Word: Neonatal Stroke: Guideline



Site ApplicabilityThis document is applicable for the management of suspected or confirmed stroke in the Neonatal ProgramPurposePerinatal stroke is a common cause of acute neonatal encephalopathy, and may manifest as seizures, altered mental status, and sensorimotor deficits. It may cause chronic neurologic disability. (Ichord, 2015) This guideline provides an approach for the diagnosis and management of suspected neonatal stroke in the NICU. This will reduce provider variability and unwarranted testingGuidelineBackgroundPerinatal stroke may be defined as an acute neurologic syndrome sometimes associated with chronic sequelae due to cerebral injury of vascular origin occurring between 20 weeks gestation and 28 days postnatal life. These disorders include focal cerebral injury due to arterial ischemic stroke, cerebral venous thrombosis, and primary intracerebral hemorrhage. Risk factors for perinatal acute ischemic stroke include maternal, placental, and fetal / neonatal factors. Some maternal factors include pre-eclampsia, diabetes, drug use, and Antiphospholipid Antibody Syndrome. Neonatal risk factors include heart disease, catheterization, infection, dehydration, and delivery complications. (Grabowski, 2007). In most cases, the etiology of stroke remains unknown. There is evidence to suggest that inherited thrombophilias increase the risk of first childhood stroke (Kenet et al, 2010); however the data in perinatal stroke is very limited. In addition, recurrence risk in neonatal stroke is very low (Kirton & deVeber, 2015), and it is unknown whether thrombophilic conditions significantly affect recurrence risk. The low recurrence rate suggests that thrombophilias are only one of many factors possibly contributing to perinatal stroke (O’Brien, 2015). Thus, the role of thrombophilia testing in this population is not fully defined, and does not guide acute management decisions (Raffini, 2008). A recent prospective Canadian study addressing this question suggests minimal association between perinatal stroke and thrombophilia, and argues testing is not indicated (Curtis et al, 2017). Our approach is therefore not to routinely test for thrombophilias in the setting of perinatal stroke, but testing may be considered in individual cases.It is suggested that perinatal stroke occurs about once in 2800 births, however, this incidence is likely to be an underestimate because it is based largely on retrospective cohort studies relying in part on administrative database search strategies, and does not include all cases of cerebral sinovenous thrombosis. (Ichord, 2015)The major clinical-anatomic subtypes comprise the following (Raju et al, 2007, Govaert et al part I&II, 2009):Arterial ischemic strokeCharacterized by an infarct that conforms to the occlusion of an arterial territory often with complex and multifactorial pathogenesis. Most cases are probably due to thromboembolism from the fetal-placental circulation. Seizures are a common presenting symptom of perinatal arterial ischemic stroke. Many infants with unilateral lesions have a hemiparesis, although this may be difficult to detect. Infants with bilateral lesions typically have a mild quadriparesis. The diagnosis of ischemic stroke is confirmed by cranial CT or MRI. Of these, MRI best defines the extent and vascular territory of the infarct, the number of lesions, and the presence or absence of hemorrhage. The site of the occluded vessel is inferred from the location and extent of the infarct in most cases. Neurovascular imaging is useful for the detection of congenital vascular anomalies and vascular occlusion (or lack thereof). In addition, neurovascular imaging can clarify the territory of the infarct when its radiologic appearance is ambiguous regarding arterial versus venous origin. (Ichord, 2015)Hemorrhagic strokeHemorrhagic stroke involves rupture of weakened blood vessel and includes parenchymal, subarachnoid, or intraventricular hemorrhage. Hemorrhagic stroke refers to acute neurologic syndromes resulting from intracranial hemorrhage of nontraumatic origin. Primary intraparenchymal hemorrhage can result from vascular anomalies (vascular malformations, and aneurysms) or from bleeding diatheses. In addition, hemorrhagic conversion can occur with ischemic infarction of arterial or venous origin. (Ichord, 2015)Cerebral sinovenous thrombosis (CSVT)Clot formation in the venous sinus which may or may not cause infarction and hemorrhagic infarction is often associated with hemorrhage. Seizures and altered consciousness are common manifestations of CSVT. Magnetic resonance or CT imaging confirms the presence and location of CSVT and associated infarction?and/or?hemorrhage. MRI, especially when combined with magnetic resonance venography (MRV), has greater sensitivity and specificity to detect sinovenous thrombosis than CT or Doppler ultrasonography. Most newborns with CSVT survive the acute period. However, the neurologic outcome in survivors is variable. (Ichord, 2015) Cerebral sinovenous thrombosis (CSVT) can cause venous infarction.Periventricular venous infarctionPeriventricular venous infarction is a focal acute or chronic infarction in the periventricular white matter, not conforming to an arterial territory. It is particularly common in premature infants. Clinical features of primary intraparenchymal hemorrhage typically include encephalopathy and seizures, and sometimes focal weakness. (Ichord, 2015)Clinical Signs Indicating Stroke:Onset of symptoms usually at 24 to 48 hours of birth, with:Focal seizures Unexplained apnea Encephalopathy not explained by a perinatal history of asphyxiaClinical Care for Suspected Stroke:Transfer to BCWH for interdisciplinary managementInitiate NICU - Suspected Neonatal Stroke – Admission Order SetIf unsure of Hypoxic Ischemic Encephalopathy (HIE) use HIE Order SetProvider (NP/MD) to review history and complete a physical examinationParticularly review family history of thrombosis/bleeding, autoimmune conditionsReview maternal history and consider testing for antiphospholipid antibodies, anticardiolipin antibodies, and lupus anticoagulant if indicated, in discussion with the mother’s health care providerAcute management of persistent seizures should be treated as with any neonateDocument ACoRN Primary Survey in progress notes Document Encephalopathy Score in progress notes Clinical Care for Confirmed Stroke:Initiate NICU - Confirmed Neonatal Stroke Order SetEchocardiogram in Consultation with Cardiology)Although rare, cardiac defects can have potentially detrimental outcomes if undiagnosed. The presence of a large patent foramen ovale (PFO) or atrial septal defect (ASD) provides a route for thrombus from the right atrium or venous circulation to embolize to the brain. Many term newborns have a clinically insignificant PFO that ultimately closes on its own, and thus should not be treated as a true cardiac defect. (Armstrong-Wells & Ferrierio, 2014)Local data from 2011-2017 at BC C&W regarding neonates with stroke did not identify any clinical related findings on echocardiogram Anticoagulation in Consultation with Hematology:Coagulation studies are not recommended in most cases of neonatal strokeAnticoagulation is rarely indicated, and usually contraindicated due to potential for a hemorrhagic transformation of an infarct. This is especially true if there is an infarct greater than 50% of the MCA territory or a large cerebellar infarct. Anticoagulation is recommended for neonates with CSVT without significant intracranial hemorrhage, using unfractionated or LMWH. For neonates with CSVT with significant hemorrhage options include consideration of anticoagulation or supportive care with radiologic monitoring of the thrombosis at 5 to 7 days, with anticoagulation if thrombus extension is noted, in consideration of risk/benefit assessment. (Armstrong-Wells & Ferrierio, 2014, Monagle et al, 2012)Anticoagulation with UFH or LMWH is recommended for neonates with acute ischemic stroke and documented cardioembolic source with unrepaired cardiac defect (Armstrong-Wells & Ferrierio, 2014, Monagle et al, 2012)Anticoagulation or aspirin therapy is recommended for neonates with recurrent IAS (Armstrong-Wells & Ferrierio, 2014, Monagle et al, 2012)DocumentationDocument ACoRN primary survey and Encephalopathy score in progress notesReferencesArmstrong-Wells, J., & Ferriero, D. M. (2014). Diagnosis and acute management of perinatal arterial ischemic stroke. Neurology: Clinical Practice, 4(5), 378–385.Curtis, C, Mineyko, A, Massicotte, P, Leaker, M, Jiang, XY, Floer, A, Kurtin, A (2017). Thrombophilia risk is not increased in children after perinatal stroke. Blood 129 (20): 2793 - aert P, Ramenghi L, Taal R, De Vries, L., DeVeber, G.(2009). Diagnosis of perinatal stroke I: definitions, differential diagnosis and registration. Acta Paediatra; 98:1556. Govaert P, Ramenghi L, Taal R, De Vries, L., DeVeber, G.(2009). Diagnosis of perinatal stroke II: mechanisms and clinical phenotypes. Acta Paediatra ; 98:1720.Grabowski, E, Buonanno, F, Krishnamoorthy, K (2007). Prothrombotic risk factors in the evaluation and management of perinatal stroke. Seminars in Perinatology 31: 243 – 249.Ichord, R. Stroke in the newborn. . 11 May 2015.Kenet, G, et al (2010). Impact of thrombophilia on risk of arterial ischemis stroke or cerebral sinovenous thrombosis in neonates and children. A systemic review and meta-analysis of observational studies. Circulation 121: 1838 – 1847.Kirton, A, deVeber, G (2015). Paediatric stroke: pressing issues and promising directions. Lancet Monagle, P, Chan, A, Goldenberg, N, Ichord, R, Jouneycake, J, Nowak-Gottl, Ulrike, Vesely, S (2012). Antithrombotic therapy in neonates and children. Chest 141 (2): e739S – e801S.O'Brien, S (2015). Perinatal thrombosis: implications for mothers and neonates. Hematology: 48 - 52.Raffini, L (2008). Thrombophilia in children: Who to test, how, when, and why? Hematology 1: 228 – 235.Raju TN, Nelson KB, Ferriero D, et al. Ischemic perinatal stroke: summary of a workshop sponsored by the National Institute of Child Health and Human Development and the National Institute of Neurological Disorders and Stroke. Pediatrics 2007; 120:609.Related DocumentsNICU - Suspected Neonatal Stroke - Admission Order SetNICU - Confirmed Neonatal Stroke - Order SetVersion HistoryDATEDOCUMENT NUMBER and TITLEACTION TAKEN01-Dec-2018C-06-07-60004 Neonatal StrokeApproved at: Neonatal Leadership Committee31-Jul-2019“Added to “Background” by Senior Practice Leader: The low recurrence rate suggests that thrombophilias are only one of many factors possibly contributing to perinatal stroke (O’Brien, 2015). Thus, the role of thrombophilia testing in this population is not fully defined, and does not guide acute management decisions (Raffini, 2008). A recent prospective Canadian study addressing this question suggests minimal association between perinatal stroke and thrombophilia, and argues testing is not indicated (Curtis et al, 2017). Our approach is therefore not to routinely test for thrombophilias in the setting of perinatal stroke, but testing may be considered in individual cases. DISCLAIMERThis document is intended for use?within?BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health Services Authority (PHSA) assumes no liability arising from use or reliance on this document.?This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.? ................
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