Elsevier

Pediatric Neurology

Volume 30, Issue 3, March 2004, Pages 151-162
Pediatric Neurology

Review article
Fetal stroke

https://doi.org/10.1016/j.pediatrneurol.2003.08.004Get rights and content

Abstract

Fetal stroke, or that which occurs between 14 weeks of gestation and the onset of labor resulting in delivery, has been associated with postnatal epilepsy, mental retardation, and cerebral palsy. The entity is caused by antenatal ischemic, thrombotic, or hemorrhagic injury. We present seven new cases of fetal stroke diagnosed in utero and review the 47 cases reported in the literature. Although risk factors could not be assigned to 50% of the fetuses with stroke, the most common maternal conditions associated with fetal stroke were alloimmune thrombocytopenia and trauma. Magnetic resonance imaging was optimal for identifying fetal stroke, and prenatal imaging revealed hemorrhagic lesions in over 90% of studies; porencephalies were identified in just 13%. Seventy-eight percent of cases with reported outcome resulted in either death or adverse neurodevelopmental outcome at ages 3 months to 6 years. Fetal stroke appears to have different risk factors, clinical characteristics, and outcomes than other perinatal or childhood stroke syndromes. A better understanding of those risk factors predisposing a fetus to cerebral infarction may provide a basis for future therapeutic intervention trials.Özduman K, Pober BR, Barnes P, Copel JA, Ogle EA, Duncan CC, Ment LR. Fetal stroke.

Introduction

Fetal stroke is defined as an ischemic, thrombotic, or hemorrhagic event occurring between 14 weeks of gestation and the onset of labor resulting in delivery. Although it may represent an important cause of postnatal seizures, mental retardation, and cerebral palsy [1], [2], [3], [4], the true incidence of fetal stroke remains unknown [5], [6], [7]. Reasons for this include difficulties with imaging the developing brain and the inclusion of cases of fetal stroke in series of infants with perinatal cerebral infarction [8], [9], [10], [11]. The diagnosis of fetal intraventricular hemorrhage and stroke first became possible with the use of fetal cranial ultrasonography [12], [13], and the utilization of fetal magnetic resonance imaging permits better definition of injury to the fetal cerebrum [14], [15], [16]. This information may, in turn, aid in the development of potential therapeutic or protective strategies.

Section snippets

Patients

Medical, gestational, and family histories were obtained on the mothers of seven patients with fetal stroke diagnosed at or referred to our institution. All mothers underwent evaluation for infection and hypercoagulability. The infection screen consisted of serology for Toxoplasma, rubella, cytomegalovirus, herpes, parvovirus B19, human immunodeficiency virus, and hepatitis viruses. The maternal hypercoagulability evaluation consisted of factor levels, antibody levels, and mutation assays

Fetal presentation

Five of our seven (71%) stroke cases were diagnosed during routine prenatal ultrasound and confirmed by further imaging (Table 1). Case 48 was a twin gestation with twin-twin transfusion syndrome. In Case 49, fetal tachycardia led to an eventual diagnosis of fetal stroke. The mean age of diagnosis of stroke was 29.2 weeks (S.D. ± 5.7) with a median age of 31.5 weeks (range 22–34 weeks). The mother of Case 54 was determined to have antibodies to human platelet alloantigen Pla1 after the

Review of the literature and discussion

Fetal stroke may represent an under-reported cause of neurodevelopmental handicap. As recently addressed by a National Institute of Neurological Disorders and Stroke Workshop, perinatal cerebral infarction has been defined as that which occurs between 28 weeks of gestation and 28 days of life [3]. Perinatal stroke is reported to occur in approximately 1 in 4000 live births, yet the true incidence, or prevalence, of fetal stroke remains unknown [5], [8], largely as a result of deficiencies in

Conclusion

Fetal stroke, although often subclinical during pregnancy, resulted in death or adverse neurodevelopmental outcome in greater than three quarters of cases. Magnetic resonance imaging was the modality of choice for defining fetal strokes, and prenatal imaging revealed hemorrhagic lesions in over 90% of studies and porencephalies in 13%.

Stroke in the fetus may be caused by hemorrhage, ischemia, thrombosis, or a combination of events, but in one half of the cases studied, risk factors for this

Acknowledgements

This work was supported by NIH grant NS 42027 and the Lawson Family Foundation. The authors thank Marjorene Ainley, BA, for administrative assistance and Hedy Sarofin, RTA, for technical assistance.

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