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Neonatal Stroke | Overview

What is neonatal stroke?

Neonatal stroke is stroke in newborns between birth and 28 days. It occurs in as many as one in 2,500 full-term infants and even more commonly in babies born prematurely. Sometimes strokes even occur before birth. Most often, neonatal stroke is discovered shortly after birth in babies who have seizures or who are weak and unresponsive, and confirmed through neuroimaging.

What are the symptoms of neonatal stroke?

The most common symptom of neonatal stroke is seizures, often occurring as early as the first day after birth. Other signs and symptoms of neonatal stroke include:

  • extreme sleepiness and lethargy (hypotonia)
  • weakness on one side of the body (hemiparesis)
  • feeding difficulties
  • apnea (periods where breathing stops temporarily)
  • neurological impairment

However, many babies don't show any noticeable symptoms of a stroke until they are older. Speech delays and balance difficulties can be signs that a child had a stroke as a newborn.

What causes neonatal stroke?

The most common type of neonatal stroke, arterial ischemic stroke, occurs when a blood clot or structural abnormality (such as moyamoya disease or other cerebral arteriopathies) obstructs blood flow within a baby's brain or spinal cord.

A hemorrhagic stroke is the result of bleeding in the brain. Common causes of hemorrhagic stroke include blood-vessel abnormalities, such as cavernous malformations, arteriovenous malformations, venous angioma, and aneurysm. Clotting disorders such as hemophilia, sickle cell disease, brain tumors, and congenital heart disease can also cause bleeds that lead to hemorrhagic stroke.

Other conditions are also associated with an increased risk of neonatal stroke. These include:

  • cardiac disorders
  • genetic conditions that increase blood clotting

How we care for neonatal stroke

Despite the immaturity of the newborn brain, neonatal stroke can have lasting effects when it occurs. For this reason, early diagnosis and prompt treatment are crucial. The diverse team of specialists in the Stroke and Cerebrovascular Center at Boston Children's Hospital provides fast, comprehensive evaluation to identify quickly if and why a stroke has occurred.

We work closely with neonatologists in the neonatal intensive care units (NICUs) at Boston Children's, Brigham and Women's Hospital, and Beth Israel Deaconess Medical Center to provide state-of-the-art care for newborns with stroke. Our team approach means that your child will benefit from the combined expertise of child neurologists, pediatric neurosurgeons, hematologists, neurointerventional radiologists, pediatric neuroradiologists, emergency medicine physicians, physiatrists, child psychiatrists, physical and occupational therapists, and speech and language therapists, not only while in the hospital, but also during extensive outpatient follow-up for years to come. We also offer long-term multidisciplinary care to help prevent future strokes.

Neonatal Stroke | Diagnosis & Treatments

How is neonatal stroke diagnosed?

Physicians will carefully image your baby's brain to determine the extent of the stroke and which areas of the brain are affected. Procedures used to diagnose stroke include:

  • imaging of the brain and blood vessels in the head and neck using MRI (magnetic resonance imaging), CT (computed tomography) and catheter angiography protocols designed at Boston Children's
  • a cardiology evaluation to look at the heart for possible cardio-embolic causes of stroke
  • blood tests, including a panel of tests associated with bleeding or clotting disorders (thrombophilia testing), inflammatory disorders or metabolic disorders
  • genetic studies to look for hereditary risk factors for blood clots
  • a transcranial ultrasound assessment to assess blood flow in the brain

How is neonatal stroke treated?

When treating an acute neonatal stroke, we quickly assess whether clot-busting (thrombolytic) medicine, such as tissue plasminogen activator (tPA), is appropriate for your child. Previously used only in adults, this treatment can open up blood vessels obstructed by blood clots and limit the stroke's effect on the brain. It must be given within the first 4½ hours after onset of symptoms to be effective.

In some critically ill patients, we may perform endovascular thrombolysis. This treatment involves navigating a very small catheter directly into the area of the clot and delivering clot-dissolving drugs like tPA.

When thrombolytic treatment isn't an option, our goal is to provide the best neuroprotective care possible to limit further damage to the brain. This care focuses on maintaining high blood oxygen levels and optimal blood pressure, to ensure the brain receives the blood flow and oxygen it needs, and controlling blood glucose levels and treating fever, which can exacerbate injury to the brain from stroke.

Long-term care

Regardless of the cause, the problems that result from the stroke (such as weakness and numbness) can sometimes be improved with therapy over time. After the acute period has passed, children are closely followed by our outpatient program, under the care of a child neurologist, hematologist, physiatrist, neuropsychologist and neuroradiologist as well as occupational and physical therapists. We offer weekly clinics to meet our patients' needs and answer any questions. Follow-up neuroimaging and laboratory studies are done as needed and reviewed in advance of the clinic visits.

The stroke team also creates a comprehensive rehabilitation plan for each child to address the long-term consequences of the stroke. This can involve physical, occupational, vision or speech and language therapies or a combination of these. Continuing neurosurgical and neuroradiologic care are also available.

Neonatal Stroke | Programs & Services