Intraventricular haemorrhage and periventricular leukomalacia — branching viva

Station opening

Examiner: "Define intraventricular haemorrhage and periventricular leukomalacia, and explain why they are grouped together as the injuries of the preterm brain." [1] [5]

Strong candidate (must-hit)

• Defines IVH as bleeding from the fragile germinal matrix that enters the ventricular system, and PVL as injury to the periventricular white matter from ischaemia and inflammation of premyelinating oligodendrocytes; explains they are grouped because they share the periventricular anatomy, the same risk profile of prematurity and haemodynamic instability, and because a severe IVH often coexists with or directly causes white-matter injury. [1] [5]

Weak candidate

• "IVH is a brain bleed in premature babies, and PVL is damage to the brain substance." [1]

Branch A — The preterm infant who suddenly deteriorated

Examiner: "A 26-week infant has a sudden fall in haemoglobin, apnoea, a bulging fontanelle and seizures after a pneumothorax at 36 hours of life. What is your diagnosis, your immediate investigation, and your first action?" [1]

Strong

• Diagnoses a large intraventricular haemorrhage precipitated by the cerebral blood-flow swing from the pneumothorax in a pressure-passive circulation; orders an urgent cranial ultrasound to confirm and grade; begins ABC stabilisation with haemodynamic gentleness, drains the pneumothorax, corrects the anaemia with packed red cells, checks and corrects coagulation and platelets, and treats the seizures with phenobarbital 20 mg/kg intravenously as first-line. Emphasises that a rough resuscitation can extend the bleed. [1]

Weak

• "Give a fluid bolus and a phenobarbital load, and scan when stable tomorrow." [1]

Branch B — The grade III bleed with ventricular dilation

Examiner: "The day-7 cranial ultrasound shows a grade III IVH with early ventricular dilation, and the head circumference is starting to accelerate. How do you monitor this, and what are the options if it progresses?" [6]

Strong

• Monitors with serial head circumference (preterm chart) and serial ultrasound ventricular-index measurement; intervention is considered when the ventricular index crosses the 97th centile plus 2 to 4 mm or when there are signs of raised intracranial pressure. Options are serial lumbar puncture, a ventricular access device, DRIFT, and ventriculoperitoneal shunt; cites the Whitelaw 2007 trial (shunt reduction, bleeding risk) and the Luyt 2020 ten-year follow-up (cognitive benefit, mortality signal); most infants who progress receive a shunt once the cerebrospinal fluid clears. [6]

Weak

• "Start acetazolamide to reduce the cerebrospinal fluid production." [6]

Branch C — Cystic periventricular leukomalacia

Examiner: "The day-28 cranial ultrasound shows well-defined cystic lesions at the external angle of the lateral ventricles. What is this, and what does it predict? How does it differ from the non-cystic form?" [5] [9]

Strong

• Identifies cystic periventricular leukomalacia, the strongest single ultrasound predictor of cerebral palsy (roughly 50–70 percent when cysts are extensive, typically a spastic diplegia). Distinguishes it from non-cystic, diffuse white-matter injury (persisting echogenicity, ventricular enlargement from volume loss, thinning of the corpus callosum), which is the commoner modern pattern and is best quantified by MRI at term-equivalent age. Frames the counselling as a calibrated, revisitable probability and enters the infant into structured neurodevelopmental surveillance with early intervention. [5] [9]

Weak

• "These cysts mean the baby will definitely have cerebral palsy, so I will tell the parents now." [9]

Branch D — Prevention and the parental question

Examiner: "The parents ask what could have prevented this bleed. Outline the evidence-based prevention bundle and cite the trials." [2] [3] [4]

Strong

• Outlines the prevention bundle: antenatal corticosteroids at 24–34 weeks (fetal maturation); delayed cord clamping at 30–60 seconds, confirmed by the Rabe 2019 Cochrane review to reduce IVH; caffeine citrate for apnoea, shown by the Schmidt 2006 CAP trial to improve survival without neurodevelopmental disability; and prophylactic indomethacin for the extremely preterm, established by the Ment 1994 trial to reduce severe IVH and PDA (without a proven long-term outcome benefit). Names haemodynamic stability — gentle ventilation, avoiding pneumothoraces and rapid carbon-dioxide change, treating a PDA — as the mechanistic thread. [2] [3] [4]

Weak

• "There is nothing that could have prevented it; these bleeds just happen to premature babies." [2]

Close

Examiner: "Summarise your approach to IVH and PVL in one sentence." [1] [5]

Strong

• "IVH and PVL are the two great injuries of the preterm brain, driven by the fragile, pressure-passive germinal-matrix vasculature and the vulnerable periventricular premyelinating oligodendrocytes; I detect them with routine cranial-ultrasound surveillance, grade IVH by Papile and distinguish cystic from non-cystic PVL, prevent them with antenatal steroids, delayed cord clamping, caffeine and haemodynamic gentleness, manage the complications supportively, and counsel the family with a calibrated, revisitable prognosis — because grade III–IV IVH and cystic PVL carry a high risk of cerebral palsy, while grade I–II carries a near-normal outlook." [1] [5]