Neonatal stroke and intracranial haemorrhage — structured clinical encounter

Station brief (candidate)

You are the neonatal registrar. A term infant (39 weeks, birthweight 3400 g) born by emergency caesarean for failure to progress after an instrumental attempt is reviewed at 30 hours of age for rhythmic jerking of the right arm and right side of the face. Between events the infant is alert but has asymmetric tone and a reduced grasp on the right. Blood glucose is 3.2 mmol/L. Cranial ultrasound on day 2 is reported as normal. The team asks you to establish the diagnosis, the imaging plan, and the management and prognostic pathway. You have 12 minutes with the team and 5 minutes for examiner discussion. [1]

Information available on request

• Term infant (39 weeks), birthweight 3400 g, emergency caesarean after failed instrumental delivery. Apgar scores 6, 8, 9. [1]
• At 30 hours: focal clonic seizures of the right arm and face, lasting two minutes; between events alert but right-sided hypotonia and reduced grasp. Blood glucose 3.2 mmol/L. [1]
• Cranial ultrasound day 2: reported as normal — no intraventricular haemorrhage, no midline shift, normal ventricular size. [1]

Tasks

1. Give the most likely diagnosis and explain why the normal cranial ultrasound does not exclude it. [1]
2. Outline your immediate management priorities and the definitive neuroimaging investigation. [1]
3. Describe the management approach to this condition, including the role of anticoagulation. [1] [3]
4. Discuss the prognosis and the follow-up pathway, citing the evidence for outcome prediction. [3] [8]

Marking anchors

Must-hit

• Diagnoses perinatal arterial ischaemic stroke (PAIS) presenting with focal clonic seizures and asymmetric tone. Explains that cranial ultrasound poorly visualises the cortical surface and may miss a focal cortical infarct; MRI with diffusion-weighted imaging is required. [1]
• Immediate management: ABC stabilisation, check and correct glucose (already normal), phenobarbital 20 mg/kg IV for the seizure, continuous EEG, and maintain normoxia, normoglycaemia, normotension, and normothermia. Arranges MRI in parallel with stabilisation. [1]
• States that PAIS is managed primarily with supportive neuroprotection — there is no neonatal thrombolysis. Anticoagulation is selective and contentious, reserved for confirmed prothrombotic conditions or CSVT under haematology guidance. [1] [3]

Merit

• Cites the Baak 2023 systematic review and meta-analysis for outcome prediction: infarct size, corticospinal tract involvement, bilateral lesions, and early severe neurological signs predict worse outcome. Approximately 30 to 60 percent of PAIS survivors develop hemiplegic cerebral palsy. [3]
• Describes the structured neurodevelopmental surveillance pathway and the Australian clinical consensus guideline (Greenham 2021) for subacute rehabilitation, emphasising early detection of cerebral palsy and early intervention. [8]
• Describes the coagulation and thrombophilia work-up (PT, aPTT, fibrinogen, platelets, factor V Leiden, proteins C and S, antithrombin) and its selective use. [1]

Fail

• Accepts the normal cranial ultrasound as ruling out stroke and discharges or does not pursue MRI. [1]
• Delays imaging until seizures are fully controlled, prolonging the window of secondary injury. [1]
• Gives routine anticoagulation for all PAIS without haematology guidance, or fails to consider CSVT or a prothrombotic condition. [1]