Fetal/Neonatal and Childhood Stroke Flashcards
At what gestational age would you expect an injury to result in porencephaly?
Prior to 20 weeks or in early second trimester
Barkovich pediatric neuroradiology “brain and spine injuries in infancy and childhood”
What is hydranencephaly?
A condition where most of the brain mantle including cortical plate and hemispheric white matter is damaged, liquefied and resorbed prenatally, usually due to a destructive process (ischemia, infection, etc). Can be considered like porencephaly of the whole cerebrum and occurs in early second trimester or sooner
Barkovich peds NeuroRads Brain and Spine injuries in infancy and childhood
What are some imaging hallmarks of porencephaly?
Focal cavity with smooth walls indicative of little glial/astrocytic response. This is due to lack of astrocytic proliferation in early in gestation, so damaged tissue undergoes liquefactive necrosis instead of astrogliosis
Barkovich chapter 4 Brain and Spine Injuries
What are the imaging hallmarks of encephalomalacia on MRI in an infant ? (presume you are obtaining imaging in the subacute phase)
Reactive astrogliosis evidenced by T1 hypointensity and T2 hyperintensity
This is thought to be due to increased water content in the infant brain
Barkovich chapter 4 Brain and Spine Injuries
In general, at what gestational age would an ischemic/destructive lesion lead to encephalomalacia?
Generally after late 2nd trimester or well into 3rd
The later the injury, the more “cystic” the encephalomalacia. For example, macrocystic encephalomalacia is characterized by large cystic spaces within the injury and is usually earlier but multicystic encephalomalacia results from injuries later in 3rd trimester or around birth since the astroglial response is more mature
Barkovich chapter 4 Brain and Spine Injuries
For neonates, what distribution would you expect to see injury in the setting of mild to moderate hypotension?
Watershed zones or intervascular boundary zones. Can sometimes effect large area of cortex with relative sparing of basal ganglia. This is poorly understood, but thought to be due to shunting from anterior to posterior circulation.
This is in contrast to severe hypotension which often damages deep structures/basal nuclei with variable amount of cortex. Shunting from ant to post is not sufficient and thus the deep structures are still profoundly affected.
Barkovich chapter 4 Brain and Spine Injuries
For neonates, in what distribution would you expect to see brain injury after severe hypotension?
Severe hypotension often damages deep structures/basal nuclei with variable amount of cortex.
This is in contrast to mild or moderate hypotension, where Watershed zones or intervascular boundary zones are more affected. Can sometimes effect large area of cortex with relative sparing of basal ganglia (poorly understood)
Barkovich chapter 4 Brain and Spine Injuries
Which brain areas are predominantly injured in neonatal hypoglycemia?
Parietal and occipital lobes
Barkovich chapter 4 Brain and Spine Injuries
What are the hallmarks of destructive injury (ie ischemia) on neonatal ultrasound? Differentiate early (days 2-5) vs later (days 7-30) and assume a term infant.
Days 2-5: increased echogenicity
Days 7-30: cystic degeneration
What timeframe defines perinatal stroke?
20 weeks gestation through 28th post natal day
Barkovich chapter 4 Brain and Spine Injuries
What are the most common manifestations of perinatal stroke in the neonatal period? Try to name at least 4
Seizures Hypotonia Decreased level of consciousness Irritability Poor feeding
Barkovich chapter 4 Brain and Spine Injuries
Try to name at least 5 causes or or conditions linked to childhood ischemic strokes
Cardiac disease Sickle Cell Anemia Moya Moya Inflammatory conditions (transient cerebral arteriopathies due to prior infections for example) Anemia Coagulopathies Metabolic disorders Vascular malformations Dissection
Name at least 5 risk factors for perinatal stroke
Maternal thrombotic disorders PROM Chorioamnionitis IUGR Complicated delivery Twin twin transfusion Heart disease Inherited thrombophilia Hypoglycemia Polycythemia Collagen vascular disease
Barkovich chapter 4 Brain and Spine Injuries
Name some categories of metabolic causes of stroke in childhood
Organic acidurias (hyperhomocystinuria, propionic aciduria, GA1)
Mitochondrial disease (MELAS, Leigh disease, cytochrome oxidase deficiency)
Lysosomal storage disease (fabry’s disease, cystinosis)
Urea cycle defects (OTC deficiency, CPS deficiency)
Sulfite oxidase deficiency
Hyperlipoproteinemia
Congenital disorders of glycosylation
What are some radiologic manifestations of prenatal periventricular venous infractions?
Hemorrhage (70%)
Ex vacuo ventricular enlargement
Brain injury not In vascular distribution (anterior temp lobe hemorrhage, absence of caudate involvement)
