Non-epileptic events and functional seizures — branching viva

Stem 1 — Thirteen-year-old with bizarre brief nocturnal attacks (5 minutes)

A thirteen-year-old boy is referred for nocturnal attacks in which he suddenly sits up, thrashes his limbs for thirty to sixty seconds with his eyes open, and then returns to sleep. The events cluster, occurring several times a night, and began after he started a new school. His interictal electroencephalogram is normal. [1]

Branch A (examiner): What are the two leading diagnoses, and which semiological features would you use to separate a functional event from frontal-lobe epilepsy? [1]

Branch B (examiner): The examiner points out that frontal-lobe epilepsy can show a normal scalp electroencephalogram. How do you resolve this, and what further investigation would you arrange? [8]

Branch C (examiner): The attacks are captured on video-electroencephalogram and the ictal recording is normal. Explain how you would deliver the diagnosis and outline the management. [3] [10]

Stem 2 — Fifteen-year-old with daily treatment-resistant spells (5 minutes)

A fifteen-year-old girl has daily spells lasting five to ten minutes with her eyes closed and resisting, a variable thrashing pattern, and rapid full recovery. She is on two escalating antiseizure medications without change in the events. Her parents separated recently and her mother has depression. [2]

Branch A (examiner): What is the most likely diagnosis, and which four features support it over epilepsy? Why have the antiseizure drugs failed? [1] [2]

Branch B (examiner): Describe the investigation that confirms the diagnosis and what it must show. Why is a normal interictal electroencephalogram not enough, and what is the place of prolactin? [1] [8]

Branch C (examiner): Outline the stepwise management, including how you withdraw the antiseizure drugs, the psychological therapy you offer, and the conversation you lead with the girl and her family. [5] [10]

Stem 3 — Sixteen-year-old in a prolonged emergency-department flurry (5 minutes)

A sixteen-year-old boy with known epilepsy arrives in the emergency department after two hours of recurrent attacks. He thrashes with his eyes closed, resists examination, and is tearful and oriented between attacks. The team asks whether this is status epilepticus and whether to give a benzodiazepine and call intensive care. [5]

Branch A (examiner): What is the most likely diagnosis, and how do you distinguish this prolonged functional flurry from convulsive status epilepticus at the bedside? [1] [5]

Branch B (examiner): Outline your immediate management and explain why escalating benzodiazepines and anaesthesia are inappropriate and potentially harmful. [5] [7]

Branch C (examiner): He continues his antiseizure drug for his epilepsy. Explain how you manage the coexistence of the two conditions, and describe the psychosocial and safeguarding assessment you undertake once the episode settles. [12] [2]