Cyanosis As a Signal of Perinatal Stroke: Findings at Ultrasound and MRI

The clinical signs and symptoms of perinatal arterial ischemic stroke (PAIS) may be subtle and nonspecific. Imaging studies provide a good choice for early diagnosis. We report a case of extensive arterial ischemic infarct in a full-term neonate, with a focus on ultrasound and MRI findings. A 1-day-old male neonate was born at 37 weeks’ gestation via cesarean section due to breech presentation. He weighed 2225 g (10-25th percentile), was 48 cm in length (50-75th percentile), and had a head circumference of 33 cm (50th percentile). Apgar scores were 6 and 8 at 1 and 5 minutes, respectively. Maternal hypertension developed 2 weeks before delivery and was treated. After birth, delayed initial crying and cyanosis were noted. Resuscitation was done and the infant was hospitalized for observation. On physical examination, weak sucking and breath holding while crying were noted. Cranial ultrasound on day 3 revealed very mild increased echogenicity over the left thalamus, basal ganglia and periventricular area with ventricular compression (Figure 1). Decreased right upper and lower limb movements were observed on day 4 of life. Repeated cranial ultrasound on day 5 of life revealed more echogenicity over left thalamus, basal ganglia and periventricular area (Figure 1). For further evaluation, magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) with diffusion-weighted imaging (DWI) were performed on day 5 of life. The T2-weighted brain MRI (T2WI) showed high signal intensity (SI) over the left fronto-parieto-occipital cortical and white matter areas. MRA showed flow reduction over the left MCA branch (Figure 1). Middle cerebral artery (MCA) infarction was diagnosed. Pre-Wallerian degeneration was also noted on DWI, with high SI over the left posterior limb of internal capsule (PLIC), cerebral peduncle and basis pontis (Figure 2).