Perinatal arterial ischemic stroke (PAIS) and neonatal cerebral sinovenous thrombosis (CSVT) in the preterm neonate: a systematic review.

Perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) cause significant neurological morbidity, including cerebral palsy, in preterm infants. Compared to term infants, the epidemiology, risk factors, and outcomes of PAIS and CSVT in preterm infants are less well understood. This systematic review aimed to summarize the literature on incidence, risk factors, clinical presentation, neuroimaging, and neurodevelopmental outcomes of PAIS and CSVT in infants born before 37 weeks' gestation. A comprehensive search of PubMed, Embase, and Web of Science for studies from 2004 to 2025 identified 14 eligible studies including 132 infants with PAIS and 57 with CSVT. Incidence rates were higher in infants of lower gestational age. Identified PAIS risk factors included twin-to-twin transfusion syndrome, fetal heart rate abnormalities, and hypoglycemia. Perforator artery strokes were most common, while CSVT frequently involved the transverse sinus. Many risk factors overlapped with term infants but preterm infants showed more prematurity-related complications, longer ventilation, and postoperative states. Neurodevelopmental outcomes were poor, with high rates of impairment and mortality, especially in CSVT. The review highlights urgent needs for larger, controlled studies to improve prevention, early diagnosis, and management in this vulnerable population. IMPACT: This review systematically summarizes incidence, risk factors, neuroimaging patterns, treatment, and outcomes of perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) specifically in preterm infants-a group often excluded from previous studies. The findings reveal that preterm infants with PAIS and CSVT have unique and overlapping risk factors (such as twin-to-twin transfusion syndrome and hypoglycemia), often present asymptomatically, and are at high risk for poor neurodevelopmental outcomes and mortality. The review highlights urgent knowledge gaps, especially regarding the safety and effectiveness of anticoagulation therapy in preterm CSVT, and stresses the need for larger studies and targeted strategies to improve recognition, management, and long-term outcomes for this vulnerable group.