Author: Adam Kirton, MD, University of Calgary/Alberta Children’s Hospital
Reviewed: April 2021 

SUMMARY

Sometimes, blood vessels in the brain get blocked or broken. Stroke is the resulting brain damage. Perinatal stroke is stroke in a fetus or newborn. It is a common cause of cerebral palsy and other disabilities. Diagnosis of this condition requires brain imaging.

There are different types of perinatal stroke. Each has different causes. However, many of these causes are only partially understood.

Most children who experience perinatal stroke have long-term neurological problems. They may require treatment for physical, developmental, and psychosocial complications.

Disorder Overview

DESCRIPTION AND DEFINITIONS 

All perinatal strokes are related to localized injuries in the brain’s blood vessels. They can occur any time during the neonatal period. The neonatal period lasts from the middle of pregnancy to the first month after birth. There are several specific perinatal stroke diseases. These are defined in two ways. The first is by how the brain’s blood vessels are affected. The second is by when the child first shows symptoms. 

Brain conditions unique to premature babies and not further discussed in this entry include: 

• Intraventricular Hemorrhage. Bleeding into cavities in the brain called ventricles. The blood vessels are fragile in preterm babies. 

• Hypoxic-ischemic Encephalopathy. Lack of blood flow and oxygen to the entire brain. 

SYMPTOMS AND PHYSICAL SIGNS 

Perinatal stroke usually presents in one of two ways. 

1. Signs may be recognized in the first hours or days of life. Seizures are the most common sign of perinatal stroke. However, a baby may also be lethargic or have breathing problems. AIS, CSVT and HS in neonates can all present this way. 

This is called an “acute symptomatic neonatal stroke.” Unlike older children and adults, most neonates do not show a sudden onset of symptoms.  

2. Signs may be recognized later in childhood. Sometimes, stroke occurs well before birth or does not result in seizures. In these cases, the first sign of stroke may be early hand preference or another motor–development asymmetry. Parents often notice these signs when a baby is about 6 months old. PVI always presents this way. AIS often does, too.

In these cases, the exact timing of when the stroke happened may be difficult to estimate. For this reason, this presentation is termed a “presumed prenatal stroke.”  

RISK FACTORS AND CAUSATION 

It is difficult to prove a definite cause for most perinatal stroke. Perinatal strokes cannot be prevented. There is nothing a mother can do to prevent perinatal stroke in a child. It is not the mother’s fault. The most likely cause depends on the type of perinatal stroke.

DIAGNOSIS: BRAIN IMAGING

Diagnosing perinatal stroke requires brain imaging. Ultrasounds or computer assisted tomography scans (CT scans) can detect acute stroke in newborns. However, magnetic resonance imaging (MRI) is the best test. MRIs can confirm all perinatal stroke types.  

MRI technology can also provide helpful images of the arteries and veins. MR angiography (MRA) can produce images of arteries. MR venography (MRV) can produce images of veins. 

Figure. Neuroimaging in perinatal stroke.
(A) MRI shows a recent arterial stroke (bright area) in a newborn. (B) A picture of the veins shows blood clots in a newborn with CSVT. (C) MRI shows recent bleeding (black area) into the brain in a newborn. This represents hemorrhagic stroke.
Sometimes signs of stroke appear later in infancy. In these cases, MRIs can show older AIS (D) or the unique pattern of PVI (E).

LABORATORY TESTS 

Neuroimaging can confirm a stroke diagnosis. However, laboratory tests can help determine possible risk factors.

These tests can include:

• Echocardiogram (ECHO). ECHOs create an ultrasound picture of the heart.
• Electrocardiogram (ECG). ECGs trace the heart’s rhythm.
• Electroencephalogram (EEG). EEGs test brain activity. They may be useful in evaluating seizure-related complications of stroke.
• Blood clotting tests. These quick tests can exclude bleeding or clotting disorders.
• Lumbar punctures. Lumbar punctures test for infection or inflammation. They are also called “spinal taps.”

THERAPEUTIC INTERVENTIONS 

It is possible to open blocked blood vessels in adult stroke. This can be done with medications or procedures. However, there are no easy ways to open blocked blood vessels in perinatal stroke patients.

Instead, acute treatment of neonatal stroke focuses on protecting the freshly injured brain. Neuroprotection may include:

• recognizing and treating seizures
• avoiding increased body temperature
• treating infection
• optimizing brain blood flow with good blood pressure
• correcting dehydration
• maintaining normal blood sugar levels

Specific medicines may also be considered. These include:

• Antibiotics. Antibiotics are used in neonatal strokes related to infection.
• Blood thinners. Blood thinners are used for CSVT or strokes related to heart disease.

Educating and counseling parents immediately after diagnosis is very important. A mother cannot prevent perinatal strokes. This must be emphasized. Education and counseling can reduce misplaced feelings of guilt. They can help with mental health consequences.

OUTCOMES AND CHRONIC MANAGEMENT 

Outcomes from perinatal stroke vary. Many factors determine outcome. Yet only some of these factors are understood. It is challenging to accurately predict the outcome of perinatal stroke.

Potential complications of perinatal stroke (and how to manage them) include:

• Hemiparesis. Weakness on one side of the body is a common complication. Hemiparesis may also be known as hemiparetic or unilateral cerebral palsy. Pediatric occupational therapy and physical therapy during childhood development can help.
• Epilepsy. Recurrent seizures may occur during childhood. This is called epilepsy. Epilepsy can often be managed with medications.
• Cognition and learning. Some children may experience differences in cognition and learning due to perinatal stroke. A neuropsychologist may be able to help. Working with teachers and education experts can, too.
• Language disorders. Language disorders include difficulty speaking or understanding language. They are relatively uncommon after perinatal stroke. However, a speech-language pathologist can help.
• Vision. Difficulties with vision or eye movement may occur with perinatal stroke. However, these vision difficulties are not usually disabling.
• Family mental health. After perinatal stroke, families must be screened for depression, anxiety, and other mental health complications. Family-centered care and peer support may be beneficial.

STROKE PREVENTION 

Perinatal strokes have a very low risk of recurrence. Medication or other stroke prevention strategies are rarely required.

Research 

ClincalTrials.gov for Perinatal Stroke are clinical trials that are recruiting or will be recruiting. Updates are made daily, so you are encouraged to check back frequently.  

ClinicalTrials.gov is a database of privately and publicly funded clinical studies conducted around the world. This is a resource provided by the U.S. National Library of Medicine (NLM), which is an institute within the National Institutes of Health (NIH). Listing a study does not mean it has been evaluated by the U.S. Federal Government. Please read the NLM disclaimer for details.   

Before participating in a study, you are encouraged to talk to your health care provider and learn about the risks and potential benefits.  

The information in the CNF Child Neurology Disorder Directory is not intended to provide diagnosis, treatment, or medical advice and should not be considered a substitute for advice from a healthcare professional. Content provided is for informational purposes only.  CNF is not responsible for actions taken based on the information included on this webpage. Please consult with a physician or other healthcare professional regarding any medical or health related diagnosis or treatment options. 

Reviews and Guidelines:

Dunbar M, Kirton A. Perinatal stroke: Mechanisms, management, and outcomes of early cerebrovascular brain injury. The Lancet Child & Adolescent Health. 2018 Sep;2(9):666–76. http://doi.org/10.1016/S2352-4642(18)30173-1

Ferriero DM, Fullerton HJ, Bernard TJ, Billinghurst L, Daniels SR, DeBaun MR, et al. Management of stroke in neonates and children: A scientific statement from the American Heart Association/American Stroke Association. Stroke. 2019 Mar;50(3). http://doi.org/10.1161/STR.0000000000000183

Ichord R. Cerebral sinovenous thrombosis. Frontiers in Pediatrics. 2017;5. http://doi.org/10.3389/fped.2017.00163

Kirton A, deVeber G. Paediatric stroke: Pressing issues and promising directions. The Lancet Neurology. 2015 Jan;14(1):92–102. http://doi.org/10.1016/S1474-4422(14)70227-3

Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, et al. Antithrombotic therapy in neonates and children. Chest. 2012 Feb;141(2):e737S-e801S. http://doi.org/10.1378/chest.11-2308

Sinclair AJ, Fox CK, Ichord RN, Almond CS, Bernard TJ, Beslow LA, et al. Stroke in children with cardiac disease: Report from the international pediatric stroke study group symposium. Pediatric neurology. 2015 Jan;52(1):5–15. http://doi.org/10.1016/j.pediatrneurol.2014.09.016