Perinatal Strokes

There are many types of injuries that can happen during pregnancy, during delivery, or after childbirth, and one serious condition is a perinatal stroke. A stroke is the sudden death of brain cells due to lack of oxygen. This is typically the result of a blockage in a blood vessel feeding the brain or a bleed within the brain. Perinatal strokes are those strokes that occur between 22 weeks of pregnancy and one month after birth. The riskiest time for a perinatal stroke is the week surrounding birth.

The diagnosis of perinatal stroke is often missed because the signs and symptoms are subtle. Forty percent of infants with early stroke do not have symptoms, and the stroke is only recognized much later because of delays in movement, development, learning, or the occurrence of seizures. Sixty percent of infants with a stroke diagnosis have specific symptoms, such as recurrent focal seizures, in the first three days of life. Those strokes should be identified early, provided healthcare workers are sufficiently knowledgeable to identify the signs and symptoms.

Doctors attending to pregnant women and newborns should always know to look for the signs of a possible perinatal stroke. When perinatal stroke goes undiagnosed, children can suffer significant harm, and parents can face serious emotional and financial losses.

Overview of Stroke in Children

About five in 100,000 children will suffer a stroke from birth through age 19. Perinatal, neonatal, infant, and childhood stroke are some of the most common causes of lasting medical issues, including:

• Hemiplegia
• Hemiparesis
• Hemiplegic cerebral palsy

Unfortunately, sixty percent of children who survive a stroke will have permanent neurological problems. Outcomes are generally poor, with disability often lasting an entire lifetime, resulting in a large global burden of disease. Perinatal stroke is the most common cause of certain types of cerebral palsy, and many survivors have additional neurological effects, including intellectual disabilities, developmental and behavioral disorders, and epilepsy.

The Most Common Type of Stroke in Children

Perinatal arterial ischemic stroke is the most common type of stroke in children. It happens due to inadequate blood supply to the brain. Perinatal strokes result in severe long-term neurologic and cognitive impairments, including:

• Cerebral palsy
• Epilepsy
• Neuropsychological impairments
• Behavioral disorders

The perinatal brain is not merely a smaller version of the adult brain. As a result, the response of the perinatal brain to stroke is not the same as the response of the adult brain.

Even among infants, the brain’s reaction to reduced oxygen due to stroke depends on the age of the brain at the time of the stroke. For example, a stroke in a two-week old baby that was born prematurely may cause more damage than the same stroke in a two-week old baby born at full term. Ischemic injury (injury due to decreased blood flow) in preterm infants generally leads to long-term disabilities, while stroke injury in full-term newborns often affects a more focused area of the brain’s gray matter.

Possible Causes of Perinatal Stroke

Perinatal stroke can happen for many reasons, some of which are easier to identify than others. Some common causes are:

• Health conditions of the mother, including gestational diabetes, pregnancy-induced hypertension, and preeclampsia, which is a pregnancy complication characterized by high blood pressure and damage to another organ system, most often the liver.
• Problems with the placenta, including placental abruption (placenta separates from the uterus before birth). Any condition causing decreased blood flow to the placenta places the baby at increased risk for perinatal stroke.
• Changing clotting factors in the pregnant mother’s blood that lead to clots, decreasing or cutting off blood flow to the placenta.
• Congenital heart disease of the infant.
• Cocaine use during pregnancy, which can cause the arteries feeding the placenta to constrict or to spasm.
• Any decreased oxygen flow to the brain, which can result in both perinatal stroke and HIE (hypoxic-ischemic encephalopathy), which often occur together.

Signs and Effects of Perinatal Stroke

Most babies with neonatal stroke show symptoms in their first three days of life, including focal seizures, apnea (stopping breathing), chewing or bicycling movements, and persistent feeding difficulties. Most newborns with perinatal stroke will not have issues on one side versus the other, but instead may have an asymmetric Moro reflex response, which doctors should look for and identify. Hemiplegia (paralysis of only one side of the body) is rare and often evolves over time.

Newborns who present with seizures due to stroke may appear normal in the hours before the onset of seizures. Epilepsy or motor impairment occurs in approximately one-half to two-thirds of injured neonates.

Perinatal stroke may be missed initially if symptoms are subtle or absent, but if new symptoms such as early handedness, hemiplegia, neurodevelopmental delay, or spasticity appear later in the first year of life, the condition should be identified.

Diagnosing Perinatal Stroke

There are many tools that doctors have to diagnose perinatal stroke, including:

• MRI (magnetic resonance imaging), which is the preferred diagnostic study for diagnosing perinatal stroke.
• CT (computed tomography) scan of the head and brain.
• Cranial ultrasound, a technique for scanning the brain using high-frequency sound waves, is used almost exclusively in babies because their fontanelle (the soft spot on the skull) provides an “acoustic window.”
• MRA (magnetic resonance angiography), which evaluates arteries in the brain.
• MRV (magnetic resonance venography), which evaluates veins in the brain.
• Lumbar puncture, which samples cerebral spinal fluid.
• EEG (electroencephalogram), which records the electrical signals of the brain.

Treatment for Perinatal Stroke

In the time after a diagnosis of perinatal stroke, treatment might include:

• Anticonvulsant medications.
• Oxygen therapy and mechanical ventilation in infants unable to breath effectively on their own.
• Medications to improve blood flow and reduce blood clotting.
• Surgical ventricular drainage/shunting in the presence of hydrocephalus, which is the buildup of fluid in the ventricles deep within the brain. This excess fluid increases the size of the ventricles and puts pressure on the brain.

The Duty of Care for a Woman and Infant During Pregnancy and the Infant After Birth

Each type of medical professional has a duty of care they must meet when treating patients. The specifics of a doctor’s duty depend on the type of medicine they practice and the circumstances of each patient. Generally speaking, a doctor should provide care that is reasonable and prudent under the circumstances.

A few examples of the standard of care for pregnancy, labor, and delivery are:

• Monitoring the mother at prenatal visits for any pregnancy complications, including routine checks of glucose levels and blood pressure.
• Monitoring the mother and baby during labor and delivery.
• Educating pregnant women on the possible complications that may occur during pregnancy, and if any complications arise, providing timely treatment.
• Careful fetal monitoring during labor when the mother has been diagnosed with gestational diabetes, hypertension, or preeclampsia. In many cases, prompt delivery by C-section can prevent perinatal stroke, but only when the delivery team recognizes signs of fetal distress due to oxygen deprivation.
• Taking immediate action in the case of placental abruption. Placental abruption usually occurs in the last trimester of pregnancy. Symptoms include vaginal bleeding, abdominal pain, symptoms of early labor such as stomach pain, uterine contraction or back pain, and the mother possibly noticing decreased movement of the fetus.

When a medical professional fails to meet the standard of care, and an infant suffers harm as a result, parents can seek to hold the doctor accountable for the mistake and liable for the harm caused.

Consult with an Experienced Ohio Birth Injury Attorney

If your child suffered a perinatal stroke, and you believe it happened due to inadequate monitoring or delayed diagnosis, you should not wait to discuss the matter with an experienced medical negligence attorney. At The Eisen Law Firm, our Ohio birth injury lawyers handle complex birth injury cases, so please contact us online or call 216-687-0900 for free today.