Secondary headache and raised intracranial pressure — branching viva

Stem 1 — Eight-year-old with a progressive morning headache (5 minutes)

An eight-year-old boy presents with a six-week history of daily headache that is present on waking, eases through the morning, and worsens with coughing and bending. His mother reports early-morning vomiting, and his teacher reports he is quieter at school. His neurological examination, including fundoscopy, is normal. [11]

Branch A (examiner): List the red flags in this history, and explain why a normal examination does not make this headache safe. State the cardinal rule about progressive, morning, or vomiting headache in a young child. [3] [12]

Branch B (examiner): State your investigation of choice and the reason it is preferred over computed tomography. Explain why a lumbar puncture is not your first step, and describe the HeadSmart symptom cluster that frames your reasoning. [1] [11]

Branch C (examiner): The imaging shows a posterior fossa tumour with early obstructive hydrocephalus. Outline your immediate disposition, who you involve, and how you address the raised pressure and the cerebrospinal-fluid flow. [10] [11]

Stem 2 — Fourteen-year-old girl with papilloedema (5 minutes)

A fourteen-year-old girl with obesity presents with three months of daily headache, transient visual obscurations on standing, pulsatile tinnitus, and new horizontal double vision. Fundoscopy shows bilateral disc swelling, and she has a bilateral sixth-nerve palsy. Her blood pressure and the rest of her examination are normal. [8]

Branch A (examiner): Give the most likely diagnosis and reproduce the Friedman 2013 revised diagnostic criteria you must satisfy to confirm it, naming the specific imaging that excludes a secondary cause. [5] [6]

Branch B (examiner): The magnetic resonance imaging with venography is normal and the lumbar puncture opening pressure is 330 millimetres with normal cerebrospinal-fluid composition. Outline the stepwise definitive management, including the drug, the dose, and the one outcome that governs escalation. [7] [9]

Branch C (examiner): Name the circumstance that converts this from a subacute problem to a neuro-ophthalmological emergency needing surgery on the same admission, and describe the visual surveillance that defines the long-term follow-up. [8] [6]

Stem 3 — Five-month-old with a full fontanelle (5 minutes)

A five-month-old infant is brought with a two-week history of increasing irritability, vomiting, and a head circumference that has crossed two centiles upward. The fontanelle is full, the rest of the examination is difficult, and the parents report the child is not their usual self. [2]

Branch A (examiner): Explain why the threshold for imaging is lower, not higher, in this age group, and name the mechanism by which the open sutures may mask the diagnosis. [2] [3]

Branch B (examiner): State the signs of raised intracranial pressure you are looking for in an infant, and explain why a lumbar puncture is not your first investigation. [2]

Branch C (examiner): The imaging shows a tumour with hydrocephalus and the infant's conscious level is falling. Outline your immediate resuscitation and your escalation, naming the role of head-of-bed elevation, controlled ventilation, and urgent neurosurgical relief. [11] [3]