JPED Journal

1.      Case Report

The male child was delivered with normal body weight after37 weeks of gestation. The physical examination after birthdid not reveal any abnormality. Gestation and delivery had beenuneventful. There were no risk factors. After 24 hours, thechild spontaneously developed clonic seizures of the right sideof the body involving both arm and leg.

Trans fontanel ultrasound and lumbar puncture were normal, rulingout intracranial hemorrhage or meningitis.Laboratoryfinding showed a leukocyte count of 5500/mm³, with differentials of 41% neutrophils, 54% lymphocytes, 4% monocytes, and 1% eosinophils. The hemoglobin level and platelet count were normal. Serum electrolytes, creatinine, albumin, total bilirubin, protein, and osmolality levels were normal. metabolic study and serum homocysteine were normal.

Factor V Leiden G506 was normal,MTHFR C677, MTHFR A1298C, Prothrombin G20210A were normal.PT,PTT BT, CT, PLT were normal.

Brain MRI revealed there was evidence of an area of hypo density of the right parietal region consisting of tubular structure representing vascular malformation (Figure 1).

2.      Discussion

The incidence of neonatal stroke has been estimatedto be in the range of 1 in 4000 deliveries [7].The causes of neonatalstroke often remain obscure, although many reasons for neonatalinfarctions have been reported. Stroke in neonatesoften presents clinically with seizures but not with focal neurologicaldeficits such as hemiparesis [2-9].

Arteriovenous Malformations (AVM) are the most common cause of hemorrhagic stroke in children. The development of an AVM results from failure in the formation of the capillary bed between primitive arteries and veins in the brain during the first trimester of fetal life[10]. The incidence of AVM in children is 1/100 000 and approximately 10% to 20% of all AVMs will become symptomatic during childhood [3,6]. The average probability of a first hemorrhage is 2% to 4% per year, with a recurrence risk as high as 25% by 5 years.44 Magnetic Resonance (MR) imaging and MRA confirm the diagnosis of AVM[4,5,7,8]. Approximately 1% to 2% of aneurysms become symptomatic during childhood. Aneurysms in children are typically associated with other vascular lesions or chronic disorders. Cavernous malformations can also lead to hemorrhagic stroke in children. One third of cavernous malformations are familial. Cavernous malformations have recently been linked to abnormalities in the long arm of chromosome 7.4[4,5,7-11].

 The risk of recurrent intracranial hemorrhage is slightly elevatedfor a short period of time after the first hemorrhage. In 2 studies[12] the risk during the first year after initial hemorrhagewas 6% and then dropped to the baseline rate, whereas in another study [13], risk of recurrence during the first year was 17.9%. The riskof recurrent hemorrhage may be even higher in the first yearafter the second hemorrhage and has been reported to be 25%during that year [10-17].

At present, there are 4 major treatment options available forpatients with an AVM of the brain. The lesion can be monitoredexpectantly with the understanding that the patient would havesome risk of hemorrhage or other neurological symptoms suchas seizures or focal deficit. Alternatively, intervention canbe undertaken with the goal of complete AVM obliteration, becausesubtotal therapy does not confer protection from hemorrhage.Management strategies include single or combined therapy applyingmicrosurgery, endovascular techniques, or radiosurgery (FocusedRadiation). Each treatment option has associated risks and benefits[13,15]. AVMs are often treated by more than one treatment modality.This occurs in one of two fashions. It is done as either a plannedmaneuver, typically with embolization followed by surgical resectionor radiosurgery, or as an unplanned maneuver where one treatmentmodality fails and a second treatment modality is necessary toobliterate the AVM. This can occur in situations such as residual AVMafter subtotalling surgical resection or resection of an AVM after incompleteradio surgical treatment [8,9,11,16].

Outcomes of treatment in subsequent sections generally includeassociated mortality and morbidity, although these are not reportedconsistently.

Figure1: Brain MRI.

Figure 2: CT Angiography.

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