Review articleFetal 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.
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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.
References (73)
- et al.
Fetal thrombotic vasculopathy in the placentaCerebral thrombi and infarcts, coagulopathies and cerebral palsy
Hum Pathol
(1999) - et al.
Cerebral infarctions in the fetus and neonateMaternal-placental-fetal considerations
Clin Perinatol
(2002) Thrombosis in pregnancyMaternal and fetal issues
Lancet
(1999)- et al.
Intraventricular haemorrhage in uteroA case-report and review of the literature
Eur J Obstet Gynecol Reprod Biol
(2000) MR imaging of fetal central nervous system abnormalities
Brain Cogn
(2002)- et al.
Outcome of fetal ventriculomegaly
Lancet
(1984) - et al.
Fetal intraventricular haemorrhage and maternal warfarin
Lancet
(1993) - et al.
Stroke in a neonate heterozygous for factor V Leiden
Pediatr Neurol
(1998) - et al.
An atypical French form of pyruvate carboxylase deficiency
Brain Dev
(1995) - et al.
Cerebral infarction in the term newbornClinical presentation and long-term outcome
J Pediatr
(2000)