Perinatal stroke and overlapping clinical presentation with HIE; studying practical diagnostic and management challenges through observational analysis of a single tertiary centre stroke patients

Background: While therapeutic hypothermia is accepted as a standard of care for improving neurological outcome for HIE patients, evidence of its benefits for neonatal stroke is lacking. Neurological presentations of HIE and neonatal stroke can be difficult to distinguish and indeed neonatal stroke can coexist with HIE. Our observational analysis of a single centre cohort of stroke infants with MRI diagnosis highlights the practical challenges for distinguishing between the two groups and reaching an early definitive diagnosis to inform appropriate treatment. Methods: A retrospective cohort study of term neonates >37 weeks gestation born between May 2011 and April 2020 born at a specialised NICU network in the East of England with a principal diagnosis of neonatal stroke were obtained from Badgernet data. Results: 81% of infants (13/16) had sentinel events around delivery. 50% (8/16) of infants were therapeutically cooled. Of the 8 cooled infants only 3 (37%) of cooled infants fulfilled both Toby A and B criteria. Infants who received therapeutic hypothermia were more likely to present with early onset seizures (5/8) than infants who were not cooled (1/8) (p=0.019) . 6 of the 8 non-cooled infants compared to 2of the 8 cooled infants (p=0.03) had a higher seizure burden requiring escalation of antiepileptic medication to second line or need for maintenance treatment. Conclusion: Infants with neonatal stroke who present with early seizures are more likely to receive therapeutic hypothermia despite failure to fulfil both Toby A and B criteria. Early suspicion to inform management can be obtained more effectively from CFM while cranial ultrasound findings are generally non-specific. A normal CFM background, unilateral abnormal background and unilateral seizure activity are highly suggestive of neonatal stroke.