Clinical Pediatrics

Biography

Biography: Fazal-e-Rabi Subhani

Abstract

Introduction:

Perinatal stroke refers to an acute neurological syndrome with chronic sequelae that develops between 20 weeks gestation & 28 days post-partum caused by cerebral injury of vascular origin (arterial thromboembolism, cerebral sinovenous thrombosis [CSVT], or primary intracranial haemorrhage [ICH]). Wide variations in morbidity & mortality rates are seen following perinatal stroke depending upon the location & extent of brain injury. Chronic disabilities may include cerebral palsy, epilepsy, cognitive impairment, behavioural & mood disturbances, visual problems & language issues.

Method:

A comprehensive search of PubMed & EMBASE from January 2000 to October 2019 was made using 3 search items: perinatal stroke, antithrombotic therapy in neonates & children, & stroke rehabilitation. The search items were combined using the Boolean operator. A further search was made of the society guidelines of American Heart Association/American Stroke Association, American College of Chest Physicians, Canadian Stroke Association, Cochrane library, & ClinicalTrials.gov with no language restriction.

Results:

The mainstay of treatment in perinatal stroke cases is supportive care aimed at preventing further cerebral injury by ensuring adequate oxygenation and correction of dehydration, electrolytes imbalances, metabolic disturbances, hypoglycaemia, hypocalcaemia, & anaemia. Antibiotics are given if infection is suspected. Anticonvulsants are given if seizures are seen or suspected (prolonged video-electroencephalogram monitoring may be necessary as clinical identification of seizures is unreliable in neonates). Unlike adults, most thromboembolic perinatal strokes do not recur or progress. Antiplatelet therapy, anticoagulant therapy, thrombolysis & mechanical thrombectomy (the usual treatment options in adults) are therefore not indicated in significant majority of perinatal stroke patients. Rare indications of antithrombotic therapy include underlying thrombophilia, complex congenital heart disease (NOT including patent foramen ovale), & atrial fibrillation. Antithrombotic treatment options include aspirin, unfractionated heparin (UH) & low molecular weight heparin (LMWH). CSVT cases require treatment with UF or LMWH even when significant secondary haemorrhage has developed. ICH cases require vitamin-K (in all), correction of severe thrombocytopenia (if present) & replacement of clotting factors (if any deficiencies are found). Those who develop hydrocephalus are initially treated with ventricular drainage, followed by ventriculoperitoneal shunting if hydrocephalus persists. Other interventions beyond the neonatal period may include surgery for drugs-resistant epilepsy & embolization of arteriovenous malformations.

Conclusion:

Long-term neuro-developmental outcomes are normal in only 19-41% of thromboembolic perinatal stroke cases. Frank hemiparesis and mild neuromotor dysfunction are respectively seen in approximately 25-30% & 30% cases. Perinatal ischaemic stroke is the commonest known cause of cerebral palsy accounting for roughly 30% of hemiplegic cerebral palsy cases amongst babies born at term. Survivors of perinatal ischaemic stroke are known to exhibit below-average IQ scores (mean 87 versus mean 100, in normal subjects). The estimated prevalence of epilepsy following perinatal ischaemic stroke is 10-40% during acute phase & 19-67% later in life. Although 93-97% of newborns with CSVT survive the acute phase, in one study, the mortality rate was 19% when followed-up at a mean age of 19 months. Prognosis in ICH cases is even worse with multiple studies showing mortality & morbidity rates ranging between 4-15% & 44-77% respectively.