Rashmitha Dachepally
Cleveland Clinic Children's Hospital
Cleveland, Ohio
Disclosure information not submitted.
Samir Latifi, MD
PHYSICIAN
Cleveland Clinic Children's Hospital, United States
Disclosure information not submitted.
Hemant Agarwal, MBBS, MD
PHYSICIAN
Cleveland Clinic Children's Hospital, United States
Disclosure information not submitted.
Title: Large vessels neonatal arterial ischemic stroke in early onset Group B Streptococcal Meningitis
Case Report Body:
Introduction: Neonatal arterial ischemic stroke (NAIS) is an uncommon complication of early onset Group B Streptococcal (GBS) meningitis reported in 11 to 28% of cases. We report NAIS involving large intracranial arteries in a neonate secondary to early onset GBS meningitis.
Description: A 6 day old, 3.6 kg, full-term neonate that delivered at home to a multigravida mother presented with fever, irritability, poor intake and apneas requiring intubation, mechanical ventilation and fluid resuscitation. Mother was simultaneously admitted for endometritis management. Sepsis work-up revealed GBS meningitis, GBS bacteremia, and subclinical status epilepticus. CT scan of brain revealed non-specific findings. An MRI and MRA of the brain was then undertaken that revealed right internal carotid artery irregularity, right middle cerebral artery occlusion with large territory acute infarction of the right anterior circulation and portions of the left anterior circulation suggestive of NAIS. Evaluation for NAIS including echocardiogram, and coagulation studies were negative. She was treated with 21 days of antibiotics and discharged home on levetiracetam. At 4 months follow-up, she has mild weakness of the left upper extremity and no seizures.
Discussion: Two distinct patterns of focal infarction of NAIS in neonatal GBS meningitis have been described before: a deep perforator arterial stroke to the basal ganglia, thalamus and periventricular white matter and a superficial injury with patchy, focal infarctions of the cortical surface. The precise mechanisms for NAIS in GBS meningitis are still unclear. It is proposed that maternofetal inflammation as seen in our patient induces focal arteritis and the regional inflammation promotes platelet aggregation, regional thrombosis, and subsequent occlusion. Invasion of the subarachnoid inflammatory exudate into the large arteries at the base of the brain may have played an additional role in our patient. Clinical presentation of NAIS is often subtle and non-specific, CT scan findings are inconclusive, and MRI and MRA are required to confirm the diagnosis of NAIS. We conclude that NAIS secondary to neonatal GBS meningitis may be more common than reported, can involve the large cerebral arteries and MRI and MRA should be undertaken in the acute phase to identify NAIS and modify treatment.