Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. (November 2018)

• Record Type: Journal Article
• Authors: Kirkham, Fenella J.; Zafeiriou, Dimitrios; Howe, David; Czarpran, Philippa; Harris, Ashley; Gunny, Roxanna; Vollmer, Brigitte
• Is Part Of: European journal of paediatric neurology. Volume 22:Number 6(2018:Nov.)
• Page Start: 989
• Page End: 1005
• Publication Date: 2018-11
• Subjects: Fetus -- Stroke -- Focal ischemia -- Intraparenchymal hemorrhage -- Posterior fossa hemorrhage -- Subarachnoid hemorrhage -- Periventricular hemorrhage -- Intraventricular hemorrhage -- Periventricular leukomalacia -- Encephalomalcia -- Porencephaly -- Polymicrogyria -- Schizencephaly -- Hydrancephaly -- Focal cortical dysplasia -- Vascular disruption -- Monochorionic diamniotic twins -- Parabiotic -- Placental anastomoses -- Twin twin transfusion syndrome -- Twin oligohydramnios polyhydramnios syndrome -- Selective intrauterine growth retardation -- Twin anemia polycythemia syndrome -- Twin reverse arterial perfusion -- TTTS -- TOPS -- sIUGR -- TAPS -- TRAP -- Fetal and neonatal alloimmune thrombocytopenia -- FNAIT -- Endothelial dysfunction -- Venous sinus thrombosis -- Dural venous ectasia with thrombosis -- Fetal periventricular venous infarction -- Lenticulostriate vasculopathy -- Middle cerebral artery peak systolic velocity -- Vein of Galen malformation -- Hypovolemia -- Anemia -- Polycythemia -- Embolus -- Pulmonary hypertension -- Right ventricular outflow tract obstruction -- Cytomegalovirus -- Zika -- Parvovirus B19 -- Thermolabile methylene tetrahydrofolate reductase polymorphism -- Factor V leiden -- Prothrombotic -- COL4A1 -- COL4A2 -- Trauma -- Maternal warfarin -- Maternal cocaine; Pediatric neurology -- Periodicals; Nervous System Diseases -- Periodicals; Child -- Periodicals; Infant -- Periodicals; Neurologie pédiatrique -- Périodiques; Pediatric neurology; Electronic journals; Periodicals; Electronic journals; 618.928
• DOI: 10.1016/j.ejpn.2018.08.008
• Languages: English
• ISSNs: 1090-3798

Abstract

Abstract: Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.