Original article
Obstetrical and neonatal characteristics vary with birthweight in a cohort of 100 term newborns with symptomatic arterial ischemic stroke

https://doi.org/10.1016/j.ejpn.2009.05.004Get rights and content

Abstract

Objectives

Many questions remain regarding the mechanism of perinatal stroke.

Methods

In a series of 100 prospectively enrolled term neonates with symptomatic arterial ischemic stroke, we explored family antecedents, pregnancy and delivery conditions and clinical presenting features and distinguished features of the 50 larger infants with the remainder. Cardiac and cervical arterial imaging were performed in 70 and 51 cases.

Results

Previous fetal loss, first pregnancy, primiparity, twin-gestation, cesarean and traumatic delivery, neonatal distress, male sex and premature rupture of membranes were statistically more common than in the general population. Normal pregnancy proportion and mean birthweight were in the normal range, arguing against a vasculo-placental origin in the majority. Furthermore, there was an excess of large babies. The larger infants were more subject to suffer from acute perinatal events, with a trend for an excess of neonatal distress (p = 0.065) and for more severe presenting features (p = 0.027), while the lighter were more likely to have experienced longstanding obstetrical risk factors such as complicated pregnancy (p = 0.047) and tobacco exposure (p = 0.028). Cervical MR angiography showed an internal carotid occlusion in two babies, whereas echo-Doppler was always normal; in one case the two methods were discordant. Echocardiography was non-informative.

Interpretation

The data from this prospective cohort of neonates with stroke confirm that many obstetrical and perinatal factors are risk determinants. They also suggest that birthweight and gender may be biomarkers of two populations of neonates with different pathological mechanisms. MR angiography appears more sensitive than echo-Doppler for the exploration of the neonatal cervical vasculature.

Introduction

Perinatal arterial ischemic stroke occurs at a frequency of 1/1600 to 1/5000 live births.1, 2 About half the children arouse no concern in the neonatal period, while the remainder present with early symptoms, characteristically recurrent focal seizures in the first 3 days of life. The diagnosis is easily confirmed by neuro-imaging.3 Even if this pathology is well-recognized, many questions remain regarding the causes and risk factors for perinatal stroke and predictors of outcome.3, 4, 5 In the absence of a known pathophysiological mechanism, only supportive care is provided and there is no evidence base for preventive strategies.

To address these issues, and in line with the conclusions of the international workshop organized on this topic in August 2006,5 a systematic assessment of family antecedents, pregnancy and delivery conditions and clinical presenting features was studied in a prospective database of term newborns with symptomatic arterial ischemic stroke.

Section snippets

Patients and methods

The original idea of the study came from the Société Française de Neurologie Pédiatrique. The chosen experimental plan was a multicenter cohort study and all authors participated to its conception and realization. After that, each contributor was individually contacted and informed about the protocol by the principal or the regional investigators. Those who agreed were designed as local investigatorsj

General information on the cases

112 newborns were reported. Thirty-two of the 39 centers (representing 89% of neonates) declared having reported all the babies they had consecutively seen. After reviewing the clinical and imaging data, 100 (62 boys and 38 girls) fulfilled all the inclusion and exclusion criteria. The reasons for a posteriori exclusion were: brain imaging not suggestive of perinatal arterial infarction (six children), infarction of four arterial territories (one child) and insufficient clinical or imaging data

Discussion

We report the family, obstetric and neonatal characteristics of 100 neonates who sustained an arterial ischemic stroke. The main objective of this multicenter prospective study was to examine the risk factors for perinatal stroke. Some were previously established: family thrombosis history, previous fetal loss, twin-gestation, infection, male sex, birth asphyxia and need for caesarian section.1, 9, 10, 11, 12, 13 On the other hand, we did not find other classical risk factors such as

Acknowledgments

We gratefully acknowledge all babies, parents and doctors who participated. We would like to thank Dr. Fenella Kirkham as well for discussion.

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      Family 8) The obstetrical and neonatal characteristics of newborns treated for a NAIS in our institution are comparable to those of other studies [15,16]. We observed, however, a higher reported incidence: around 1 in 4250 births, as opposed to commonly reported rates of 1 in 6000 to 1 in 8000 births in the literature, which is often population-based rather than hospital-based [1,17].

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