For Crying Out Loud
Answer: B
This baby boy presents with a vague history that may cause consideration of an apparent life-threatening event (ALTE), and like most ALTE cases, appears normal in the ED.
With young infants who present with a vague or unclear history, at times a brief observation period can be helpful. In this case, the boy had a repeat episode consistent with a focal seizure. Seizure is the
presentation of 10% of cases of acute stroke in the perinatal period (B). Stroke is underdiagnosed in this age
range.
Pediatric stroke is receiving more attention in clinical and research arenas. Recent studies suggest that, like adults, ischemic stroke (A) is the most common type overall in children (approximately 80% of cases of childhood
stroke), with the remainder being cerebral venous sinus thrombosis and hemorrhagic stroke. These figures
do not include subarachnoid hemorrhage and intraventricular hemorrhage that are seen almost exclusively in premature babies. The majority of strokes in neonates however, occur in full-term infants (D) and – like children overall – are ischemic in etiology.
Stroke in older children is a longer, separate discussion – here we will focus on stroke in the perinatal period, which includes the first month of life.
Risk factors for perinatal (neonatal) stroke include cardiac disorders, coagulopathies, infection, trauma, drugs, maternal illness, placental abnormalities, and perinatal hypoxia/asphyxia. Some children do not present overtly in the acute period, but rather show early “handedness” – i.e. appearing to have a dominant hand before this is an appropriate developmental finding. These children, in fact, do not have a preference for a hand, but a deficit in the other.
Outcome in acute stroke in the perinatal period varies widely. In-hospital mortality for perinatal stroke has been estimated to be as high as 10% – compare this with the in-hospital mortality rate for ischemic stroke in US adults (4-5%) (C).
Supportive care is the cornerstone of treatment of ischemic stroke in the perinatal period. There is very little evidence available for the use of thrombolytics in children in general, and much less so in this population.
Although some children with known severe prothrombotic disorders or those with cardiac emboli may benefit from anticoagulation with heparin or LMWH, thrombolytic therapy is not recommended in neonates due to lack of information regarding safety and efficacy.
Bottom Line
● Neonates can present to the ED with acute stroke, possibly with seizure, focal deficits, or altered mental
status
● Absence of prematurity is not protective from stroke in neonates
● Supportive care is the mainstay of treatment in the acute setting
References
Ferriero D, Jones BV, Kirkham FJ et al for the Writing Group of the American Heart Association Stroke Council and the Council on Management of Stroke in Infants and Children. Stroke. 2008; 39:2644-2691
Hanchate AD, Schwamm LH, Huang W, Hylek EM. Comparison of ischemic stroke outcomes and patient and hospital characteristics by race/ethnicity and socioeconomic status. Stroke. 2013; 44(2):469-76.
Nelson KB, Lynch JK. Stroke in newborn infants. Lancet Neurol. 2004; 3:150-58.
Sehgal A. Perinatal stroke. Eur J Pediatr. 2012; 171:225-234.
This baby boy presents with a vague history that may cause consideration of an apparent life-threatening event (ALTE), and like most ALTE cases, appears normal in the ED.
With young infants who present with a vague or unclear history, at times a brief observation period can be helpful. In this case, the boy had a repeat episode consistent with a focal seizure. Seizure is the
presentation of 10% of cases of acute stroke in the perinatal period (B). Stroke is underdiagnosed in this age
range.
Pediatric stroke is receiving more attention in clinical and research arenas. Recent studies suggest that, like adults, ischemic stroke (A) is the most common type overall in children (approximately 80% of cases of childhood
stroke), with the remainder being cerebral venous sinus thrombosis and hemorrhagic stroke. These figures
do not include subarachnoid hemorrhage and intraventricular hemorrhage that are seen almost exclusively in premature babies. The majority of strokes in neonates however, occur in full-term infants (D) and – like children overall – are ischemic in etiology.
Stroke in older children is a longer, separate discussion – here we will focus on stroke in the perinatal period, which includes the first month of life.
Risk factors for perinatal (neonatal) stroke include cardiac disorders, coagulopathies, infection, trauma, drugs, maternal illness, placental abnormalities, and perinatal hypoxia/asphyxia. Some children do not present overtly in the acute period, but rather show early “handedness” – i.e. appearing to have a dominant hand before this is an appropriate developmental finding. These children, in fact, do not have a preference for a hand, but a deficit in the other.
Outcome in acute stroke in the perinatal period varies widely. In-hospital mortality for perinatal stroke has been estimated to be as high as 10% – compare this with the in-hospital mortality rate for ischemic stroke in US adults (4-5%) (C).
Supportive care is the cornerstone of treatment of ischemic stroke in the perinatal period. There is very little evidence available for the use of thrombolytics in children in general, and much less so in this population.
Although some children with known severe prothrombotic disorders or those with cardiac emboli may benefit from anticoagulation with heparin or LMWH, thrombolytic therapy is not recommended in neonates due to lack of information regarding safety and efficacy.
Bottom Line
● Neonates can present to the ED with acute stroke, possibly with seizure, focal deficits, or altered mental
status
● Absence of prematurity is not protective from stroke in neonates
● Supportive care is the mainstay of treatment in the acute setting
References
Ferriero D, Jones BV, Kirkham FJ et al for the Writing Group of the American Heart Association Stroke Council and the Council on Management of Stroke in Infants and Children. Stroke. 2008; 39:2644-2691
Hanchate AD, Schwamm LH, Huang W, Hylek EM. Comparison of ischemic stroke outcomes and patient and hospital characteristics by race/ethnicity and socioeconomic status. Stroke. 2013; 44(2):469-76.
Nelson KB, Lynch JK. Stroke in newborn infants. Lancet Neurol. 2004; 3:150-58.
Sehgal A. Perinatal stroke. Eur J Pediatr. 2012; 171:225-234.