A male infant was born at 39 weeks of gestation by planned cesarean section delivery for macrosomia. Mother had a pregnancy history of diet-controlled gestational diabetes mellitus and preeclampsia. Prenatal US was normal. Birth weight was 3935 g. The infant emerged with a vigorous cry and a good tone for gestational age. Respiratory support was not provided in the delivery room. Heart rate was greater than 100 during delivery room observation and interventions. Apgar scores at 1 and 5 minutes were 8 and 9, respectively. The patient had difficulties with breastfeeding from the first day of birth. He developed a seizure on day 3 of life, which lasted 90 seconds with myoclonic jerking of his right arm and leg. There were no abnormal facial movements, eye deviation, eyelid fluttering, or lip smacking. There was no family history of seizures. His exam was otherwise appropriate for his age with soft, flat fontanelles.

Head US at 3 days after birth was normal. Brain MRI without contrast on day 4 showed confluent restricted diffusion consistent with an acute ischemic infarct involving the left middle and inferior frontal gyri ( Fig. 10.1 ).

Perinatal arterial ischemic stroke. Brain MRI, (A and B) axial T2, and (C and D) axial ADC, show cytotoxic edema and restricted diffusion in the left frontal cortex in the superior MCA territory ( arrows ). ADC , Apparent diffusion coefficient; MCA , middle cerebral artery .

The most common clinical symptom of neonatal arterial ischemic stroke (NAIS) in term infants is seizures, especially focal seizures with onset after 12 hours of life. The timing is different than in HIE, for which seizures most often occur in the first 12 hours. In one study, the mean time of seizure onset in NAIS was 27.8 hours versus 5.1 hours in HIE. Other differential diagnoses for neonatal seizure include intracranial hemorrhage, intracranial infection, developmental defects, hypoglycemia, hypocalcemia, metabolic disorders, and epilepsy syndromes.