Clinical Prediction of Perinatal Arterial Ischemic Stroke
Perinatal stroke is a well-defined but heterogenous group of disorders involving a focal disruption of cerebral blood flow between 20 weeks gestation and 28 days of life. At a combined incidence of 1:1000 live births, stroke in the perinatal period is more common than at any other time in childhood. Morbidity of perinatal stroke is high, and it is the most common cause of hemiparetic cerebral palsy. Years living with disability are amplified with deficits lasting a lifetime. Perinatal arterial ischemic stroke (PAIS) is the most common type of perinatal stroke. Advances in neuroimaging have allowed for exceptional growth in stroke diagnosis. However, etiology is poorly understood. Many pregnancy, delivery, and fetal risk factors have been considered, but targeted treatment and prevention efforts are still not possible. This thesis reviewed perinatal stroke and developed a diagnostic risk prediction model for PAIS. Pathophysiology, strategies for diagnosis, investigations, management, and outcomes were broken down by perinatal stroke disease, with an additional focus on family mental health and active trials for acute intervention. A diagnostic prediction model was then developed using novel, multisource data and multivariable logistic regression. Clinical pregnancy, delivery, and neonatal risk factors were collected from four registries including the Alberta Perinatal Stroke Project, Canadian Cerebral Palsy Registry, International Pediatric Stroke Study, and Alberta Pregnancy Outcomes and Nutrition study. Variable selection was based on peer-reviewed literature. The final model included nine clinical factors – maternal age, tobacco exposure, substance exposure, pre-eclampsia, chorioamnionitis, intrapartum maternal fever, emergency c-section, low 5-minute Apgar score, and male sex – to predict the risk of PAIS in a term neonate with good discrimination between cases and controls (C-statistic 0.73). This work highlights the lifelong effects of perinatal stroke on patients and families, and the potential for early perinatal stroke diagnosis. Findings suggest that clinical prediction and early, accurate diagnosis of PAIS may be possible using common clinical variables. Future research is needed to optimize risk prediction by better understanding perinatal stroke pathophysiology, including the role of the placenta, and identifying high-risk groups.
Srivastava, R. (2022). Clinical prediction of perinatal arterial ischemic stroke (Master's thesis, University of Calgary, Calgary, Canada). Retrieved from https://prism.ucalgary.ca.