LAUSR

Dear Editor: Perinatal ischemic stroke is a cerebrovascular disease that results in ischemic and hemorrhagic injury around focal or multifocal cerebral vessels [1]. In this article, we presented clinical and neuroimaging findings of infants with perinatal ischemic stroke (PAIS) to emphasize the importance of PAIS. The study includes three infants with PAIS, admitted to a tertiary referral university hospital Necmettin Erbakan University, Meram Medical Faculty, Department of Neonatology, between January 2011 and May 2018. The patients’ data were obtained from chart review of hospital records. Firstly, the records of all those diagnosed with PAIS were reviewed from the hospital database. We identified 36 infants with a possible diagnosis of PAIS. Clinical, laboratory, and neuroimaging findings of these infants were carefully reevaluated. Three infants were diagnosed with definite PAIS. PAIS was defined by either of two methods: (i) documented partial or complete occlusion of the vessel in relation to a focal brain lesion or (ii) documented lesion pattern with imaging that can only be explained by occlusion of a specific brain vessel. Demographic, clinical, and laboratory characteristics in infants with PAIS are seen in Table 1. Cranial magnetic resonance angiography was also performed in case 1 (Fig. 1). In case 1, homocysteine and factor Xa levels were normal; however, factor V Leiden (G1691A) gene mutation was heterozygous positive He was also operated because of patent ductus arteriosus. Our patients had at least one maternal or neonatal risk factor for PAIS. In a meta-analysis including a total of 11 studies, intrapartum fever > 38 °C, pre-eclampsia, oligohydramnios, primiparity, forceps delivery, vacuum delivery, fetal heart rate abnormalities, abnormal cardiotocography tracing, cord abnormalities, birth asphyxia, emergency caesarean section, tight nuchal cord, meconium-stained amniotic fluid, umbilical arterial pH < 7.10, Apgar score at 5 min < 7, resuscitation at birth, hypoglycemia, male gender, and small for gestational age were identified as risk factors for PAIS [1]. In our study, three infants were diagnosed with definite PAIS after ruling out disorders mimicking arterial ischemic stroke. The most important imaging mimics in arterial ischemic stroke imaging are those conditions associated with brain cytotoxic edema on diffusion-weighted imaging-apparent diffusion coefficient studies and false penumbra on perfusion studies [2]. Although typically associated with arterial ischemic stroke, brain cytotoxic edema may also be present in other disorders such as acute demyelinating lesions, encephalitides, diffuse axonal injury, hypoglycemia, hemiplegic migraine, seizures, transient global amnesia, and carbon monoxide poisoning [3]. Sepsis, hyperglycemia, hyponatremia, and hypernatremia may also mimic arterial ischemic stroke [4]. It is also well known that hypoxic-ischemic lesions appear as areas of diminished signal intensity on the apparent diffusion coefficient maps (i.e., restricted diffusion) in neonatal encephalopathy following perinatal asphyxia [5]. The main limitation of our study is that some infants with definite PAIS may have overlooked because this is a retrospective study. In conclusion, our findings showed that PAIS was uncommon because only three infants were diagnosed in a tertiary referral university hospital for over 7 years. Based on our findings, we suggest that infants with possible PAIS should be carefully evaluated for disorders and diseases mimicking arterial ischemic stroke. * Hüseyin Çaksen [email protected]