A perinatal stroke is a stroke that usually occurs during or around the time of birth. Perinatal strokes that occur before birth may also be referred to as “fetal strokes,” and those occurring after birth may be called “neonatal strokes.” Strokes occur when blood supply to a part of the brain is cut off; often this is associated with birth injuries such as hypoxic-ischemic encephalopathy (HIE), trauma, or infection.
The risk of stroke at or around the time of birth is much higher than the risk for older children; the only age group at higher risk is the elderly (1). Medical professionals should be aware that fetuses and newborns are particularly vulnerable, and do all they can to prevent strokes (i.e. ensure that there is not an interruption in blood flow). If a perinatal stroke occurs, they should provide prompt and appropriate treatment in order to reduce the likelihood/severity of permanent disabilities such as cerebral palsy (2).
Classification of perinatal stroke
There are a variety of systems for classifying perinatal strokes. These take into consideration the following variables (1, 3):
- Type: ischemic (caused by a clot in a vessel) or hemorrhagic (caused by the rupture of a vessel)
- Affected blood vessel: this could be a vein or an artery
- When the stroke occurred: either before or after birth
- When the symptoms first appeared: shortly after birth (during the neonatal period) or later in infancy
Causes and risk factors for fetal stroke
There are many events that can occur during late pregnancy, delivery, or the neonatal period that can cause the baby to have a stroke. These include the following (please note that many of these conditions are also interrelated) (1):
- Blood clots (e.g. embolism, thrombosis)
- Hemorrhages/brain bleeds, such as:
- Hypoxic-ischemic encephalopathy (HIE): when the baby sustains brain damage due to a lack of oxygenated blood flow
- Traumatic birth injuries: these can involve damage to an infant’s brain due to excessive mechanical force during delivery, and use of forceps and vacuum extractors.
- Infections such as chorioamnionitis, sepsis, and meningitis
- Maternal fever: a possible indication of infection
- Preeclampsia: when a woman who previously had a healthy blood pressure develops high blood pressure during pregnancy
- Diabetes/gestational diabetes
- Placental abruption: when the placenta separates prematurely from the uterus, depriving the baby of oxygen-rich blood
- Premature rupture of membranes: when the amniotic sac membranes rupture too early (before the start of labor)
- Prolonged rupture of membranes: when the time period between rupture of membranes and delivery is too long
- Twin-twin transfusion syndrome (TTTS): a rare condition in which abnormal blood vessel connections cause blood to flow unevenly between identical twins
- Certain genetic abnormalities (e.g. those that increase the risk of blood-clotting)
- History of infertility
- Drug use during pregnancy
- Neonatal hypoglycemia
- Periventricular leukomalacia (PVL)
- Low Apgar scores
Signs and symptoms of perinatal stroke
Possible signs and symptoms of stroke in a baby include the following (1):
- Neonatal seizures/abnormal electroencephalogram (EEG) readings
- Signs of encephalopathy (brain damage)
- Problems feeding
- Hypotonia (low muscle tone)
- Trouble breathing or pauses in breathing (apnea)
If a stroke is not diagnosed shortly after birth, parents or medical professionals may notice other signs. These may include developmental delays (such as rolling over or crawling later than normal) or an early preference for use of one hand over the other (4).
Some of these signs aren’t noticed until well after treatment should have been given for the stroke, which is why early, close observation for signs of a stroke and early head imaging is imperative.
Diagnosing a perinatal stroke
Early diagnosis of perinatal stroke is critical so the baby can receive timely treatment. Below are some of the tests that may be used to diagnose a stroke and/or related complications (1):
- MRI (magnetic resonance imaging): This is generally the preferred type of brain imaging for diagnosing perinatal stroke, but in some cases (e.g. if the infant is too ill to wait for an MRI) other tests may be better.
- CT (computed tomography) scans
- Cranial ultrasounds
- Neurovascular imaging, such as the following:
- MRA (magnetic resonance angiography): This is an MRI of specific arteries in the brain.
- MRV (magnetic resonance venography): This is an MRI of specific veins in the brain.
- Lumbar puncture: This is a procedure that is performed to collect cerebrospinal fluid for diagnostic purposes.
- Blood tests
- Urine tests
- EEG (electroencephalogram)
Treatments for perinatal stroke
It is crucial that babies who have had a stroke receive immediate medical attention in order to minimize permanent impacts. Among other interventions, they may require the following:
- Anticonvulsant medications
- Help with oxygenation and ventilation
- Treatment of dehydration
- Treatment of anemia
- Management of metabolic disturbances such as hypoglycemia and electrolyte issues
- Antibiotics (if infection is detected)
- Medications to improve blood flow and reduce coagulation
- Ventricular drainage/shunting (if hydrocephalus occurs)
- Therapeutic hypothermia (discussed below)
Perinatal stroke, hypoxic-ischemic encephalopathy (HIE), and cerebral palsy
Research shows that hypoxic-ischemic encephalopathy (HIE) and stroke often occur together. Hypoxic-ischemic encephalopathy is a type of brain injury caused by a lack of oxygen to the baby’s brain. This oxygen deprivation can be due to a lack of oxygen in the baby’s blood (hypoxemia/hypoxia) and/or a restricted blood supply (ischemia) in the brain. HIE often causes cerebral palsy.
In many cases, perinatal stroke, HIE, and cerebral palsy can be prevented with careful fetal monitoring, and prompt response when a baby begins to exhibit signs of fetal distress (oxygen deprivation). Often, this means delivery via emergency C-section.
Using therapeutic hypothermia (neonatal cooling) after a stroke to reduce the risk of cerebral palsy
Therapeutic hypothermia has been shown to reduce the risk of death and neurological impairments (such as cerebral palsy) in newborns with hypoxic-ischemic encephalopathy (HIE). This treatment must be given very shortly after birth/the oxygen-depriving event: within 6-12 hours. It involves cooling a baby to about 33.5-34.5 degrees Celsius, for 72 hours. This is done either by using a cooling cap or cooling blanket. Therapeutic hypothermia can slow the spread of cellular injury, allowing the baby’s brain to heal and minimizing the spread of damage. Clinical evidence has shown that therapeutic hypothermia has benefited full-term infants with moderate to severe HIE (5).
Attorneys helping children with perinatal stroke, HIE, and cerebral palsy
There are many medical conditions that can cause a perinatal stroke. When these or any risk factors are present, it is crucial for the physician to monitor the mother and baby very closely. The doctor and medical team must be skilled at quickly handling issues that arise during labor and delivery that can potentially deprive the baby of blood and oxygen and cause clotting and strokes. If the baby is showing signs of distress on the fetal heart monitor, the doctor must perform a quick delivery, usually by emergency C-section.
If you suspect that your baby was the victim of medical malpractice related to a stroke and/or hypoxic-ischemic encephalopathy (HIE), call the birth injury lawyers at ABC Law Centers (Reiter & Walsh, P.C.). Our team has been helping children with perinatal strokes, HIE, cerebral palsy, and other birth injuries for over two decades. Jesse Reiter, the firm’s president, has been focusing on birth injury cases his entire legal career, and most of Jesse’s cases involve helping children who have cerebral palsy and hypoxic-ischemic encephalopathy (HIE). When Jesse and his team of lawyers take a case, they spend a lot of time getting to know the child and family they are helping so they can fully understand the child’s needs.
The ABC Law Centers team has won many awards for their advocacy of children. Our attorneys have been recognized by U.S. News and World Report, Super Lawyers, The New York Times, Best Lawyers, and other prestigious publications.
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- (n.d.). Retrieved June 13, 2019, from https://www.uptodate.com/contents/stroke-in-the-newborn-classification-manifestations-and-diagnosis
- (n.d.). Retrieved June 13, 2019, from https://www.uptodate.com/contents/stroke-in-the-newborn-management-and-prognosis
- Perinatal Stroke: Classification. (n.d.). Retrieved June 13, 2019, from https://ucalgary.ca/perinatalstroke/stroke_classification
- Pediatric Stroke – Children’s Hemiplegia & Stroke Association. (n.d.). Retrieved June 13, 2019, from https://chasa.org/medical/pediatric-stroke/
- Hypothermia Therapy | Treatment for Hypoxic-Ischemic Encephalopathy. (n.d.). Retrieved June 13, 2019, from https://www.abclawcenters.com/practice-areas/treatments-and-therapies-for-birth-injuries/hypothermia-cooling/