seizures

Question 1

Seizures - types

Answer 1

1. partial: affect single area of the brain (and one part of the body)
2. generalized: diffuse
3. partial that secondary generalize

Question 2

partial (focal) seizures - types and characteristics

Answer 2

1. simple partial - intact consciousnesses

2. complex partial - unconscious

Question 3

generalized seizures - types

Answer 3

1. absence
2. myoclonic
3. tonic clonic
4. tonic
5. atonic

Question 4

generalized tonic-clonic - causes related to electrolyic abnormalites

Answer 4

1. hyponatremia
2. hypernatremia
3. hypocalcemia
4. hypomagnesemia (rare)

Question 5

seizures - when to do Electroencephalogram

Answer 5

not before CT or MRI and exclude metabolic, toxic or anatomic defects

Question 6

epilepsy - definition

Answer 6

• a disorder a recurrent seizures

- unclear etiology (if there is a clear cause, it is not epilepsy)

Question 7

status epilepticus?

Answer 7

continuous or recurring seizure(s) that may result in brain that variably defined as >10-30 min

Question 8

treatment of status epilepticus

Answer 8

• best initial: benzodiazepine (lorazepam or diazepam IV)
• if persistsL phenytoin or fosphenytoin (same efficacy but fosphenytoin has fewer SE)
• if not stopped –> phenobarbital
• if not stopped –> Neuromuscular block to intubate and then general anesthesia (midazolam or propofol)
  (the patient must be of ventilator before propofol –> stop breathing)

Question 9

phytoin vs fosphenytoin

Answer 9

same efficacy but when IV, phenotoin has hypotension and AV block –> so fosphenytoin can be given more rapidly

Question 10

generally the treatent of status epilepticus in order

Answer 10

1. Benzodiazepine
2. fosphenytoin
3. phenobarbital
4. general anesthesia

Question 11

treatment of seizures for a single seizure?

Answer 11

NO: exceptions

1. presentation in status epilepticus or with focal neurological signs
2. abnormal EEG or lesions on CT
3. family history of seizure

Question 12

best treatment for epilepsy, most common medications and explain

Answer 12

not clear
levetiracetam, phenytoin, valproicand carbamazepine all have equal efficacy, but lavetiracetam has the fewest SE
alternate treatment is gabapentin, topiramate, lamotrigine, oxcarbazepinem
if seizures are not controlled with a single, try an alternative. if still not contrlled, add a 2nd –> if multiple do not control –> surgical correction of the focus

Question 13

1. 1st line for absence
2. 1st line for tonic clonic seizure
3. 1st line for status epilepticus prophylaxis
4. 1st line for simple seizure
5. 1st line for trigeminal neuralgia
6. 1st line for complex seizres
7. 1st line in neonates

Answer 13

1. ethosuximide
2. phenytoin or valproic
3. phenytoin
4. carbamazepine
5. carbamazepine
6. carbamazepine
7. phenobarbital

Question 14

when to stop medication for epilepsy

Answer 14

• standard of care wait until the patient has been seizure free for 2 years
• a sleep deprivation EEG is the best way to tell if there is the possibility of recurrence (it can elicit abnormal activity, but it lasts high sensitivity)

Question 15

best initial test for Myasthenia gravis

Answer 15

• acetylcholine recetor antibodies (80-90% sensitivity)

- for patients without those antibodies, get anti-MUSK antibodies (muscle specific antibodies)

Question 16

Myasthenia gravis - other test for diagnosis

Answer 16

edrophonium: short acting inhbitor of acetylcholinesterase –> improvement lasts for few minutes

Question 17

Myasthenia gravis - most accurate test

Answer 17

Selectromyography shows decreased strength with repetitive stimulation

Question 18

Myasthenia gravis - image?

Answer 18

yes –> chest something (chest x-ray, MRI, CT) to look for thymoma or thymuc hyperplasia
CT with contrast is the best

Question 19

Myasthenia gravis - best initial treatment

Answer 19

Neostigmine or pyridostigmine

Question 20

Myasthenia gravis - treatment if resistant to best initial

Answer 20

if under 60: thymectomy

if over 60: prednisone (azthioprine, tacrolimus, cyclophosphamide, mucophenolate to get the paitent off of steroids

Question 21

Myasthenia gravis - management of acute crisis

Answer 21

• severe overwhelming disease with profound weakness or respiratory involvement
• IVIG or plasmapheresis

Question 22

causes of dementia

Answer 22

1. Alzheimer 2. Frontotemporal dementia (Pick disease) 3. Lewy body dementia 4. Creutzfeldt-Jakob disease 5. other causes

Question 23

other causes of dementia

Answer 23

1. Multi-infarct (vascular) 2. Syphilis 3. HIV 4. Wilson disease 5. Normal pressure hydrocephalus
2. Vitamins B1, B3 or B12 deficiency
3. Chronic substance abuse (neurotoxicity of drugs)
4. Huntington

Question 24

causes of diffuse symmetrical atrophy of the brain on mri

Answer 24

1. alzheimer 2. chronic alcoholism 3. untreated HIV

Question 25

diagnostic tests for dementia

Answer 25

1. MRI of the brain 2. thyroid function test 3. B12 with possible methylmalonuc acid level 4. VDRL or RPR to exclude syphilis

Question 26

Altered proteins - Alzheimer disease

Answer 26

ApoE2 (decreased risk of sporadic) ApoE4 (increased risk of sporadic) , APP (increased risk for early onset (familiar)) presenilin-1 (increased risk for early onset (familiar)) presenilin-2 (increased risk for early onset (familiar))

Question 27

Alzheimer disease - histology

Answer 27

1. loss of ach neurons 2. senile plaques in gray matter (extracellular β-amyloid (Aβ) core) 3. Neurofibrillary tangles (intracellular, hyperphosphorylated tau protein)

Question 28

Alzheimer disease - senile plaques CAN CAUSE (how)

Answer 28

amyloid angiopathy --> intracranial haemorrhage | deposition around vessels

Question 29

Alzheimer drugs (and SE)

Answer 29

Ache inh: Dnepezil, rivastigmine, galantamine (insomnia) | 2ND LINE) NMDA receptor antagonists (Hallucinations

Question 30

Lewy body dementia - manifestation and histology and treatment

Answer 30

- initially dementia + visual distarbances followed by parkinonian features - intracellular Lewy body: insoluble aggregates a-synuclein in cortex - levodopa/carbidopa

Question 31

Frontotemporal dementia - histology / treatment

Answer 31

1. silver-staining spherical tau protein aggregates (Pick bodies) 2. inclusions of ubiquitinated TDP-43 3. no special treatment, ACEi

Question 32

Frontotemporal dementia - manifestation

Answer 32

1. Dementia (later) 2. aphasia (early) (primary progressive aphasia) 3. movement disorders (eg. parkinsonism, ALS-like UMN/LMN degeneration) 4. early change in personality and behaviour

Question 33

Creutzfeldt-Jakob disease - tests

Answer 33

1. normal head MRI or CT 2. CSF with 14-3-3 protein 3. Biopsy is most accurate