Frequently Asked Questions

In the majority of perinatal stroke cases, a definitive cause cannot be found.

This is the single biggest question in perinatal stroke research today but a very difficult one to answer.

One of the only established risk factors is congenital heart disease, usually severe varieties that are easily diagnosed. Such heart problems likely account for <20% of perinatal strokes.

Serious infections in the newborn including bacterial meningitis may cause strokes. This diagnosis is usually easily made and only accounts for a small fraction of cases.

Blood clotting disorders may play a role in some perinatal stroke cases but are seldom the lone factor. You and your child may be evaluated for blood clotting disorders, especially if you have a personal or family history of blood clotting problems.

Disorders of the placenta that could lead to blood clots entering the babies circulation around the time of birth are a suspected cause. This is very difficult to establish as most children present days or months after birth when the placenta has usually been destroyed.

Complications of pregnancy and delivery are common occurrences. They are therefore commonly found in the histories of children ultimately diagnosed with perinatal stroke. However, this does not mean that those factors caused the stroke. In fact, most research to date has not found a strong association between common conditions of pregnancy and delivery with perinatal stroke. Research in this area is ongoing.

It is very important for mothers to know that there is usually nothing they did or did not do during their pregnancy that caused their child’s stroke.

It is human nature to desire a specific answer for such a serious problem. However, it is very important to not attribute the stroke to factors that seem like possible causes if they are not. Please ask your doctor to explain this difficult issue further.

In almost every case, the answer is no.

Since we don’t understand the causes of most perinatal strokes, it is not possible to identify mothers or children at risk. As a result, there are no preventative measures that could have been taken.

It is very reasonable to wonder if anything could have been done differently during the pregnancy, labour, or delivery that might have prevented the stroke. However, no factors have been identified within the current standards of prenatal or obstetrical care that could be changed to try and prevent perinatal strokes.

It is very important for mothers to know that there is usually nothing they did or did not do during their pregnancy that caused their child’s stroke.

The majority of pediatric strokes occur in the perinatal period. To many people’s surprise, the most focused period of risk for ischemic stroke in your lifetime is the week you are born.

Previous estimates suggested an incidence (occurrence) of about 1 per 3000 live births. However, our new data on all perinatal stroke types suggests the risk may be as high as 1:1000 live births. These numbers translate into >1000 Alberta children (0-18 years of age) currently living with the consequences of perinatal stroke.

Diagnosis of perinatal stroke requires a careful assessment of both clinical factors and brain imaging by a specialist familiar with perinatal stroke (usually a pediatric neurologist). There are two main clinical presentations (signs) that alert parents and doctors to a perinatal stroke.

A. Acute presentation as a newborn
Some babies have symptoms in immediate time period (hours to days) after birth. These are most often seizures though other neurological concerns may be present. This in turn leads to imaging being performed that reveals the stroke.

Imaging options include ultrasound, computed tomography (CT or CAT scan), and MRI. Magnetic Resonance Imaging (MRI) is usually the preferred method. Modern MRI is now very sensitive at detecting perinatal stroke. Such imaging could diagnose any of the following:

• Neonatal Arterial Ischemic Stroke (NAIS)
• Neonatal Cerebral Sinovenous Thrombosis (CSVT)
• Neonatal Hemorrhagic Stroke (HS)

B. Delayed presentation later in infancy
As mentioned above, symptoms of perinatal stroke may not be evident in the newborn. Such children present later in infancy with neurological symptoms referable to a stroke on MRI. Weakness on one side is the most common such presentation but other developmental concerns or seizures can occur. Such delayed presentations are called presumed perinatal ischemic stroke (PPIS) and the two main types are arterial presumed perinatal ischemic stroke (APPIS) and periventricular venous infarction (PVI).

Brain Imaging
Once symptoms are recognized, pictures of the brain (neuroimaging) are required. MRI (Magnetic Resonance Imaging) is the best method to do this. Other types of imaging like computed tomography (CT or CAT scans) or ultrasound may suggest a perinatal stroke though MRI is usually still required. MRI is a very safe form of imaging with no radiation. Modern MRI has many new advantages that have improved the diagnosis of perinatal stroke. 

This will depend on each child’s individual circumstance.
Your doctor will consider the following tests for specific reasons:

1. MRI of the brain. Usually required for accurate diagnosis.
2. Electroencephalogram (EEG). Often done for concern of seizures/epilepsy that may be a complication of the stroke. Not always required.
3. Testing for blood clotting disorders. Importance varies depending on stroke type.
4. Educational or Neuropsychology Testing. Important for children who may have problems with areas of development including learning.

This is one of the most common and important questions asked by parents. It is also one of the most difficult to answer accurately.

Stroke is an injury to the brain. Therefore, it is possible that long term challenges in virtually any area of brain function can occur after perinatal stroke. Unfortunately, most children with perinatal stroke suffer at least one such long term challenge. Fortunately, most children avoid most of the different difficulties and many children function extremely well and lead what most would consider very normal and healthy lives.

It is important to remember that a child’s brain development is a constantly evolving process over many years. As a result, any difficulties they might encounter can only be recognized around the age where those abilities are supposed to develop. For example, reaching and grasping objects only begins around 3-4 months. This is why most presumed perinatal ischemic stroke (PPIS) cases are recognized at this age. In comparison, complex learning in the brain (such as calculus) is usually not learned until high school. Therefore, such difficulties might not be recognized for many years.

Recent research has improved our ability to try and predict certain long-term outcomes at the time of diagnosis. However, even in the clearest cases, your doctor can only provide you with a range of possible outcomes. These are often best considered across each of the major elements of child development as follows.

A. Motor or movement system. This is the most common complication of perinatal stroke. The opposite side of the body does not work fully. The range of severity is very wide – from almost normal function to severe impairment. This is what was traditionally called hemiplegic or hemiparetic CP.

B. Learning. Many children with perinatal stroke will have normal learning. However, perhaps 25-30% will encounter difficulties and need extra help in school.

C. Language. Many children with perinatal stroke will have normal language development. However, perhaps 25-30% will encounter difficulties and need extra help, often from a speech language pathologist. Unlike adult stroke, the side of the brain affected seems to have little impact on the risk of language problems.

D. Behaviour. Many children with perinatal stroke will have normal behaviour and mental health. Such problems are not well studied but do occur more commonly in children with perinatal stroke. These can range from relatively mild or common problems like attention deficit or hyperactivity to more significant problems.

E. Vision. Most children with perinatal stroke will have normal vision. The visual parts of the brain seem to be particularly resistant to perinatal stroke though a small proportion of children may have trouble with their vision including a loss of parts of their vision. Common pediatric eye conditions like a lazy eye are probably more common in children with perinatal stroke.

F. Epilepsy. Recurrent seizures can occur in children with perinatal stroke. The onset of seizures can occur at any age, even into adulthood. These can usually be managed with medication. The relative risk varies widely and depends somewhat on the type of stroke. Your child’s approximate risk can be discussed with their neurologist.

It is certainly true that young brains respond differently to injuries like stroke. However, we are still just learning about how this occurs in perinatal stroke. Early studies suggest that different children’s brains will change (“plasticity”) in different ways after a perinatal stroke. Some of these changes will favour better function while others may not. This information is beginning to help develop new treatment strategies. However, a complete understanding of such plasticity remains many years off.

Treatments are designed around each specific complication that may arise. Every child and family are different and treatment plans must be designed accordingly. Generally agreed upon approaches to helping include the following:

Physical disabilities
Treatment options depend on the individual but often include the following:

• Occupational therapy and Physical therapy. Usually includes assessments and ongoing follow-up. Common interventions include exercise and stretching programs carried out mostly in the home.
• Assistive devices. These may help with the positioning of limbs such as an ankle-foot orthosis (AFO) or splints to help positioning of the hand and wrist. These are fitted by therapists.
• Botox. Some specialists can inject botulinum toxin (Botox) to help relax tight muscles that may be impeding function. This requires carefull assessments and the benefits to children with perinatal stroke have not been well studied.
• Surgery. Orthopedic surgeons can sometimes offer procedures such as tendon lengthening or tendon transfers to help improve positioning and function of the affected extremities.

Language delays. Any concerns with language development should be assessed by a speech language pathologist. Supportive treatments and follow-up may be required.

Learning difficulties. Children with perinatal stroke encountering learning difficulties should be assessed by a neuropsychologist or educational psychologist. These experts can perform detailed testing of the brain's highest functions. There is no established ideal time for initial or repeat testing but an evaluation prior to starting school is often reasonable. The evaluator can also communicate their findings to educators to try and ensure the learning environment is as best suited as possible to the individual child.

Behavioural problems. Behavioural and mental health issues may require formal assessments. A pediatrician is a good place to start as they are very familiar with normal child development where behaviour questions are common. From there, your child’s physicians may recommend referral to a child psychologist or psychiatrist for the assessment and management of their behaviour.

Seizures and Epilepsy. Seizures are best diagnosed and managed by a pediatric neurologist. There are many safe and effective medical treatments that are usually successful in controlling seizures. Special treatments such as surgery are indicated in a smaller proportion of cases.

New treatments are always being developed to deal with many of the potential complications of perinatal stroke outlined above. However, parents must be cautious as not all so-called “treatments” are validated as effective or even safe (see below).

A few examples of emerging, potential treatments are listed here:

Constraint-induced movement therapy (CIMT)
This therapy uses gentle restraint of the unaffected upper limb to promote better function in the impaired hand and arm. Such constraint is usually achieved by applying a cast or splint. CIMT has been tried for many years in different neurological disorders and appears generally safe when used for days or weeks at a time. More recently, evidence has shown that CIMT can be effective in adult stroke patients treated many months after their stroke. In addition, a small but growing number of studies in children with hemiplegia / hemiparesis (many of which are likely due to perinatal stroke), appear to also be beneficial. CIMT programs are now being developed at many pediatric care centers including the CPSP. You can ask your therapist or neurologist for more details.

Brain Stimulation
Modern technologies can now “stimulate” the brain non-invasively. This allows measurements to be made to understand brain recovery after stroke but may also be a new way to help the brain function better. The most common example is Transcranial Magnetic Stimulation or TMS. TMS has shown some potential in enhancing function after stroke in adults and in a small study in children with stroke.

The ACH Pediatric TMS Laboratory is currently conducting research on the ability of TMS to both study and help children with perinatal stroke.

Another variety of brain stimulation called Transcranial Direct Current Stimulation (TDCS) is being studied in adult stroke and is just starting to be applied to children with perinatal stroke.

For more information on non-invasive brain stimulation trials going on in our lab, please see our For Researchers and News pages.

Unfortunately, there are a growing number of unproven, potentially dangerous treatments being promoted for children with neurological disabilities. Such options are usually promoted with outright false claims, a complete lack of scientific evidence (or even a good theory), and at the direct financial profit of those offering it.

Things that sound too good to be true almost certainly are.

It is therefore essential that parents encountering potential treatments for their children be aware of this problem and discuss all options carefully with their physician(s). Some common examples include:

Stem cells:

This is an exciting area of research but is unfortunately many years from being tested in children with stroke. This partly for safety reasons as effects of injecting such cells into the bodies of children has not been well studied. Finding a way for such cells to reach the brain, become brain cells, and make the highly complex connections with other brain cells required for brain function is also a major hurdle. Many developing countries are offering stem cell therapies to patients with neurological disability with no evidence of safety or benefit but huge costs to families and profits for themselves. Such therapies should be carefully discussed with your child’s physician.

Hyperbaric Oxygen: 

This provides an excellent example of the challenges parents currently face in caring for their children with stroke. High pressure oxygen therapy has been around for many years. In theory, there is no reason why delivering high oxygen to the brain years after a stroke would have any benefit. Unlike many other therapies, hyperbaric oxygen has been carefully studied in multiple scientific studies to determine if it can help. These studies have clearly shown that there is absolutely no benefit in children with cerebral palsy such as that caused by perinatal stroke. In addition, these and other studies have shown that hyperbaric oxygen can in fact be harmful in several ways. Despite this, it continues to be promoted and offered by those who would profit from its use.

Alternative Medicines:

There are many different forms of alternative medicine that might be considered to help with perinatal stroke. Unfortunately, none have been properly tested to make sure they are both safe and effective. Some well established treatments like massage and perhaps acupuncture seem to help some people with physical disabilities and are probably reasonable to try. However, there is no evidence that other treatments traditionally said to help with “strokes” or “the nervous system” such as herbal supplements, vitamins, or homeopathy offer any benefit. In fact, studies have shown that many such substances can in fact interfere with the blood clotting system or some medications used to treat stroke.

Talking about Alternative Therapies for Cerebral Palsy

The recurrence risk of stroke in additional children / pregnancies is EXTREMELY LOW.

Few studies have addressed this issue but current evidence would suggest the risk to the same parents who are otherwise healthy is probably <1%. Genetic factors have not been strongly implicated in causing perinatal stroke. However, details of your family history might suggest a somewhat higher recurrence risk though the overall risk in most cases will remain low.

You should discuss your child and family’s specific circumstances with your doctor.

The recurrence risk of stroke in children with a perinatal stroke is EXTREMELY LOW. Current evidence suggests the overall risk is probably <1% (i.e. >99% of children with a perinatal stroke will not have another childhood stroke).

The only exception to this appears to be children who have an ongoing significant risk factor for stroke. The most significant examples of this would be complex congenital heart disease. Serious blood clotting disorders are very rare in perinatal stroke children but could also increase the risk of recurrence.

You can discuss your child’s specific circumstances with their doctor.

• Pediatrician is a community-based child health specialist and can often help coordinate multiple issues with child’s general health
• Rehabilitation specialists includes doctors such as physiatrists and developmental pediatricians with expertise in child rehabilitation
• Speech language pathologist for assessment and help with speech or language challenges
• Neuropsychologist for assessment and help with learning and education needs
• Psychologist can assist with the psychological stresses in both child and family that are common in perinatal stroke
• Orthopedic surgeon expert in the “mechanical” complications of stroke such as tightness in the arm or leg that might be helped by surgery
• Hematologist a blood specialist who helps with testing for blood clotting disorders or occasional rare causes of stroke in children
• Neonatologist a pediatrician expert in newborn care is usually involved early in the care of children diagnosed with acute neonatal strokes
• Neurosurgeon occasionally involved when certain types of stroke can be helped with surgical procedures

A list of links to supportive services within the CPSP and additional external sites are provided on our For Families page.

If you cannot find an answer to your question here, please also see our About Stroke page.

If you have concerns or suggestions on additional questions that might be added to this section, please contact the clinic. See our Contact Us page for ways to get in touch with us.