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Fetal stroke and cerebrovascular disease: advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke and cerebrovascular disease: advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins
Fetal stroke and cerebrovascular disease: advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.

Journal Article, Review
1090-3798
989-1005
Kirkham, Fenella J.
1dfbc0d5-aebe-4439-9fb2-dac6503bcd58
Zafeiriou, Dimitrios
6311a98f-008c-4a32-a414-9b37c088d737
Howe, David
3a4ff013-9aac-4e5f-bb15-67df52fc97fa
Czarpran, Philippa
3e1d3d21-e497-4154-b96c-6dbe7205a7c5
Harris, Ashley
7a2e28eb-3f0e-4847-8c65-6ed6d6eb6715
Gunny, Roxanna
754f0f73-e540-40a1-ab61-809ce35affcd
Vollmer, Brigitte
044f8b55-ba36-4fb2-8e7e-756ab77653ba
Kirkham, Fenella J.
1dfbc0d5-aebe-4439-9fb2-dac6503bcd58
Zafeiriou, Dimitrios
6311a98f-008c-4a32-a414-9b37c088d737
Howe, David
3a4ff013-9aac-4e5f-bb15-67df52fc97fa
Czarpran, Philippa
3e1d3d21-e497-4154-b96c-6dbe7205a7c5
Harris, Ashley
7a2e28eb-3f0e-4847-8c65-6ed6d6eb6715
Gunny, Roxanna
754f0f73-e540-40a1-ab61-809ce35affcd
Vollmer, Brigitte
044f8b55-ba36-4fb2-8e7e-756ab77653ba

Kirkham, Fenella J., Zafeiriou, Dimitrios, Howe, David, Czarpran, Philippa, Harris, Ashley, Gunny, Roxanna and Vollmer, Brigitte (2019) Fetal stroke and cerebrovascular disease: advances in understanding from lenticulostriate and venous imaging, alloimmune thrombocytopaenia and monochorionic twins. European Journal of Paediatric Neurology, 22 (6), 989-1005. (doi:10.1016/j.ejpn.2018.08.008).

Record type: Review

Abstract

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.

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Fetal stroke final - Accepted Manuscript
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e-pub ahead of print date: 11 September 2018
Published date: November 2019
Keywords: Journal Article, Review

Identifiers

Local EPrints ID: 426780
URI: http://eprints.soton.ac.uk/id/eprint/426780
ISSN: 1090-3798
PURE UUID: 403cbb6a-9434-4897-993b-d3b3d8ca179f
ORCID for Fenella J. Kirkham: ORCID iD orcid.org/0000-0002-2443-7958
ORCID for Brigitte Vollmer: ORCID iD orcid.org/0000-0003-4088-5336

Catalogue record

Date deposited: 12 Dec 2018 17:30
Last modified: 22 Nov 2021 07:01

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Contributors

Author: Dimitrios Zafeiriou
Author: David Howe
Author: Philippa Czarpran
Author: Ashley Harris
Author: Roxanna Gunny

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