Perinatal stroke

How does this happen?

A brain area loses its blood supply, and the tissue it fed is injured. The result is a fixed area of damage, and the functions that area handled are affected.

The reason newborns are at higher risk than older children comes down to the state of their circulation at birth. Blood clots more readily in the days around delivery, the circulation is rerouting itself as the fetal pathways close, and the placenta can send small clots into the baby's circulation. ¹

The basal ganglia and the territory of the middle cerebral artery are most often affected, most often on the left. Because the left side of the brain controls the right side of the body, right-sided weakness is the common outcome. ¹

There is a second important form. In babies born early, grade IV bleeding is itself a venous infarction, which is a kind of stroke caused by blocked drainage rather than blocked supply. ³

What causes it?

Two different questions get mixed together here. The first is what leads to this injury in the body. The second is whether anyone could have prevented it. They are not the same question, and the answer to the first does not settle the second.

Happens even with perfect care

In most babies no cause is found, and the guidance is to think of several small factors combining rather than one clear culprit. ¹

• Clots from the placenta entering the baby's circulation.
• Inherited clotting differences, in the baby or the mother.
• Infection, including chorioamnionitis and newborn sepsis. ⁴
• Congenital heart disease, which can send clots to the brain.
• Dehydration or a high blood count in the newborn period.
• preeclampsia and other placental conditions. ⁵

Parents commonly search for what they did wrong. The evidence does not support that search. ¹

Associated with gaps in care

These are situations where published standards say what the care team should watch for and do. A gap here does not prove anyone caused your child's injury. It points to where the medical records will have an answer.

• Seizures not recognized. Newborn seizures often show as lip smacking, bicycling legs, eye deviation or apnea rather than shaking, and many are electrical only. Missing them delays the diagnosis. ⁶
• EEG not done in a newborn with suspicious movements.
• Imaging not done, or the wrong imaging done. cranial ultrasound frequently misses arterial stroke. MRI with diffusion-weighted imaging in the first days is the test. ³
• Newborn infection not recognized and treated. ⁷
• Early hand preference dismissed. A clear preference before 12 months is not typical and should trigger evaluation, not reassurance. ²
• Referral to therapy delayed while waiting for certainty. ²

Whether any of this changed the outcome in an individual case takes a physician expert reading the whole record.

What are the signs, by age?

Signs change as a child grows. A newborn cannot show you a walking problem. Some children look fine at first and show differences months later.

At birth and the first hours

Usually nothing. Most babies with perinatal stroke have a normal birth, normal Apgar score scores and a normal examination.

The first week

• Seizures. This is the most common presentation, typically in the first three days, often affecting one side. ¹
• Apnea, staring, lip smacking, bicycling legs, or eye deviation, all of which can be seizures in a newborn. ⁶
• Sleepiness or poor feeding in some babies.

Around 3 months

• Often nothing yet. Many babies with stroke look entirely typical at this age.
• Subtle differences in how one arm moves, or a hand that stays fisted on one side.

Around 6 months

• A clear hand preference. This is the classic sign, and before 12 months it is not typical development. Raise it with a doctor. ²
• Reaching with only one hand.
• One leg kicking less than the other.
• Difficulty bringing both hands to the middle.

Around 12 months

• One-sided weakness that is now clear.
• Fisting on one side.
• Crawling with an asymmetric pattern.
• Not sitting or pulling to stand, in more affected children. ⁸

Toddler years

• Walking, often on time or a little late, with a limp or with the affected arm held bent.
• The affected hand used as a helper rather than as a doer.
• Speech usually develops typically, even after a left-sided stroke, because a young brain can move language function.
• Seizures in some children.

School age

• Hemiplegic cerebral palsy, most often mild to moderate.
• Learning, attention or visual field differences.
• Epilepsy in a minority. ⁹
• Emotional and social differences, which are common and often overlooked.

How is it diagnosed?

MRI with diffusion-weighted imaging is the test. Diffusion-weighted imaging shows a fresh stroke clearly, and it is most informative in the first several days before the appearance changes. ³

cranial ultrasound frequently misses arterial stroke, especially near the surface of the brain. A normal ultrasound does not rule it out. ³

EEG is used to confirm seizures and to see which side of the brain they come from. Many newborn seizures produce no visible movement, so an EEG is not optional in a baby with suspicious episodes. ⁶

Other tests commonly include blood cultures and infection screening, an echocardiogram of the heart, and clotting studies. Testing for inherited clotting disorders is done selectively, because a positive result rarely changes newborn treatment. Ask what a given test would change. ¹

Some strokes are only diagnosed months later, after an early hand preference leads to an MRI that shows an old injury. That is a recognized route to diagnosis, and it is not a failure by the family. ¹

What is the treatment?

There is no clot-busting treatment for newborn stroke. Adult stroke treatments have not been shown to be safe or useful in newborns, and they are not standard care. ¹

Treatment has three parts.

Supportive care. Keeping blood sugar, temperature, oxygen and blood pressure in a normal range. Treating infection. Treating seizures. ⁶

Seizure medicine, usually short term. Many babies come off medicine within weeks or months. Ask what the plan is for stopping, because staying on it by default is a common drift.

Early, specific therapy. This is where the most can be gained. A young brain can reorganize, and the evidence supports starting intervention as soon as a child is identified as high risk rather than after a confirmed diagnosis. ²

For one-sided weakness, constraint-induced movement therapy has the strongest evidence in the field for improving use of the affected arm. ¹⁰ Ask about it specifically and ask at what age your center starts.

Blood thinning medicine is used only in specific situations, such as a clot source in the heart. It is not routine. ¹

What is the long-term outlook?

Outcomes cover a wide range and, as a group, are better than families expect when they first hear the word stroke.

• Motor. Roughly the most common outcome is hemiplegic cerebral palsy, usually with the arm more affected than the leg. Most children walk. ¹
• Language. Even after a large left-sided stroke, most children develop speech, because a young brain can move language to the other side. This is one of the genuinely encouraging findings in the field. ¹
• Epilepsy. A minority of children develop epilepsy, and it usually appears in the first years. ⁹
• Learning and behavior. Differences are common and are often under-recognized, because attention goes to the arm.

The size and location of the injury predict outcome better than the fact of a stroke does. Ask which arteries were involved and how much tissue is affected.

What does daily life look like?

Therapy focused on the affected arm and hand, often including constraint-induced movement therapy blocks where the stronger arm is gently constrained.

Two-handed tasks are the daily challenge: buttons, cutting food, opening containers, bike handlebars. occupational therapy works on these directly and adaptive tools help.

Many children with perinatal stroke go through mainstream school with accommodations rather than significant support. Watch for the quieter needs: fatigue, attention, visual field, and the social side of being visibly different.

Ask about visual fields at some point. A stroke can take out part of the field of vision on one side, and children adapt so well that nobody notices until it causes a problem crossing a road.

What does care cost over a lifetime?

No agency publishes a lifetime cost for perinatal stroke. Where it leads to cerebral palsy, the CDC estimate of about $921,000 in 2003 dollars is the published anchor, and hemiplegic cerebral palsy generally sits below that average because fewer children need complex equipment or personal care. ¹¹

The costs families most often report are therapy over many years, orthotics, and adaptive equipment. See the cost of care estimator.

What can you do this week?

1. Ask for the MRI report, including which artery territory and which side.
2. Ask whether an EEG was done and what it showed.
3. Ask what the plan is for stopping seizure medicine, if your baby is on it.
4. Ask about constraint-induced movement therapy and at what age your center offers it.
5. Refer to early intervention now. ¹²
6. Ask whether the placenta was examined, since placental pathology sometimes explains a stroke.
7. If your child is older and you have noticed a hand preference, say so today. Before 12 months it is a finding, not a quirk. ²

What should you ask each specialist?

Take these with you. Write the answers down in the moment, because you will not remember them later.

For the neonatologist or neurologist

• Which artery territory, which side, and how large?
• Did the EEG show seizures we could not see?
• What tests were done to look for a cause, and did any change treatment?
• When do we stop the seizure medicine?
• What should we watch for over the next year?

For the therapy team

• When can we start constraint-induced therapy?
• What do we do at home for the affected hand?
• Should my child have a brace, and what is it for?
• How will we measure whether the arm is improving?

For the ophthalmologist

• Is any part of the visual field affected?
• How would we notice that at home?
• When should we recheck?

You can also build a printable list with the question generator.