Distinguishing Arterial Ischemic Stroke From Hypoxic-Ischemic Encephalopathy in the Neonate at Birth

Abstract

Objective: To identify perinatal risk factors that can distinguish arterial ischemic stroke from hypoxic-ischemic encephalopathy at birth.

Methods: This is a cohort study of all neonates born at 35 weeks of gestation or greater admitted to our neonatal intensive care unit from January 1, 2010, to December 31, 2015, that compares neonates with stroke with those with hypoxic-ischemic encephalopathy undergoing whole-body hypothermia with abnormal brain magnetic resonance imaging.

Results: During this 6-year period, there were 22 neonates with stroke and 47 with hypoxic-ischemic encephalopathy undergoing whole-body hypothermia with abnormal magnetic resonance imaging. Three neonates triaged to hypothermia initially thought to have hypoxic-ischemic encephalopathy were later diagnosed with stroke. All neonates with stroke had a negative thrombophilia workup. Neonates with stroke had a significantly higher incidence of seizures and increased initial platelet counts on univariate analysis. A multivariable model of variables with P<.1 on univariate analysis present within 6 hours of birth found significant increases in nonreassuring fetal heart rate tracings, sentinel events, low Apgar score at 5 minutes, and metabolic acidosis at birth with hypoxic-ischemic encephalopathy. Stroke was associated with a significantly increased initial platelet count.

Conclusion: Stroke is associated with increased initial platelet counts and is not associated with cesarean delivery for nonreassuring fetal heart rate tracings, sentinel events, or perinatal metabolic acidosis. Stroke is a form of neonatal brain injury not associated with perinatal risk factors that allow early identification.

Fig. 1

Axial T2-weighted magnetic resonance (MR) image (A), trace of diffusion map (B), and apparent diffusion coefficient (ADC) map (C) of a 3-day-old neonate with arterial ischemic stroke show hyperintense T2 signal of the cortical gray and subcortical white matter within the vascular territory of the left middle cerebral artery with absence of the normal cortical T2-hypointese signal and matching bright signal on trace of diffusion map and low ADC values (dark on C) representing restricted diffusion in the infarcted brain tissue. Axial T2-weighted MR image (D) of a 9-day-old neonate with hypoxic–ischemic encephalopathy and hypothermia therapy reveals global T2-hyperintense signal of the cerebral white matter. Axial trace of diffusion map (E) and ADC map (F) of a 6-day-old neonate with hypoxic–ischemic encephalopathy and hypothermia therapy show bright signal within the bilateral basal ganglia and thalami with matching low ADC values (dark on F) representing cytotoxic edema.

Fig. 2

Receiver operating characteristic (ROC) curve for initial neonatal platelet count in distinguishing perinatal arterial ischemic stroke from hypoxic—ischemic encephalopathy treated with whole-body hypothermia with abnormal brain magnetic resonance imaging. CI, confidence interval.

Fig. 3

Receiver operating characteristic (ROC) curve for initial neonatal nucleated red blood cell count in distinguishing perinatal arterial ischemic stroke from hypoxic–ischemic encephalopathy treated with whole-body hypothermia with abnormal brain magnetic resonance imaging. CI, confidence interval.