Predictive Value of Clinical and EEG Features in the Diagnosis of Stroke and Hypoxic Ischemic Encephalopathy in Neonates With Seizures

Department of Pediatrics and Child Health, Winnipeg Children's Hospital, University of Manitoba, Winnipeg, MB, Canada.
Stroke (Impact Factor: 5.72). 05/2009; 40(7):2402-7. DOI: 10.1161/STROKEAHA.109.547281
Source: PubMed


In neonates, the differentiation of stroke and hypoxic ischemic encephalopathy (HIE) is important. Neuroimaging presents technical challenges in unstable neonates, resulting in frequently delayed or missed diagnosis of stroke. Differentiating clinical and electroencephalographic (EEG) features would assist physicians in the timely diagnosis. We sought to determine, in neonates with seizures, clinical and EEG features that differentiate stroke and HIE.
Retrospective cohort study comparing clinical, seizure, and EEG features in term neonates with ischemic stroke or HIE and seizures within 7 days after birth, admitted at The Hospital for Sick Children. Putative clinical and EEG predictors of stroke were analyzed with univariate and multivariate methods.
Sixty-two newborns with stroke (n=27) or HIE (n=35) were studied. With univariate analysis, predictors of stroke included delayed seizure onset (>or=12-hours after birth) (P<0.0001; OR, 26.4; 95% CI, 6.8, 102.5), focal motor seizures (P=0.001; OR, 7.2; 95% CI, 2.0, 26.0) and pattern of neurological abnormalities (P<0.0001). With multivariate analysis, delayed seizure onset (P<0.0001; OR 39.7; 95% CI, 7.3, 217.0) and focal motor seizures (P=0.007; OR, 13.4; 95% CI, 2.1, 87.9) predicted stroke. Presence of both predictors had 100% positive predictive value and specificity, 61% negative predictive value and 37% sensitivity.
In neonates, onset of seizures beyond 12 hours of birth and clinically observed focal seizures are predictive of stroke. These preinvestigation indicators of stroke may facilitate earlier diagnosis and institution of specific management strategies.

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Available from: Amna Al Futaisi, May 06, 2014
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    • "Neonatal seizures and especially hemiconvulsions often suggest the diagnosis of perinatal arterial ischaemic stroke (PAIS). Compared to those who develop seizures due to HIE, seizures related to PAIS tend to develop significantly later and are more often focal (Rafay et al., 2009). It is important to use at least a two-channel aEEG or standard EEG recording in infants presenting with hemiconvulsions (van Rooij et al., 2010). "
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    ABSTRACT: AimThe aim of this study was to delineate aetiologies and explore the diagnostic value of cerebral magnetic resonance imaging (MRI) in addition to cranial ultrasonography (cUS) in infants presenting with neonatal seizures.Method This retrospective cohort study comprised infants (gestational age 35.0–42.6wks) with seizures, confirmed by either continuous amplitude-integrated electroencephalography (aEEG) or standard EEG and admitted during a 14-year period to a level three neonatal intensive care unit (n=378; 216 males, 162 females; mean [SD] birthweight 3334g [594]). All infants underwent cUS and MRI (MRI on median of 5 days after birth, range 0–58d) within the first admission period.ResultsAn underlying aetiology was identified in 354 infants (93.7%). The most common aetiologies identified were hypoxic–ischaemic encephalopathy (46%), intracranial haemorrhage (12.2%), and perinatal arterial ischaemic stroke (10.6%). When comparing MRI with cUS in these 354 infants MRI showed new findings which did not become apparent on cUS, contributing to a diagnosis in 42 (11.9%) infants and providing additional information to cUS, contributing to a diagnosis in 141 (39.8%). cUS alone would have allowed a diagnosis in only 37.9% of infants (134/354).InterpretationCerebral MRI contributed to making a diagnosis in the majority of infants. In 11.9% of infants the diagnosis would have been missed if only cUS were used and cerebral MRI added significantly to the information obtained in 39.8% of infants. These data suggest that cerebral MRI should be performed in all newborn infants presenting with EEG- or aEEG-confirmed seizures.
    Developmental Medicine & Child Neurology 11/2014; 57(3). DOI:10.1111/dmcn.12629 · 3.51 Impact Factor
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    • "[18], [33]–[35] Approximately 20% of neonatal seizures in term neonates are due to PAIS. [2] Conversely, while neonatal seizures have been noted in 26% of neonates with PAIS, [3] we believe these numbers could be much higher if detection of seizures is based on prolonged multichannel EEG monitoring. A limitation of our study is the small number of neonates with PAIS. "
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    ABSTRACT: Stroke is the second most common cause of seizures in term neonates and is associated with abnormal long-term neurodevelopmental outcome in some cases.
    PLoS ONE 07/2014; 9(7):e100973. DOI:10.1371/journal.pone.0100973 · 3.23 Impact Factor
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    • "Since the occurrence of stroke in this cohort was more frequent than in population-based data, neuro-imaging should be performed in these infants. And the study comparing neonates with seizures caused by stroke with seizures caused by HIE reported that seizure onset >12 h and clinically observed focal seizures are more often associated with AIS [35]. So our findings suggest the use of MRI as the first-line imaging modality in most cases of neonatal encephalopathy, which facilitates the accurate diagnosis of AIS [23]. "
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    ABSTRACT: Perinatal arterial ischemic stroke (AIS) occurs in an estimated 17 to 93 per 100000 live births, yet the etiology is poorly understood. Although investigators have implicated hypoxia as a potential cause of AIS, the role of hypoxia in AIS remains controversial. The aim of this study was to estimate the association between perinatal hypoxia factors and perinatal arterial ischemic stroke through a meta-analysis of published observational studies. A systematic search of electronically available studies published through July 2013 was conducted. Publication bias and heterogeneity across studies were evaluated and summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated with fixed-effects or random-effects models. A total of 8 studies describing the association between perinatal hypoxia factors and neonatal arterial ischemic stroke (AIS) met inclusion criteria, and 550 newborns with AIS were enrolled. The associations were found for AIS: preeclampsia (OR 2.14; 95% CI, 1.25 to 3.66), ventouse delivery (OR 2.23; 95% CI, 1.26 to 3.97), fetal heart rate abnormalities (OR 6.30; 95% CI, 3.84 to 10.34), reduced fetal movement (OR 5.35; 95% CI, 2.17 to 13.23), meconium-stained liquor (OR 3.05; 95% CI, 2.02 to 4.60), low Apgar score (OR 5.77; 95% CI, 1.66 to 20.04) and resuscitation at birth (OR 4.59; 95% CI, 3.23 to 6.52). Our data did not show any significant change of the mean risk estimate for oxytocin induction (OR 1.33; 95% CI, 0.84 to 2.11) and low arterial umbilical cord ph (OR 4.63; 95% CI 2.14 to 9.98). There is a significant association between perinatal hypoxia factors and AIS. The result indicates that perinatal hypoxia maybe one of causes of AIS. Large scale prospective clinical studies are still warranted.
    PLoS ONE 02/2014; 9(2):e90106. DOI:10.1371/journal.pone.0090106 · 3.23 Impact Factor
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