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Juvenile myoclonic epilepsy — MSRA MCQ

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HardMRIJuvenile myoclonic epilepsyMSRA

A 19-year-old university student is assessed in a first-seizure clinic after 2 unprovoked generalised tonic-clonic seizures, 5 months apart. Both occurred shortly after waking following marked sleep deprivation. On direct questioning, she reports brief, bilateral, shock-like jerks of both arms on most mornings for the past year, occasionally causing her to drop objects. There has been no focal motor onset, prolonged focal neurological symptom, head injury, substance misuse or developmental disorder. Neurological examination is normal. EEG shows generalised 4–6 Hz polyspike-and-wave discharges. The neurologist diagnoses juvenile myoclonic epilepsy. She has no contraindication to MRI. What is the most appropriate neuroimaging plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Do not arrange neuroimaging at present

Explanation lettering: E = shown as A · A = shown as B · B = shown as E

This presentation is juvenile myoclonic epilepsy, an idiopathic generalised epilepsy: characteristic morning myoclonic jerks, generalised tonic-clonic seizures precipitated by sleep deprivation, normal neurological examination and generalised polyspike-and-wave EEG. NICE recommends MRI for people diagnosed with epilepsy, but specifically excludes idiopathic generalised epilepsy because a causative structural brain abnormality is not expected. Therefore, no neuroimaging is indicated at present. B would be appropriate for most people with newly diagnosed focal epilepsy or epilepsy not classified as idiopathic generalised epilepsy; the usual target is MRI within 6 weeks using a regionally agreed epilepsy protocol. C is not indicated because there are no focal features, neurological signs or other concern for an intracranial structural lesion, and routine contrast MRI is not the recommendation. D is appropriate when MRI is contraindicated in a person who otherwise requires structural imaging, not as routine imaging for juvenile myoclonic epilepsy. E adds CT without an indication and does not overcome the fact that MRI is unnecessary in this syndrome. New focal seizure features, focal neurological signs, diagnostic uncertainty or a change in seizure pattern would warrant reassessment of the need for imaging.

Reference: NICE NG217: Epilepsies in children, young people and adults — Diagnosis and assessment of epilepsy (Updated 30 January 2025) — https://www.nice.org.uk/guidance/ng217/chapter/diagnosis-and-assessment-of-epilepsy NICE NG217: Epilepsies in children, young people and adults — Rationale and impact (Updated 30 January 2025) — https://www.nice.org.uk/guidance/ng217/chapter/rationale-and-impact