Presentation
Abnormal brain findings at the 2nd trimester screening. Previous personal, familial and obstetrical history is non relevant.
Patient Data
In the left frontal lobe, hyperechoic with hypoechoic centre lesion within the deep and periventricular white matter. Interestingly, this lesion has no mass effect on the lateral ventricle, and it has smooth margins.
The left frontal lesion hence shows DWI hyperintensity, with T2* and T1 peripheral hyperintensity: ischaemia with peripheral subacute haemorrhage. Note also that there is an associated blood clot in the left lateral ventricle.
There is no obvious mass effect, nor peripheral oedema.
All these findings are very suggestive of a clastic lesion.
The evolution of the images is typical of a clastic lesion: after resorption of the ischaemic tissue and haemorrhage, there was now a focal porencephaly with haemosiderin tattooing on its margins.
Case Discussion
Our diagnosis was hence fetal stroke: probably ischaemic stroke with secondary haemorrhagic transformation.
(Haemorrhagic stroke could also be a possibility although the absence of mass effect and central lucency without haemorrhagic signal make this hypothesis less likely. Besides, in most paediatric and fetal clastic lesions, haemorrhage and ischaemia are associated.)
We performed a second fetal brain MRI at 32WG (not shown), which showed the same findings as the postnatal neonatal brain MRI displayed.
The evolution of the images is typical of a clastic lesion: after resorption of the ischaemic tissue and haematoma, there was now a focal porencephaly with haemosiderin tattooing on its margins.
(Conversely, persistence of the same MRI findings would have indicated a hypercellular brain tumour, which could have been a differential diagnosis.)
The child was delivered normally at 38WG. Neonatal clinical examination was normal. Neurological development will be under close watch for the next few years.
We screened both child and mother for infectious causes (CMV, toxoplasmosis, syphilis, CMV, hepatitis B, rubeola, Parvovirus B19), for alloimmune thrombocytopenia and for autoimmune diseases: the extensive screening did not pick up any risk factor.
Fetal stroke has been associated with postnatal epilepsy, intellectual disability, and cerebral palsy. The entity is caused by antenatal ischaemic, thrombotic, or haemorrhagic injury. Although roughly half of the cases are idiopathic, the most common maternal conditions associated with fetal stroke are alloimmune thrombocytopenia and trauma. Fetal and paediatrics stroke display different patterns from those expected in adult patients: lenticulostriate territory is often involved.
For more information, refer to the references below.
Unable to process the form. Check for errors and try again.