Neonatal Arterial Ischemic Stroke (NAIS)

Presentation & Risk Factors

• Most common presentation: Focal motor seizures (e.g., rhythmic twitching of one arm/leg) occurring at 12 to 72 hours of life in a term infant.
• Non-specific signs: Encephalopathy, hypotonia, apnea.
• Maternal/Placental risk factors: Chorioamnionitis, preeclampsia, placental abruption, fetal growth restriction.
• Neonatal risk factors: Complex congenital heart disease, polycythemia, sepsis, extremely difficult instrumented delivery.
• Most common territory: Left Middle Cerebral Artery (MCA).

Diagnostic Imaging & Workup

• MRI Brain (without contrast) including Diffusion Weighted Imaging (DWI) and Apparent Diffusion Coefficient (ADC) is the GOLD STANDARD.
• DWI effectively shows intensely bright restricted diffusion within hours of the purely ischemic event.
• Head Ultrasound with Doppler: May miss early ischemic changes but required to rule out acute massive intraventricular/parenchymal hemorrhage.
• Extensive thrombophilia workup: Factor V Leiden, Prothrombin gene mutation, Protein C/S deficiency, Antithrombin III, Lupus anticoagulant (must draw prior to any blood transfusions).
• Echocardiogram: Mandated absolutely to rule out structural cardiac clots or paradoxical emboli through a PFO/ASD.

Acute Management & Neuroprotection

• Treatment consists strictly of supportive care and precise seizure control. (tPA / thrombolytics are universally CONTRAINDICATED in neonates).
• Strict stabilization: Avoid both hypoglycemia and hyperglycemia. Target SpO2 94-99%. Strictly maintain normothermia (avoid hyperthermia).
• Anticonvulsant therapy (Phenobarbital, Levetiracetam) explicitly required if continuous clinical or subclinical aEEG seizures persist.
• Anticoagulation (LMWH - Enoxaparin): Indicated ONLY if a massive ongoing cardioembolic source is proven, or there is severe progressive venous sinus thrombosis. Routine use in NAIS is not backed by evidence.

Diagnostic & Management Algorithm

• Neonatal Stroke Management: [START] Focal seizures / hemiparesis -> [ACTION] MRI Brain -> [EVALUATE] Infarct vs Hemorrhage -> [DECISION] Hypercoagulable workup -> [GOAL] Supportive care

References

1. Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke.