Introduction:
A stroke, also called a brain attack, occurs due to blockage of the blood supply to the brain or bursting of a blood vessel in the brain. The neonatal period is between the middle of pregnancy and the first few weeks following birth. A stroke in a fetus from the middle of pregnancy or in a newborn up to a few weeks after birth (up to 28 days after birth) is called a perinatal stroke. Studies show that perinatal stroke is reported at 1 per 1600 to 5000 births. Perinatal stroke is one of the commonest causes of cerebral palsy and often results in long-term neurological complications in the affected.
What Are the Different Types of Perinatal Stroke?
Based on the occurrence or onset of symptoms and based on how the brain’s blood vessels are affected, perinatal strokes are divided into the following types:
Cerebral Sinovenous Thrombosis (CSVT):
In cerebral sinovenous thrombosis (CSVT), blood clot formation occurs in the brain's veins or sinuses (channels or pathways that drain venous blood). CSVT may affect superficial and deeper veins and block blood drainage from the brain, resulting in swelling and stroke.
Perinatal Arterial Ischemic Stroke (PAIS):
Perinatal arterial ischemic stroke (PAIS) occurs due to blockage of the artery supplying the brain. Brain damage occurs as blood flow to the brain is restricted (ischemia). It is the most common type of perinatal stroke.
Periventricular Venous Infarction (PVI):
PVI is a unique type of perinatal stroke. This condition occurs due to the breakage of blood vessels in the brain's white matter, which damages the motor pathways resulting in cerebral palsy.
Hemorrhagic Stroke:
Hemorrhagic Stroke occurs due to rupture of blood vessels resulting in bleeding (hemorrhage).
What Are the Causes and Risk Factors of Perinatal Stroke?
There is nothing one can do to prevent perinatal stroke.
There are different causes for the condition which vary depending on the type of stroke:
Causes of PAIS (Perinatal Arterial Ischemic Stroke)
The causes of PAIS include the following:
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Severe bacterial infections like bacterial meningitis result in inflammation of arteries.
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Blood clots in the placenta may enter the fetal circulation, reaches the brain, and blocks blood vessels.
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Congenital heart disorders may increase the risk of stroke.
Causes of Cerebral Sinovenous Thrombosis (CSVT)
The causes of CSVT include the following:
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Infections like bacterial meningitis may lead to CSVT.
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Dehydration due to poor feeding.
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Blood clotting disorders.
Causes of Periventricular Venous Infarction (PVI)
The causes of PVI are unknown.
Causes of Hemorrhagic Stroke:
The causes of Hemorrhagic Stroke include the following:
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Blood clotting disorders.
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Rupture of abnormal blood vessels.
What Are the Signs and Symptoms?
Sometimes perinatal stroke results in signs and symptoms in the first few hours or days of life. This condition is acute symptomatic neonatal stroke, and most seizures are the commonest early signs. In some other cases, the stroke must have happened in the neonatal period, but the signs are not recognized earlier; the signs may appear delayed or maybe after six months of birth. This condition is referred to as presumed perinatal stroke. This is mostly seen in the case of Periventricular Venous Infarction. The affected infants also present with difficulties in feeding, breathing issues, and sleep apnea (stoppage of breathing for a short interval during sleeping).
What Diagnostic Tests Are Done?
If a perinatal stroke is suspected in a newborn, the physician enquires the following:
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Mother’s health during pregnancy.
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Familial medical history.
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Other underlying medical conditions.
The diagnostic tests carried out include the following:
Brain Imaging:
Perinatal stroke is diagnosed with the help of brain imaging. Ultrasound scanning and CT (computed tomography) are used for detecting acute stroke in neonates. MRI (magnetic resonance imaging) is the most effective in detecting perinatal stroke type. MRA (MR Angiography) is used for producing images of arteries, and MRV (MR Venography) is used for getting images of veins.
Blood tests:
Blood tests are done to detect clotting disorders and infections that may have led to stroke.
Electrocardiogram (ECG):
ECG is used for measuring the electrical activity of the heart and the heart rhythm.
Echocardiogram (echo):
An echocardiogram helps detect heart issues like improper functioning, clot formation, etc. which may have led to a stroke.
Electroencephalogram (EEG):
EEG is used for detecting the brain's electrical activity and helps detect seizures.
How Is the Condition Treated?
The treatment of perinatal stroke mainly focuses on protecting the damaged brain.
The following steps are taken for neuroprotection:
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Recognition and management of seizures.
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Management of infections.
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Maintaining normal body temperature.
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Correction of dehydration.
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Maintaining normal blood glucose levels.
Blood thinners (anticoagulants) are used for treating heart diseases and blood clotting disorders which lead to stroke, and antibiotics are used for treating infections. Anticoagulants are also used to treat cerebral sinovenous thrombosis as it helps in dissolving the clot. Counseling and education are also important as it helps the mother to overcome mental trauma and understand that stroke is not preventable.
What Are the Possible Complications?
The complications of perinatal stroke include the following:
Hemiparesis:
It is also called unilateral cerebral palsy, leading to weakness in one side of the body. Physiotherapy and occupational therapy are useful in such cases.
Recurrent Seizures:
Recurrent episodes of seizures (epilepsy) can occur, requiring medication management.
Language Disorders:
Language disorders (including difficulty understanding and speaking the language) are not very common after a perinatal stroke. But if present, a speech pathologist should be consulted.
Vision Problems:
Vision problems may occur as a result of perinatal stroke.
Cognition Problems:
Cognition and learning problems may occur in some children following perinatal stroke.
Mental Health:
Perinatal stroke greatly affects the mental health of the family member affected. Peer support and family-centered care are required in such cases.
Conclusion:
Perinatal stroke is a stroke that takes place during the neonatal period, which is the period starting from the middle of pregnancy to twenty-eight days after birth. Dehydration due to poor feeding, infections in the mother or fetus, complicated delivery, clotting disorders, cardiac problems, and placental disorders are said to be the possible risk factors. Treatment involves neuroprotective measures and treatment of the cause. The recurrence rate is very low, and preventive strategies are rarely needed.
