Curriculum standards

Knowledge guides

LG20: Paroxysmal disorders, including seizures, syncope, and stroke

Key presentations and conditions

Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Advanced Trainees will understand these presentations and conditions.

Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations

Breath-holding – cyanotic / pallid
Confusion / Fugue
Fainting / Loss of consciousness
Fatigue
Impaired awareness or staring, with or without motor accompaniment
Jerky, rhythmic, or twitching motions
Light-headedness and/or dizziness
Muscular difficulties, such as coordination problems, stiffness, weakness, and/or paralysis
Nausea and/or vomiting
Poor feeding
Seizures
Sensory disturbances
Speech difficulties
Sweating

Conditions – epileptic

Childhood epilepsy syndromes
Developmental and epileptic encephalopathy
First seizure
Focal epilepsy
Generalised epilepsy
Immunological
Inborn errors of metabolism associated with epilepsy
Infantile epileptic spasms syndrome
Inflammatory epilepsies
Metabolic disturbance
Provoked seizures
Status epilepticus

Conditions – haemorrhagic

Primary intracranial haemorrhage
Subarachnoid haemorrhage
Venous infarction

Conditions – ischaemic

Amaurosis fugax
Ischaemic stroke:
- acute thromboembolic
- arterial
Non-atherosclerotic arteriopathies, such as moyamoya disease
Transient ischaemic attacks
Vasculitides
Venous sinus thrombosis
Watershed infarcts

Conditions – non-epileptic

Alternating hemiplegia
Benign neonatal sleep myoclonus
Benign paroxysmal torticollis
Breath-holding
Episodic ataxias
Febrile seizures
Hyperekplexia
Migraine with brainstem features
Non-epileptic seizures:
- non-epileptic status parasomnias
Paroxysmal dyskinesia
Recurrent vertigo of childhood / Benign paroxysmal vertigo of childhood
Shuddering spells
Stereotypies
Tics
Tonic upgaze of infancy

Conditions – stroke mimics

Functional neurological disorder
Migraine
Mitochondrial disorders
Todd’s paresis

Conditions – syncope

Cardiac arrhythmias
Dehydration
Reflex anoxic
Vasovagal syncope

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients’ needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Conditions – dizziness / vertigo

Benign paroxysmal positional vertigo (BPPV)

Conditions

Autonomic failure
Carotid sinus hypersensitivity
New-onset refractory status epilepticus (NORSE)

For each presentation and condition, Advanced Trainees will know how to:

Synthesise

recognise the clinical presentation
identify relevant epidemiology, prevalence, pathophysiology, and clinical science
take a comprehensive clinical history
conduct an appropriate examination
establish a differential diagnosis
plan and arrange appropriate investigations
consider the impact of illness and disease on patients and their quality of life when developing a management plan

Manage

provide evidence-based management
prescribe therapies tailored to patients’ needs and conditions
recognise potential complications of disease and its management, and initiate preventative strategies
involve multidisciplinary teams

Consider other factors

identify individual and social factors and the impact of these on diagnosis and management

Age-related presentations in epileptic symptoms
Arterial blood supply, vascular anatomy, and venous drainage of the brain and spinal cord
Causes of stroke in children, such as non-atherosclerotic arteriopathies and congenital heart disease, and the potential genetic variants associated with these
Causes of stroke syndromes:
- haemorrhagic
- ischaemic
- mimics
Classification and clinical features of the different types of epileptic seizures, as from International League Against Epilepsy (ILAE)
Classification of epilepsy and childhood epileptic syndromes
Common, primary, rare, and secondary diseases that result in seizures and syncope
Evidence-based pharmacological therapy and other forms of management of stroke and related syndromes, in relation to acute presentation, prophylaxis, and rehabilitation
Neuroanatomy, neurophysiology, and related imaging of paediatric stroke
Neuroanatomy, neuropharmacology, and neurophysiology involved in the generation of epilepsy and syncope
Neuropharmacology and surgical interventions for paediatric stroke, based on national clinical guidelines
Paroxysmal non-epileptic attacks presenting at different ages, and their key features

Cerebrospinal fluid (CSF) procedures and investigations

Lumbar puncture (LP) and interpretations results of investigations, such as:
- basic CSF analysis:
  - cell count
  - cytology
  - glucose level, including:
    - paired serum ratio
  - immunological tests
  - microbiological tests
  - protein level
  - xanthochromia
- opening pressure
- special tests:
  - amino acids
  - CSF lactate
  - oligoclonal bands

Clinical neurophysiology investigations

EEG:
- prolonged video EEG
- sleep-deprived EEG
- standard EEG
- stereotactic EEG (SEEG)
Vestibular function tests

Neurogenetic investigations

Genetic testing, including, but not limited to:
- chromosomal testing, such as:
  - karyotype
  - microarray
- genomic testing, including whole exome or genome sequencing
- mitochondrial genome sequencing
- targeted panel testing
Referral to a neurogeneticist

Neuroimaging investigations

CT, including:
- CT angiography
- perfusion
Functional imaging:
- functional MRI (fMRI)
- PET
- single photon emission computed tomography (SPECT)
Magnetic resonance:
- angiography (MRA)
- spectroscopy (MRS)
- venogram (MRV)
MRI
Vascular imaging:
- catheter angiography
- Doppler ultrasound

Neuropathology investigations

Brain biopsy

Other investigations

Cardiac investigations:
- 24-hour electrocardiogram monitoring
- bubble study
- ECG
- echocardiography
Other laboratory tests:
- leukocyte enzymes
- plasma amino acids
- plasma lactate
- plasma pyruvate
- thrombophilia screen
- urinary metabolic screen
- urinary porphyrins
- vasculitis screen
Polysomnography

Appropriate potential candidates for epilepsy diet service
Appropriate potential candidates for evaluation for epilepsy surgery, including implantable devices
Awareness of appropriate and timely neurogenetic testing, what is available to the neurologist, and what requires genetic referral / consultation
Awareness of national clinical stroke guidelines, and application of this within each network employed
Maintain up-to-date knowledge of childhood epilepsy syndromes, particularly those identified by the ILAE position papers
Management of diagnostic uncertainty and counselling in relation to risk management
Management strategies, such as:
- antiseizure medicine
- diet
- epilepsy surgery
- vagal nerve stimulator
Overlap with other allied health and medical specialties, such as:
- dietetics
- general paediatricians
- occupational therapy
- physiotherapy
- rehabilitation medicine
- speech pathology
Overlap with other medical conditions, such as:
- cardiac disorders
- functional neurological presentations
- non-epileptic disorders
- sleep disorders
- syncope
Prognosis, implications, and management strategies for dealing with epilepsy
Prognosis, implications, and management strategies for stroke, such as:
- acute management
- impact on the family
- rehabilitation
- secondary prevention