J Clinical Chiropractic Pediatrics 2012 (Jun); 13 (1): 958–967 ~ FULL TEXT
Lise Hestbaek, PhD, Annette Jørgensen, DC, and Jan Hartvigsen, PhD
Nordic Institute of Chiropractic and Clinical Biomechanics,
Introduction: In recent years, improvements in medical techniques and technology have enabled primary health care practitioners to diagnose perinatal strokes in infants far earlier than ever before. This new technology can also support chiropractors, especially those working with pediatric patients, in order to validate their diagnosis when they recognize these initial symptoms.
Objective: The aim of this paper is to raise awareness and assist doctors of chiropractic in recognizing the physical and behavioral signs of perinatal stroke as they present in a chiropractic office for assessment and treatment. The paper will relate the case of a
7–month-old infant who, after visiting a chiropractic office with apparent hemiparesis and delayed developmental milestones, was post-medically diagnosed as having suffered a presumed perinatal stroke.
Discussion: Early recognition of perinatal stroke is vital since late diagnosis can lead to a lifetime of debilitating neurological conditions as well as potential increased direct and indirect costs to society. For those who receive a late diagnosis, a chiropractor, as a member of a multidisciplinary team, can play a major role in rehabilitation by supporting the function of the nervous system,
reducing muscle and joint rigidity and optimizing neuronal plasticity.
Conclusion: It would be prudent for chiropractors to receive more training in the detection of perinatal stroke. Early detection can be accomplished by way of a comprehensive questionnaire and focused physical examination. The early detection of possible perinatal stroke will permit a referral to the proper professional and rapid intervention which will increase the likelihood of a positive outcome. More studies need to be done to reach a better understanding of the pathophysiology of perinatal strokes. Clinical guidelines also need to be established that will improve the prognosis for pediatric patients.
Key words: perinatal stroke, infantile stroke, fetal stroke, presumed prenatal stroke, chiropractic, west syndrome, hemiparesis, cerebral palsy, delayed milestones, rehabilitation
From the FULL TEXT Article
Perinatal strokes are now estimated to occur in 1 in
4,000–5,000 newborn babies. [1–4] As a result of today’s new
imaging technologies, the rate of diagnosis of this condition
is on the rise. Because symptoms may not appear until a
baby is between the ages of 4 to 6 months, a chiropractor
may be the first health care professional that parents seek
out when they encounter difficulties while breastfeeding
or become aware of a delay in reaching expected developmental
milestones. Chiropractic is a health care profession
that focuses on disorders of the musculoskeletal system and
the nervous system, and the effects of these disorders on
At a perinatal stroke workshop held in 2007, perinatal
ischemic stroke was defined as a group of heterogeneous
conditions where neither a focal disruption of cerebral
blood flow secondary to arterial ischemic stroke (AIS) or
cerebral venous thrombosis (CVT) occurs nor embolization
(hemorrhage) between 20 weeks of fetal life to the
28th post-natal day, and confirmed by neuroimaging or
neuropathological studies. [5–7] If blood flow is interrupted
for a period of time longer than a few seconds, the brain
can be permanently damaged. Early recognition is important
and contributes to an improved prognosis. 80% of
all perinatal strokes are ischemic while the remainder are
hemorrhagic or venous. 
As recommended by Raju et al. (2007), perinatal
strokes can be classified more effectively by the timing of
their detection rather than by the time of onset.  Therefore,
we divide them into three categories;
neonatal stroke and
presumed fetal or neonatal stroke.
category involves obtaining evidence from an imaging
study of a long-standing stroke without previous clinical
symptoms. In these cases, though, suspicions were raised
because of the higher prevalence of chronic neurological
deficits and cerebral palsy. [5, 7, 9]
The clinical presentation of a perinatal stroke depends
on the age of the child at the time of diagnosis. In newborns
that are diagnosed in the early stages, 25 to 40% have seizures. 
This is the most common trigger for the provision
of more detailed assessment. Most seizures are focal and
infants may appear well between seizures. Other systemic
signs, if present, are nonspecific and subtle and may include
difficulty feeding, hypotonia, lethargy, or apnea. In neonatal
strokes diagnosed retrospectively (also called presumed
neonatal stroke), the presentation includes asymmetry of
reach and grasp, hemiparesis, failure to reach developmental
milestones, or post-neonatal seizures. 
Medical management consists of aggressively treating
the symptoms, mostly seizures. In the presence of refractory
hemispheric epilepsy, hemispherotomy and functional
hemispherectomy could be indicated to reduce or eliminate
seizures and promote neurological development  in the
infant, and later, the child. To our knowledge, the current
literature contains no studies or case reports on chiropractic
management (CINAHL (EBSCO), Medline, Pubmed,
Index to chiropractic literature). It is possible that chiropractors
can play a major role in increasing brain plasticity
thereby optimizing long term functionality as part of a
multi-disciplinary team approach. Today’s chiropractors
need to remain current on the information pertaining to
this condition in order to assess patients utilizing detailed
case history, a thorough physical examination to clarify the
diagnosis, recommend referrals, and be members of the rehabilitation
team alongside other health care professionals.
For the purposes of this paper, childhood stroke will
not be discussed; detailed information is provided elsewhere.
[1, 8, 11]
A female infant was born at 38 weeks, 4 days gestation
to a 37–year-old mother, gravida 4 para 4. The history of the
pregnancy was unremarkable with the exception of some
medication administered for nausea (Diclectin®) which was
taken in the first trimester. Two ultrasounds were performed
at 12 and 28 weeks respectively and were normal. The birth
was a normal vaginal delivery with APGAR scores of 9–10
after 1 and 5 minutes. Total labor time was 6 hours with
45 minutes of pushing; the baby presented posteriorly and
had to be assisted by manual extraction. No medication/
sedation was administered during labor, no stimulation
of labor or epidural anesthesia; no placental examination
was performed. The mother was discharged from the
hospital within 72 hours, without any apparent problems.
Breastfeeding was difficult at first. When the baby initially
latched, the suckle was weak attributed to the sleepy state
of the baby, but the mother persevered and was ultimately
successful. In this case, the mother was experienced, knowledgeable
and was a breastfeeding support mother in a lactation
group. During her hospital stay, she was expressing
milk and giving it to the infant with a spoon. In her first
month of life, the baby also required an intervention for a
posterior tongue tie which also contributed to difficulties
with latch and transfer of milk.
In the first months, the mother reported some slight
delays in the baby’s attainment of expected developmental
milestones. She noticed that her baby was not as alert as
her other children were at the same age, but she was able to
smile and interact with others. By comparison, eventually
she noticed that some significant milestones were delayed,
these included; head holding, an absence of ventral positioning
and an asymmetry in the use of her upper extremities.
She reported that a few weeks after birth, the baby was
not using her right arm as much as the left one and that her
hand was mostly held in a fist and maintained in flexion. At
the age of six months, the baby was moving her arm at the
elbow joint and her hand was able to open more frequently.
During her last medical visit at 6½ months, the medical
doctor expressed no concern about the infant’s condition
and the delayed milestones and suggested a follow up a
month later. She demonstrated no ability to sit and was not
comfortable lying in the prone position (“tummy time”).
It is notable that the child was the family’s 4th daughter
and that the mother, based on her previous experiences,
was aware that something was wrong.
The baby was brought to our office for a physical
evaluation at 7 months. Observations showed reduced
facial expressions with an asymmetry of the eye gaze, the
right eye having a tendency to diverge at some point and a
delay in the active cervical motion when following objects.
She was able to smile although she was reluctant, not often
making eye contact. The level of activity of the upper
extremity was reduced and asymmetrical although she was
using the upper extremity mostly at the elbow and within
60 degrees of shoulder flexion on the right side. The baby
was uncomfortable in the ventral position and displayed a
lack of extension at the occipital and cervicothoracic areas.
She wasn’t able to turn on either side and failed to attempt
to do so even when stimulated. The infant could not sit up,
with or without support, and she was unable to be pulled
up by hand into a sitting position. She was able to bring
objects close to her mouth with her left hand only.
The cranial evaluation showed normal fontanels. Some cranial restrictions were noted in the following bones;
parietal, frontal, temporal, occiput, and sphenoid. Light
palpation of the cranials elicited a withdrawal reflex accompanied
by crying and palpation of the upper cervical region
as well. Tongue movement was within normal limits and
sucking occurred during breastfeeding though the infant
refused to do so when stimulated digitally.
The range of motion of the cervical spine was restricted
in right rotation and in flexion/extension with tension at the
suboccipital area. The occiput was slightly fixed in extension.
The range of motion (ROM) of the right shoulder,
clavicle and scapula were restricted and elicited a crying
response from the baby. The pectoralis, SCM, scalene, subclavian,
biceps, subscapularis, upper trapezius, and levator
scapula muscles were all hypertonic on the right side; The
ROM of the right hip was also reduced mostly in long axis
traction and internal rotation but both legs were restricted
and positioned in abduction and external rotation.
During the neurological examination, the Babinski
reflex was present bilaterally but slightly reduced on the
right side. The palmar grasp reflex, the Moro reflex and the
ATNR (asymmetric tonic neck reflex) were reduced on the
right side. Deep tendon reflexes were not performed at the
The chiropractic examination showed vertebral subluxations
upon palpation at C0–C2, C6–T1, T3–5, T9–T10
with a posterior left sacrum at the S1 segment.
The first working diagnosis at that time was of an
obstetrical brachial plexus injury with biomechanical
dyskinesia (vertebral subluxation complex) around the C0–
C2 and C7–T5 areas also involving the shoulder area complex.
Other differential diagnosis included complications
of consolidated clavicle fracture, a possible cerebral lesion
like cerebral palsy or tumor. Two weeks after the first visit,
some additionally symptoms were observed and relayed by
the mother. The mother noticed that her baby was having
some absences during the day followed by some flexor
spasms of the neck, mostly when she was tired or upon
awakening. The possibility of a cerebral lesion then became
the first probable diagnosis. With videos of the spasms of
hand, she was then able to see a pediatric neurologist who
ordered scans. At 7½ months, the baby girl was diagnosed
with West syndrome and spastic hemiplegia caused by
a presumed fetal stroke. The ischemic area involved was
in the territory of the left middle cerebral artery and the
majority of her left parietal lobe was liquefied by the time
Interventions and outcomes
After the initial examination of the baby, we made it
clear to the mother that co-management of medical and
chiropractic professionals was necessary in order to clarify
the diagnosis and to gather more facts on the extent of the
condition. Fortunately, within three weeks, we received
the medical diagnosis and the multidisciplinary approach
became essential, optimizing a long-term functional outcome
and impacting the brain and nervous system plasticity.
In view of the fact that the condition is non-reversible,
the management of the baby’s condition would consist of
follow-ups on a long term basis. Rehabilitation would potentially
improve the deficiencies and help the baby develop
to the maximum of her potential while simultaneously
improving the quality of her life. Given the state of the
health care system (Quebec), delays in multidisciplinary
referrals are common. Consequently, the chiropractor was
the only health care provider working with the patient from
the age of 7½ months to 9½ months at which time she was
seen by the consulting physician and the multidisciplinary
Initially, we saw the patient twice a week for 6 weeks,
once a week for 5 months and then every two weeks for 6
months. Between the ages of 18 months to 28 months, we
saw her for adjustments at intervals of 3 to 5 weeks working
around the mother’s and child’s many other associated
appointments and interventions.
Chiropractic management started gradually with the
application of the following techniques:
Fascial release to upper and lower extremities; slight
mobilization on clavicle, arm, scapula, elbow, wrist and hip joints
Slight traction of occiput-sacrum in the cephalic direction
Chiropractic adjustments in the thoracic and sacral regions T2–3, T8–T10 and sacrum (low force manual techniques)
C1 and C6–7: Activator method in cervical spine or sustained pressure especially C1 on right side in laterality and C6–7
Low force manual cranial techniques
** Note: Neither manual nor activator adjustments were delivered to
correct the atlas laterality in the first 2 weeks; we decided to proceed
with additional cranial work after the diagnosis of a possible fetal
stroke while waiting for information on the probable cause(s).
After the initial 6 weeks we added the following:
Joint mobilizations exercises (mostly arm and hip)
Stimulation exercises to stimulate right and left hemispheric communication and the vestibular system performed in the clinic and given to the mother to do at home:
Frog and spider exercises
Contralateral hand to toe touch
Hip and arm passive mobilizations
Ventral exercises on a roll + gym ball
After the first two weeks of working with the infant,
the mother immediately noticed improvement in shoulder
mobility through active motion. By helping her with passive
stretching and movements, the mother noticed less
resistance. Of note, during the first visits, the baby cried
simply after being touched or as a result of movement
in the shoulder-clavicle-scapula area. This intense crying
decreased in the first two weeks. The ROM in the cervical
area improved rapidly with less resistance than was present
at the outset of the treatment. No adverse effect from any
of the treatments provided was reported by the mother.
Two thermal scans were performe (Millenium Insight®)
at the ages of 12 and 15 months. Both scans showed hyperactivity of
the autonomic nervous system in the upper
cervical and the cervicothoracic regions.
Co-management was recommended soon after the
initial examination in order to further clarify the diagnosis.
During the third week of care, the mother saw a neurologist
about the cervical flexion spasms that had now begun: the
head was falling into flexion and left lateral flexion with
a superior eye-glaze in a cluster-like pattern, mostly when
she was waking up. At 7½ month, a brain EEG confirmed
hypsarrythmia patterns typical of infantile spasms\West
syndrome related to a possible intrauterine or fetal stroke.
Hypsarrythmia is an abnormal interictal pattern, consisting
of high amplitude and irregular waves and spikes in a
background of chaotic and disorganized activity seen on
electroencephalogram (EEG), frequently encountered in
an infant diagnosed with infantile spasms. Blood tests were
done at 8 months to confirm a lowered resistance to the
C-protein. A cerebral MRI was done at 9½ months and it
confirmed a left middle cerebral artery (MCA) lesion that
affected most of the parietal lobe. Involvement of the factor
V Leiden (FVL) was confirmed at the time for the baby and
the mother also tested positive for the Leiden V factor a few
months later. Maternal and neonatal thrombophilia in the
presence of FVL has been investigated scientifically in the
pathogenesis of perinatal arterial ischemic stroke.
Initial management consisted of controlling the spasms
with pharmacological agents. A trial of three different types
of medication was run:
Sabril® (Vigabatrin) was first introduced;
Lamictal® (Lamitrogine) as a secondary medication;
The spasms were difficult to control so a third medication was prescribed for epileptic spasms at 12 months: Keppra. XR® (Levetiracetam)
Keppra® was removed after a trial of a few days because
the baby was exhibiting side effects (anorexia, insomnia,
sudden mood changes and unusual behavior). At that
time, the neurologist recommended that the baby undergo
surgery to control the epilepsy that was preventing the
brain from developing. A functional hemispherectomy
was performed on the child at 15½ months. The first two
medications were administered for a year following surgery
and were gradually eliminated; Sabril® at six months postsurgery
and Lamictal® at twelve months.
In order for the baby to reach maximal function, a
multi-disciplinary approach was essential. Since the initial
application of chiropractic adjustments and recommendations,
several health care professionals were added:
At 13½ months, right before surgery, the infants expressive
language included the words “mommy and “yes”
and nodded her head yes and no. But the seizure activity
was so frequent that it was preventing the brain creating and
maintaining developing neuronal connections. Subsequent
to surgery, motor and developmental improvements were
noted. The baby was relating to people more readily; she
was more alert, started to babble more and developed both
her receptive and expressive language skills. At 20 months she started sitting unattended. At 27 months, she is still unable to crawl, kneel or roll.
Perinatal arterial ischemic stroke (AIS) is defined as
a fetal or neonatal cerebrovascular event and is 17 times
more common than strokes later in childhood and represents
80% of neonatal strokes [1–3] with a recurrence rate of
3–5% in later childhood. Some cases present in the first
days of life but many can be delayed in their presentation.
Hand preference will assist in establishing a diagnosis of
hemiparesis. To complicate matters, in some cases there are
no episodes of seizure as in the clinical presentation of our
case. Infants presenting neurological signs and seizures (or
epilepsy) soon after birth can be diagnosed as early as their
stay in the hospital. Because delayed presentations can be
revealed first in our chiropractic practices, it is essential
that chiropractors be trained to recognize the associated
signs and symptoms of AIS (including seizures). Parents
typically come to us after having noticed delayed milestones
or other early physical or behavioral concerns. The signs
and symptoms of AIS are outlined in Table 1. [3, 9]
Cognitive impairment after a neonatal stroke ranges
from 0 to 55% and language delay up to 25%. More than
50% of cortical strokes are located in the middle cerebral
artery (MCA) territory with complete and posterior truncal
area being more common.  Children who suffer a neonatal
stroke or infarction in the MCA territory may develop
thalamic atrophy but whether this has long-term implications
for sensory integration is not clear and difficult to
assess in this age group. The incidence of cerebral palsy
after perinatal AIS ranges widely, from 6 to 88% according
to the literature. Most infants will walk by the age of 2
and will eventually be able to be assimilated into a regular
classroom. Only a small percentage will have to undergo
surgery for major and intractable epileptic syndromes like
West syndrome as in our case study.  A study done on 40
children who had suffered perinatal stroke found that the
extent of the stroke and injury to any of the a number of
regions (Broca’s region, the internal capsule, Wernicke’s
area or basal ganglia) were associated with cerebral palsy. 
Children who appear normal in the neonatal period but
develop a hand preference or have a seizure after 2 months
of age as a result of perinatal AIS may have a worse prognosis
than children who displayed neurological signs as neonates.
In such cases, the presenting hemiparesis is more likely to
persist. [13, 14] This was also the situation in our case-report.
The causes of perinatal AIS are presently poorly
understood. Risk factors for perinatal strokes can be classified
under maternal conditions, complications during
pregnancy and delivery and fetal conditions as shown in
Table 2. [1, 3, 4] It must also be noted that multiple risk factors
increase the rate of AIS.
Infantile spasms/West syndrome
West syndrome is described by a characteristic triad
of infantile spasms, interruption in psychomotor development
and hypsarrythmias. Only 5 to 12% of patients
exhibit normal mental and motor development, 50% are
left with motor impairment and 70 to 78% are mentally
challenged.  The severe spasms related to this condition
are usually resistant to usual seizure medication and the
prognosis is poor and associated with increased morbidity
because maturation and cognitive development of
the brain are affected by the spasms. This category of
epileptic encephalopathy responds more favorably to
hormonal treatment like ACTH and steroids than conventional
antiepileptic medication.  However, for some
geographic and availability reasons, our case study patient
was prescribed Vigabatrin, and ACTH/steroids were
never considered by the medical team unlike in many other
cases described in the literature. [15–17] Most cases respond
well to medication but in some cases, the patients have
to undergo surgery for refractory spasms. The favorable
outcome of surgical treatment for refractory spasms is
well supported in the literature. [10, 18] Unfortunately, this
was the scenario in this case report which led to major
developmental changes in the following 6 to 12 months
post-surgery. At this time, the relationship between children with epilepsy and perinatal AIS is not well understood
compared to other pharmaco-responsive epilepsies in the
same age group. 
The Factor V Leiden mutation and its relation to perinatal stroke
The factor V Leiden is an autosomal dominant mutation
that, genetically, is most commonly related to deep
vein thrombosis in children.  It is known that the resistance
of the factor V Leiden mutation to activated protein
C results in increased thrombin generation and a shift
towards increased coagulability. Recent literature is not
conclusive regarding whether or not the factor V Leiden,
and prothrombin 20210G>A, can be related to arterial
ischemic stroke.  It may be a factor but cannot contribute
alone to the development of the condition. In presumed
pre- or perinatal arterial ischemic stroke, coagulopathies in
the fetus or infant and maternal/ infant thrombophilia may
be important in the etiology of infarcts. Anticardiolipin
antibody (ACLA) and Antiphospholipid antibody, even
if the role is unclear, may also be a major player in these
strokes. [14, 21]
The average 5–year cost of treating neonatal stroke
in a 2010 study,  after adjustments for control costs, was approximately $50,000 USD. That study found that the
financial burden of strokes in neonates and children is both
substantial and long term, and increases the cost of health
care over five years 15–fold compared to age-matched children
who have not suffered a stroke. The birth admission
costs for patients with presumed perinatal strokes, even if
diagnosed later, still exceeds those of stroke-free controls
by an average of almost $7,000 USD, suggesting that these
children have greater medical needs in the perinatal period,
prior to diagnosis.
Chiropractic management of infantile strokes
In the chiropractic profession, one study showed improvement
in paraspinal muscle tone for four children with
cerebral palsy and resulted in the improvement of their daily
lives including mobility, feeding, and postural control. 
Besides the benefits of chiropractic care for children with
cerebral palsy, there is still nothing specific pertaining to
chiropractic and infantile stroke in the current literature.
Healthcare professionals need to collaborate on therapies
and interventions for infants with neonatal strokes because,
besides acute intervention, not much is available in terms
of medical management.
In our case, it is difficult to speculate on the real
cause of the perinatal arterial ischemic stroke. Medical
specialists do not agree on the actual causes. The presence
of genetic factors and coagulation risk factors were probable,
but at this time it is difficult to conclude whether or
not they were related to the factor V Leiden because of
the arterial nature of the stroke. Many factors led to this
patient’s poor prognosis: she showed late symptoms with
severe hemiparesis and infantile spasms; she was resistant
to the medication and the seizure activity was progressing
despite trials of several medications. Due to this patients’
very poor prognosis, cranial surgery was required to optimize
long-term functional outcome. The mother saw
immediate improvement after chiropractic adjustments
but because of the severity of the situation, we could not
assess the effectiveness of the chiropractic interventions
on their own. Without documented outcomes of previous
cases, the late diagnosis reduced the window of time
within which it felt responsible to work alone and referral
for collaborative care was made. In such a case, known
as a non-reversible severe condition, a multi-disciplinary
approach proved essential to realize maximal improvement.
The major limitation of this study was the difficulty
in isolating each professional intervention and its individual
effects on the outcome.
Many studies show a greater potential for improvement
in the long-term outcome for infants and children when
compared to adults because of the greater brain plasticity
of the young brain.  A study done in 2007 suggests that
spinal manipulation of dysfunctional joints may modify
transmission in neuronal circuitries not only at a spinal
level but also but at a cortical level and possibly also in the
deeper brain structures such as the basalganglia. [24–27] In view
of the fact that chiropractors have an impact on brain plasticity,
future studies should be undertaken to gain further
knowledge and understanding of the causes, diagnosis and
treatment of perinatal strokes.
Knowing that 40% of the infants who are later diagnosed
with perinatal stroke do not have specific symptoms
in the neonatal period and that they are recognized only
later with the emergence of breastfeeding problems, motor
impairment, developmental delays and specific cognitive
deficiencies or seizures, chiropractors may see many of these
infants and young children in their practices.
Even as stroke in infants is increasingly being recognized
as a serious neurological disorder that places a
major financial burden on parents and the government,
limitations in knowledge and awareness have hampered
it’s recognitions among the population and health care
professionals including chiropractors. Late diagnosis limits
the opportunities for timely interventions that could
improve the functional outcome and impact the quality
of life of the patients and their families. As primary health
care providers who play a major role in diagnosing and
treating this condition, chiropractors should have the
skills needed to detect its early signs so that they can them
make the proper and necessary timely referrals. Guidelines
for treatment are limited in the current literature and
there is no current consensus. More research needs to be
done to understand the pathophysiological mechanisms,
the risk factors and clinical interventions that lead to an
improved outcome. Ongoing and future multidisciplinary
cooperative studies, which include chiropractors, are necessary
in order to establish comprehensive evidence-based
guidelines for the rehabilitation of perinatal stroke. Knowing
that the young brain has a strong potential for neuronal
plasticity, the chiropractic profession need to demonstrate
how adjustments have a major impact on brain plasticity
and how they can improve the long-term outcome for
their patients. This subject is one of importance for future
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Cervical Spine Manipulation Alters Sensorimotor Integration:
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Clinical Neurophysiology 2007 (Feb); 118 (2): 391–402
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Sacroiliac joint manipulation decreases the H-reflex.
Electromyography And Clinical Neurophysiology 1995, 35(2), 87-94
Symons BP, Herzog W, Leonard T, Nguyen H.
Reflex responses associated with activator treatment.
Journal Of Manipulative And Physiological Therapeutics 2000, 23(3), 155-159
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