need to take a thorough and systematic approach so that any urgent interventions can take place without delay.

Unfortunately, a perinatal stroke often leads to poor neurological outcomes – the neurodevelopmental team will need to be closely involved in ongoing care.

Key learning points

  • Perinatal strokes are rare overall, but are the most common type of paediatric stroke
  • They will often present as seizures in neonatal period, and more extensive neurological signs in later childhood
  • Initial investigations will include bloods, CFM, and a cranial ultrasound
  • Acute management involves IV fluids, full septic screen and IV antibiotics, and phenobarbitone if clinical or electrical seizures are confirmed

Dr Arameh Aghababaie, NICU ST2, supervised by Dr Hesham El Sayed, Consultant Neonatologist, Newham University Hospital

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