Neonatal stroke and intracranial haemorrhage — branching viva

Station opening

Examiner: "Define perinatal stroke and distinguish the main entities within it." [1]

Strong candidate (must-hit)

• Defines perinatal stroke using the Raju 2007 NICHD-NINDS workshop time window (20 weeks fetal to 28 postnatal days), then distinguishes the ischaemic group (perinatal arterial ischaemic stroke, cerebral sinovenous thrombosis) from the haemorrhagic group (neonatal haemorrhagic stroke, germinal matrix-intraventricular haemorrhage), explaining that each has a different mechanism, imaging signature, and management pathway. [1]

Weak candidate

• "A neonatal stroke is a brain bleed in a newborn." [1]

Branch A — The term infant with focal seizures

Examiner: "A term infant at 39 weeks has focal clonic seizures of the right arm at 30 hours of life. Cranial ultrasound is normal. What is your diagnosis, and why might the ultrasound be normal?" [1]

Strong

• Diagnoses perinatal arterial ischaemic stroke (PAIS) presenting with focal clonic seizures. Explains that cranial ultrasound may be normal in PAIS because it poorly visualises the cortical surface and may miss a focal cortical infarct; MRI with diffusion-weighted imaging is required and would show restricted diffusion in an arterial territory. [1]

Weak

• "The normal ultrasound rules out stroke — the seizures are probably benign." [1]

Branch B — The preterm infant with grade III IVH

Examiner: "A 26-week infant has bilateral grade III IVH on routine day 4 cranial ultrasound. Grade the haemorrhage, explain the mechanism of the white matter injury, and describe how you would monitor for complications." [4]

Strong

• Grades it as grade III (intraventricular haemorrhage with acute ventricular dilation, Papile). Explains that the white matter injury in severe IVH is a periventricular haemorrhagic infarction from terminal vein compression and venous obstruction — not simple extension of blood — and that blood breakdown products are toxic to oligodendrocyte precursors (Ballabh 2010, 2021). Monitors with serial cranial ultrasound (weekly) and serial head circumference for post-haemorrhagic ventricular dilation. [4] [5]

Weak

• "Grade III means blood in the ventricle. I would just observe." [4]

Branch C — The PHVD intervention decision

Examiner: "The same infant's ventricles are progressively dilating at day 14, and the head circumference has crossed two centile lines. What is the complication, and at what point do you intervene?" [6]

Strong

• Identifies post-haemorrhagic ventricular dilation (PHVD). Cites the de Vries 2019 randomised controlled trial, which established treatment thresholds based on the Levene ventricular index and anterior horn width — intervene at the threshold rather than waiting for severe hydrocephalus, because earlier intervention reduces the need for permanent shunt surgery. The stepwise ladder: serial ultrasound, temporising measures (lumbar puncture, ventricular access device), ventriculosubgaleal shunt, then permanent VP shunt if progression continues. [6]

Weak

• "Wait until the head is very large, then put in a shunt." [6]

Branch D — The late-presenting infant

Examiner: "A 4-month-old is referred for early hand-preference. MRI shows a chronic encephalomalacic infarct in the left middle cerebral artery territory. What happened, and what is the management now?" [3] [8]

Strong

• Diagnoses presumed perinatal stroke — the infarct occurred perinatally but was not recognised acutely; the chronic encephalomalacic appearance on MRI confirms the lesion is old. The management shifts from acute intervention to early developmental surveillance and rehabilitation: the Baak 2023 meta-analysis identifies corticospinal tract involvement and infarct size as outcome predictors; the Australian clinical consensus guideline (Greenham 2021) outlines the rehabilitation pathway. Early intervention includes constraint-induced movement therapy and multidisciplinary support. [3] [8]

Weak

• "This is a new stroke — send the baby to the emergency department." [3]

Close

Examiner: "Summarise your approach to neonatal stroke and intracranial haemorrhage in one sentence." [1]

Strong

• "A focal seizure in a term neonate is perinatal arterial ischaemic stroke until MRI proves otherwise — so I stabilise ABC, check glucose, treat the seizure with phenobarbital 20 mg/kg, obtain MRI with DWI, and manage supportively with neuroprotection. For the preterm infant, cranial ultrasound screens for GMH-IVH, Papile grades severity, and progressive PHVD is managed at the de Vries RCT thresholds. Prognosis is driven by lesion size and corticospinal involvement, and all survivors enter structured neurodevelopmental surveillance." [1] [3] [6]