Neonatal Stroke: Clinical Presentation, Imaging, Treatment, and Prognosis

Stroke comprises acute focal brain injury due to arterial or venous occlusion, or due to primary hemorrhage. In the perinatal context its onset can be in utero, during delivery or at any time in the neonatal period. Although seizures and apnea are characteristic presentations, other signs and chance imaging finding are common. Staging with imaging, be it ultrasound or MRI, proceeds from acute lesional swelling with cell invasion, over frank necrosis in the core, to organization and tissue loss. The flow of diagnosis is often suspicion on ultrasound followed by clear definition of the lesion with diffusion weighted MRI in the acute stage. Knowledge of the developmental anatomy of brain vessels is indispensible because the recognition of the vessel signature (the template: for cerebral pial and perforator as well as brainstem and cord arteries, and for superficial as well as deep brain veins) is often the only manner to define the stroke type; it is only in a minority that description with imaging of arterial occlusion or venous thrombosis will confirm the fact the injury is due to stroke. Focal changes on the EEG guide diagnosis but especially management. Anticoagulants or antiplatelet agents may play a role in the (sub)acute stage. Pharmacological neuroprotection and cooling are subject of research and will find their place in the near future. Any stroke where the mechanism is elusive is open to a query of genetic causes, including prothrombotic conditions, mutations of collagen A4 and of brain-barrier junctional molecules. Genetic inflammatory conditions may be complicated by vascular lesions mimicking stroke.