title: [Neonatal arterial ischemic stroke: Review of the current guidelines].
abstract: Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.
authors.affiliation: Service de réanimation néonatale et pédiatrique, hôpital Clocheville, CHU de Tours, 49, boulevard Béranger, 37000 Tours, France; Inserm U930, université François-Rabelais de Tours, bâtiment Vialle, 10, boulevard Tonnellé, 37032 Tours, France. Electronic address: elie.saliba@univ-tours.fr.
authors.forename: E
authors.initials: E
authors.lastname: Saliba
authors.affiliation: Clinique universitaire de médecine et réanimation néonatale, CHU de Grenoble, BP 217, 38043 Grenoble, France.
authors.forename: T
authors.initials: T
authors.lastname: Debillon
authors.affiliation: Paris, France.
authors.forename: S
authors.initials: S
authors.lastname: Auvin
authors.affiliation: Paris, France.
authors.forename: O
authors.initials: O
authors.lastname: Baud
authors.affiliation: Paris, France.
authors.forename: V
authors.initials: V
authors.lastname: Biran
authors.affiliation: Clamart, France.
authors.forename: J-L
authors.initials: JL
authors.lastname: Chabernaud
authors.affiliation: Saint-Étienne, France.
authors.forename: S
authors.initials: S
authors.lastname: Chabrier
authors.affiliation: Grenoble, France.
authors.forename: F
authors.initials: F
authors.lastname: Cneude
authors.affiliation: Paris, France.
authors.forename: A-G
authors.initials: AG
authors.lastname: Cordier
authors.affiliation: Dijon, France.
authors.forename: V
authors.initials: V
authors.lastname: Darmency-Stamboul
authors.affiliation: Lille, France.
authors.forename: J-F
authors.initials: JF
authors.lastname: Diependaele
authors.affiliation: Grenoble, France.
authors.forename: T
authors.initials: T
authors.lastname: Debillon
authors.affiliation: Angers, France.
authors.forename: M
authors.initials: M
authors.lastname: Dinomais
authors.affiliation: Grenoble, France.
authors.forename: C
authors.initials: C
authors.lastname: Durand
authors.affiliation: Grenoble, France.
authors.forename: A
authors.initials: A
authors.lastname: Ego
authors.affiliation: Tours, France.
authors.forename: G
authors.initials: G
authors.lastname: Favrais
authors.affiliation: Tours, France.
authors.forename: Y
authors.initials: Y
authors.lastname: Gruel
authors.affiliation: Paris, France.
authors.forename: L
authors.initials: L
authors.lastname: Hertz-Pannier
authors.affiliation: Le Kremlin Bicêtre, France.
authors.forename: B
authors.initials: B
authors.lastname: Husson
authors.affiliation: Rouen, France.
authors.forename: S
authors.initials: S
authors.lastname: Marret
authors.affiliation: Lille, France.
authors.forename: S
authors.initials: S
authors.lastname: N'Guyen The Tich
authors.affiliation: Tours, France.
authors.forename: T
authors.initials: T
authors.lastname: Perez
authors.affiliation: Tours, France.
authors.forename: E
authors.initials: E
authors.lastname: Saliba
authors.affiliation: Tours, France.
authors.forename: J-B
authors.initials: JB
authors.lastname: Valentin
authors.affiliation: Lyon, France.
authors.forename: C
authors.initials: C
authors.lastname: Vuillerot
mesh_terms: D002544:Cerebral Infarction / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D003937:Diagnosis, Differential; D019983:Guideline Adherence; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D033183:Interdisciplinary Communication; D000070516:Intersectoral Collaboration; D012008:Recurrence; D012307:Risk Factors