Neonatal Cerebral Investigation

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Newborn infants with diagnosis of seizure due to hypoglycemia or hypocalcemia with a good response to treatment, and neonates who had not a stable condition for conducting a neuroimaging during the neonatal period were excluded. For all participants, diagnostic investigations for seizure such as clinical and neurological assessment, lumbar puncture, check of serum electrolytes and sepsis workup were performed. While the neonate was stable and seizure free at least for 48 h, a Doppler transcranial sonography performed.

Transcranial Doppler sonography was carried out via fontanel by radiologist of the team who was expert in brain Doppler sonography of neonates and children.

The sonography machine used was Siemens G50 with special probe and 12 MHz frequencies. Perfusion index PI and resistance index RI in middle cerebral artery were measured and abnormal flow or radiological evidence of flow arterial infarction was reported as stroke 3. Then in neonates who had a sonographic scan compatible with diagnosis of stroke, whenever the baby was stable enough to be moved a Diffuse-Weighted DWI MRI was carried out for confirmation of the result of transcranial Doppler sonography at least three days after the last episode of seizure.

The MRI and CT scan were interpreted by a radiologist, reviewed by a pediatric neurologist, and reevaluated for diagnosis of neonatal stroke. An echocardiography performed for all neonates with a diagnosis of stroke in sonography. For analysis of dichotomous variables, the chi-squared test and fisher exact test were used. Of these, 89 Mean birth weight in neonates was Computed tomography in 4 2.

The characteristics of 14 individual neonates with stroke are shown in Table 1. Clinical features of seizure were focal clonic in 11 None of these patients showed tonic seizures. In assessment of neonates with stroke, none of them had polycythemia, birth trauma and history of prolonged rupture of membrane or chorioamnionitis in mother. In addition, EEG was abnormal in all cases of stroke. Impairment in initial coagulation tests such as Prothrombin time PT or Partial thromboplastin time PTT were only observed in two patients of stroke group and these tests were normal in all neonates without stroke.

Other investigated predictors such as gestational age, underline congenital heart diseases and history of diabetes mellitus in mother were not significantly different between stroke or non-stroke group Table2. Based on our knowledge, this is the first study that reported the incidence of stroke in neonates with seizures in Iran. In previous studies, the incidence of stroke was reported about Gender and racial differences have been identified for stroke in pediatrics, but such information is not available about stroke in neonates 6 , 9.

Twelve percent of neonatal seizures were due to stroke 5. This prevalence in Lynch et al. However, this fact is clear that seizure is the most common presentation of neonatal stroke Doppler ultrasonography has an important role in initial diagnosis of neonatal cerebral infarction and definite diagnosis is confirmed by CT scan or MRI In other words, Doppler ultrasonography is not diagnostic modality of choice but can be a guiding tool for further diagnostic study.

Volumetric techniques are increasingly used to investigate the neonatal brain injuries Eleven of 14 cases of neonatal stroke detected by MRI were also detected by ultrasonography Their results revealed that although CT scan had better sensitivity than ultrasonography, it might not be able to identify the abnormalities in the early phase of an acute ischemia in neonates.

They also believed that Doppler ultrasonography was a most widely used form modality for screening Focal seizures are the most common form of seizures, which has been seen, in neonatal stroke and typically are contralateral to the infarct Similarly, in our study focal clonic seizures were the most type of seizures observed in Similarly, Rafay et al.

Prevalence of Stroke in Neonates Who Admitted With Seizures in Neonatal Intensive Care Unit

In Lynch et al. Electroencephalographic EEG results in neonatal stroke may be normal or show sharp and spike waves, focal slowing, or periodic lateralized epileptiform discharges 9. EEG findings in all affected cases of our study with stroke were abnormal but in 3 of 11 cases of Laugesaar study and in 20 from 48 neonates of Rafay et al. Evaluation of risk factors for neonatal stroke in our study revealed that umbilical venous catheterization has been increased the risk of stroke. Unfortunately, a few casecontrol studies have been carried out to identify risk factors of neonatal stroke and the etiology and prognosis of neonatal stroke have not been exactly described.

Therefore, this is a large field for further evaluation 8 , They proposed that in the absence of any identifiable etiologies for the neonatal stroke, portal vein thrombosis should be considered and a Doppler ultrasonography of portal system was recommended because the authors believed that the source of thromboembolism commonly was undetermined.

Instrumentalism, particularly umbilical venous vein catheterization is the most common cause of portal vein thrombosis 9. Although we did not carry out portal vein ultrasonography, our results are partly confirmed Dajani et al. This association has been demonstrated in other studies and umbilical venous catheterization is a well-known risk factor that increased risk of thrombovascular events and neonatal stroke 10 , 18 , In our study, congenital heart disease has not increased the risk of neonatal stroke.

Although congenital heart diseases are a known risk factor for ischemic stroke in neonates, it is less commonly implicated in the etiology of neonatal stroke and usually has been seen in cases who tolerated cardiac surgery and silent infarction may occur.

On the other hand, stroke with cardiogenic origin is the only type of stroke, which need to anticoagulant therapy 7 , 18 , We had a number of limitations in our study. First, not all of the neonates were tested for specific prothrombotic factors such as Pr C, S, antitrombin III, anti cardiolipin antibodies, lupus anticoagulant and factor V leiden and we might have missed some risk factors of stroke. Second, in an ideal condition, an MRI would be done first followed by a magnetic resonance angiogram but we did nott request MRI as an initial step and MRI was carried out for patients only according to results of Doppler ultrasonography because MRI was not available in our hospital and we had to give sedation to the neonates and transferred them to another hospital that was far from our center that it was impossible for all neonates.

Therefore, we used Doppler ultrasonography as an initial investigation. Third, the follow up of most of the neonates with stroke was not completed for further evaluation and investigation of outcomes. In conclusion, the prevalence of 3. In addition, the noninvasiveness and portability of Doppler ultrasonography can promote its use in diagnosis of stroke, especially in monitoring of the critically ill infants and in conditions that MRI is not easily accessible.

Further studies with more sample size and assessment of other risk factors, outcome assessment and determination of prognosis in neonatal stroke are recommended.

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The authors would like to thank Masume Jafari and Nahid Shayesteh for their assistance in data collection of some cases. No conflict of interest. Help in writing of manuscript and collecting data. National Center for Biotechnology Information , U. Iran J Child Neurol. Author information Article notes Copyright and License information Disclaimer. Results From newborn infants, Conclusion Investigation of stroke as an etiology of neonatal seizures is essential because seizure may be the only symptom of neonatal cerebral infarction.

Introduction Neonatal seizure is one of the most important causes of neurological impairment in newborn infants 1. Table 1 Characteristics of neonates with stroke. Open in a separate window. Description Neonatal Cerebral Investigation reviews all aspects of the investigation of the neonatal brain, bringing together diagnostic and prognostic information in a highly illustrated and practical text.

These chapters are followed by a detailed review of normal neonatal imaging appearances and normal EEG, artefactual imaging appearances and imaging of various stages of the immature brain.

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Subsequent chapters discuss pre-term and term screening and review the imaging appearances in a variety of clinical conditions such as suspected seizure, suspected infection and enlarging head. Highly illustrated with over ultrasound and MRI scans and EEG and CFM traces and providing detailed diagnostic and prognostic information on a wide range of clinical problems, Neonatal Cerebral Investigation provides the reader with a comprehensive overview of all aspects of investigation of the newborn baby with a potential neurological problem.

The Best Books of Check out the top books of the year on our page Best Books of Looking for beautiful books? Visit our Beautiful Books page and find lovely books for kids, photography lovers and more. Table of contents Preface; Glossary and abbreviations; 1. Principles of ultrasound; 2. Principles of EEG; 3. Principles of magnetic resonance imaging and spectroscopy; 4.

Normal neonatal imaging appearances; 5. The immature brain; 7. The baby with a suspected seizure; 8. The baby who was depressed at birth; 9.

Screening the preterm infant at high risk of brain injury;

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