What is Perinatal Stroke?
A stroke occurring around the time of delivery can be referred to as a perinatal stroke.
Specifically: “An area of damaged cerebral (brain) tissue resulting from disruption to blood flow in a major cerebral artery from thrombosis or embolism … which occurs between 20 weeks of fetal life and the 28th postnatal day, and confirmed by neuroimaging (brain MRI) studies” and it is in relation to this where the term is most frequently used.
It is important to add that strokes presenting in newborn babies, or in older children with the long-term effects of perinatal stroke, are very different from the strokes seen in adults.
How Does Perinatal Stroke Present?
Perinatal stroke often presents in the newborn period with seizures or can masquerade as Hypoxic – Ischaemic Encephalopathy.
Later in infancy and childhood the long-term effects of perinatal stroke on the brain frequently present as hemiplegic cerebral palsy; that is cerebral palsy affecting one side of the body. As the brain supplies the muscles of the opposite side of the body a right-sided perinatal stroke will cause a left-sided hemiplegia (and vice versa).
Healthcare needs following a perinatal stroke can be lifelong and in addition to hemiplegia, children can be affected by epilepsy, learning difficulties and behavioural problems.
However, some children affected by perinatal stroke can have a normal outcome.
How Big Is the Problem?
Approximately 1 in every 2500 newborns will have a perinatal stroke each year.
In a large city such as Leeds where my clinical practice is based that would mean approximately 4 affected babies per year.
Why Is It Important in Clinical Negligence?
I have been involved in several clinical negligence cases involving a child affected by perinatal stroke. Cases in this area highlight the importance of joint working across specialities in clinical negligence cases.
- Firstly, midwifery and/or obstetric opinion when the management of labour is a matter of concern and could potentially have had serious subsequent effects on the baby.
- Paediatric Neurology opinion to review the child’s condition and prognosis,
- Neuroradiology opinion to opine on the MRI scan findings, and
- Paediatric Neuropsychology and Educational Psychology opinion to review the child’s condition and prognosis
Perinatal stroke is challenging in terms of causation where there are associations with aspects of maternal health and labour but these remain associations rather than causes. For example, evidence of fetal distress in labour is not uncommon in cases where a diagnosis of perinatal stroke is subsequently made, but is this the cause of the stroke, or, in fact, a result of the stroke?
This then makes causation challenging in cases where there are concerns, or even admitted breaches in the management of labour.
Chorioamnionitis has been described as a risk factor for stroke, therefore, along with fetal distress causation is often explored following a potentially delayed delivery.
Being able to state however, on balance of probability, when delivery should have occurred in order to avoid the perinatal stroke can also be a challenge.
To Summarise – The 5 Key Points
- Perinatal stroke frequently presents in the neonatal period or in infancy / childhood with hemiplegic cerebral palsy.
- Cerebral palsy is a descriptive term for the consequences on movement and muscle control of a static insult to the brain before or around the time of birth.
- Hemiplegia describes a weakness or stiffness or lack of control of one side of the body.
- Additional effects of stroke on learning and development can result in lifelong education and healthcare needs.
- Medical negligence cases in perinatal stroke frequently centre around the management of labour and whether appropriate management of the labour could have avoided the development of the perinatal stroke. Causation in such cases can be challenging.
- Joint working across specialities in these cases is important.