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Outcome after neonatal stroke
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Editorial correspondence
Because electrocardiograms are not routinely performed in patients with tuberous sclerosis, 2 it is difficult to establish the frequency (or association) of WPW syndrome in patients with tuberous sclerosis. These experiences indicate that an ECG should be performed in patients with tuberous sclerosis to define this possible relationship. Alfonso Casta, M.D. Department o f Pediatrics University o f Texas Medical Branch Galveston, TX 77550
The Journal o f Pediatrics August 1986
2.
3.
4. 5.
6. REFERENCES
1. Jayakar PB, Stanwick RS, Seshia SS. Tuberous sclerosis and Wolff-Parkinson-White syndrome. J PEDIATR 1986; 108:259. 2. Bass JL, Breningstall GN, Swaiman KF. Echocardiographic incidence of cardiac rhabdomyoma in tuberous sclerosis. Am J Cardiol 1985;55:1379.
Outcome after neonatal stroke To the Editor: I read with interest the follow-up study of newborn infants with focal cerebrovascular accidents by Drs. Trauner and Mannino ~ and commend the authors for their efforts to provide data for informed discussion of prognostic implications with parents. Although I agree that the developmental outcome of term infants with focal brain insults is generally better than in those with multifocal injuries or in premature infants with intraventricular hemorrhage, I question the statement that "the prognosis after neonatal CVA is relatively favorable for normal developmental and motor skills." We have previously reported two patients with spastic hemiparesis and seizures despite normal nonmotor development in a follow-up study of five patients with neonatal cerebral infarction) i have also reviewed the published outcome for an additional 34 term infants with radiographic evidence of unifocal brain injury variously termed stroke or cerebral infarction. 3"6Twenty (59%) of these infants were abnormal at the time of follow-up: 11 had hemiparesis, five had delays in nonmotor development, and four had combinations of motor abnormalities and developmental delay. Permanent hemiparesis in one third of reported patients, significant developmental delays including spastic quadriparesis in others, and continuing seizures in 40% of their own cases cause me to question Trauner and Mannino's conclusions and to recommend a more cautious approach in discussion with affected families. Additional outcome studies with more detailed neurodevelopmental evaluations and follow-up for longer periods will be helpful in resolving this issue. John F. Mantovani, M.D. St. John's Mercy Medical Center 621 S. New Ballas Rd. St. Louis, MO 63141
Reply To the Editor." Dr. Mantovani's comments highlight the diversity of disorders that have been labeled perinatal stroke or infarction. In our series we included only infants who had a single, unilateral infarction that occurred around the time of birth, based on CT scan evidence of recent infarction? "2 We specifically excluded infants with multiple areas of infarction and those with strokes in utero. We believe that the differences between our results and those of other published reports are based, at least in part, on these facts. Ment's study consisted of a diverse group of infants, including preterm patients with intraventricular hemorrhage and those with multiple areas of infarction. O'Brien's report of infants with hypoxic/ischemic lesions is difficult to interpret because they admit that there may he false negative results or that the major site of disease might not have been visible on brain scan; thus we are skeptical about comparing their patients with "unilateral infarction" with ours. Some of Clancy's patients were more comparable to ours, and of the seven infants with unilateral infarcts for whom follow-up information was available, six were normal at up to 24 months of age. The retrospective study of Levy also included infants who seem comparable to ours, and we cannot readily explain the difference in outcome. It is possible that with longer follow-up, results in their patients will be more in line with ours. We expressed cautious optimism about the developmental outcome in children after neonatal stroke. If our experience is to be useful to others, the same criteria of unilateral, single infarctions occurring around the time of birth must be applied. Prognosis is likely to be quite different when a heterogeneous population is included in the category of neonatal stroke. Doris A. Trauner, M.D. Frank L. Mannino, M.D. Departments o f Neurology and Pediatrics H-815-B, UCSD Medical Center San Diego, CA 92103 REFERENCES 1.
REFERENCES
1. Trauner DA, Mannino FL. Neurodevelopmental outcome after neonatal cerebrovascular accident. J PEDIATR 1986;108:459-461.
Mantovani JF, Barnard M, Mendell C, et al. Outcome following neonatal cerebral infarction: preliminary report. Dev Med Child Neurol 1985;27:113. O'Brien M J, Ash JM, Gilday DL. Radionucleotide brainScanning in perinatal hypoxia-ischemia. Dev Med Child Neurol 1979;21:170. Ment LR, Duncan CC, Ehrenkranz RA. Perinatal cerebral infarction. Ann Neurol 1984;16:559-568. Levy SR, Abroms IF, Marshall PC, Rosquete EE. Seizures and cerebral infarction in the full-term newborn. Ann Neurol 1985;17:366-370. Clancy R, Malin S, Laranque D, et al. Focal motor seizures heralding stroke in full-term neonates. Am J Dis Child 1985;139:601-606.
2.
Mannino FL, Trauner DA. Stroke in neonates. J P~DIATR 1983;102(4):605-610. Trauner DA, Mannino FL. Neurodevelopmental outcome after neonatal cerebrovaseular accident. J PEDIATR 1986;108(3):459-461.
Editorial correspondence
Because electrocardiograms are not routinely performed in patients with tuberous sclerosis, 2 it is difficult to establish the frequency (or association) of WPW syndrome in patients with tuberous sclerosis. These experiences indicate that an ECG should be performed in patients with tuberous sclerosis to define this possible relationship. Alfonso Casta, M.D. Department o f Pediatrics University o f Texas Medical Branch Galveston, TX 77550
The Journal o f Pediatrics August 1986
2.
3.
4. 5.
6. REFERENCES
1. Jayakar PB, Stanwick RS, Seshia SS. Tuberous sclerosis and Wolff-Parkinson-White syndrome. J PEDIATR 1986; 108:259. 2. Bass JL, Breningstall GN, Swaiman KF. Echocardiographic incidence of cardiac rhabdomyoma in tuberous sclerosis. Am J Cardiol 1985;55:1379.
Outcome after neonatal stroke To the Editor: I read with interest the follow-up study of newborn infants with focal cerebrovascular accidents by Drs. Trauner and Mannino ~ and commend the authors for their efforts to provide data for informed discussion of prognostic implications with parents. Although I agree that the developmental outcome of term infants with focal brain insults is generally better than in those with multifocal injuries or in premature infants with intraventricular hemorrhage, I question the statement that "the prognosis after neonatal CVA is relatively favorable for normal developmental and motor skills." We have previously reported two patients with spastic hemiparesis and seizures despite normal nonmotor development in a follow-up study of five patients with neonatal cerebral infarction) i have also reviewed the published outcome for an additional 34 term infants with radiographic evidence of unifocal brain injury variously termed stroke or cerebral infarction. 3"6Twenty (59%) of these infants were abnormal at the time of follow-up: 11 had hemiparesis, five had delays in nonmotor development, and four had combinations of motor abnormalities and developmental delay. Permanent hemiparesis in one third of reported patients, significant developmental delays including spastic quadriparesis in others, and continuing seizures in 40% of their own cases cause me to question Trauner and Mannino's conclusions and to recommend a more cautious approach in discussion with affected families. Additional outcome studies with more detailed neurodevelopmental evaluations and follow-up for longer periods will be helpful in resolving this issue. John F. Mantovani, M.D. St. John's Mercy Medical Center 621 S. New Ballas Rd. St. Louis, MO 63141
Reply To the Editor." Dr. Mantovani's comments highlight the diversity of disorders that have been labeled perinatal stroke or infarction. In our series we included only infants who had a single, unilateral infarction that occurred around the time of birth, based on CT scan evidence of recent infarction? "2 We specifically excluded infants with multiple areas of infarction and those with strokes in utero. We believe that the differences between our results and those of other published reports are based, at least in part, on these facts. Ment's study consisted of a diverse group of infants, including preterm patients with intraventricular hemorrhage and those with multiple areas of infarction. O'Brien's report of infants with hypoxic/ischemic lesions is difficult to interpret because they admit that there may he false negative results or that the major site of disease might not have been visible on brain scan; thus we are skeptical about comparing their patients with "unilateral infarction" with ours. Some of Clancy's patients were more comparable to ours, and of the seven infants with unilateral infarcts for whom follow-up information was available, six were normal at up to 24 months of age. The retrospective study of Levy also included infants who seem comparable to ours, and we cannot readily explain the difference in outcome. It is possible that with longer follow-up, results in their patients will be more in line with ours. We expressed cautious optimism about the developmental outcome in children after neonatal stroke. If our experience is to be useful to others, the same criteria of unilateral, single infarctions occurring around the time of birth must be applied. Prognosis is likely to be quite different when a heterogeneous population is included in the category of neonatal stroke. Doris A. Trauner, M.D. Frank L. Mannino, M.D. Departments o f Neurology and Pediatrics H-815-B, UCSD Medical Center San Diego, CA 92103 REFERENCES 1.
REFERENCES
1. Trauner DA, Mannino FL. Neurodevelopmental outcome after neonatal cerebrovascular accident. J PEDIATR 1986;108:459-461.
Mantovani JF, Barnard M, Mendell C, et al. Outcome following neonatal cerebral infarction: preliminary report. Dev Med Child Neurol 1985;27:113. O'Brien M J, Ash JM, Gilday DL. Radionucleotide brainScanning in perinatal hypoxia-ischemia. Dev Med Child Neurol 1979;21:170. Ment LR, Duncan CC, Ehrenkranz RA. Perinatal cerebral infarction. Ann Neurol 1984;16:559-568. Levy SR, Abroms IF, Marshall PC, Rosquete EE. Seizures and cerebral infarction in the full-term newborn. Ann Neurol 1985;17:366-370. Clancy R, Malin S, Laranque D, et al. Focal motor seizures heralding stroke in full-term neonates. Am J Dis Child 1985;139:601-606.
2.
Mannino FL, Trauner DA. Stroke in neonates. J P~DIATR 1983;102(4):605-610. Trauner DA, Mannino FL. Neurodevelopmental outcome after neonatal cerebrovaseular accident. J PEDIATR 1986;108(3):459-461.