2024 American Academy of Neurology Abstract Website

Objective:

Background:

Pediatric strokes occur with the highest incidence perinatally with 1 of 1600-5000 births in term babies and 1 in 140 preterm births. Around 80% are classified as ischemic and cerebral venous sinus thrombosis (CVST) and hemorrhage comprise the remainder. Risk factors can coexist and include maternal, fetal, and placental characteristics. Neonatal stroke presents with focal seizures in 60% of cases, usually within 12-72h after delivery. The approach to neuroimaging is institution dependent. MRI is considered the modality of choice compared to CT, with MRV and MRA used to evaluate vasculature. Treatment of stroke in neonates is typically supportive and focuses on risk factor reduction and avoidance of complications. CVST in neonates is challenging as consensus guidelines are limited, and use of anticoagulation is less straightforward than in adults.

Design/Methods:

Literature review performed on PubMed and Cochrane review using “perinatal stroke”, “CVST neonates”, “guidelines stroke in neonates.”

Results:

We present a term newborn following a difficult delivery with significant head molding and cephalohematoma admitted to the NICU because of hypotonia and status epilepticus refractory to treatment with 3 antiepileptic medications. MRI showed multifocal ischemic strokes and MRV showed possible bilateral transverse sinus thrombosis and left sigmoid sinus thrombosis. For clarity, CTV head was obtained and confirmed left transverse sinus thrombus. There were no clear risk factors. After extensive interdisciplinary discussion among pediatrics, child neurology, and hematology, anticoagulation with therapeutic enoxaparin was started for 6 weeks with no complications. Repeat MRV at 6 weeks showed persistent thrombus and anticoagulation was maintained for the remaining 4.5 months.

Conclusions:

Neonates with CVST are challenging to manage given the absence of a consensus approach to anticoagulation, including duration of treatment. The case exemplifies the challenges child neurologists and NICU providers face and expands the discussion of the subject and need for further studies.