Common Problems in Neurology

Question 1

How are seizures classified?

Answer 1

Focal seizures: consciousness may or may not be impaired. Local, may generalize or propogate

Generalized seizures:

• nonconvulsive (absence)
• convulsive: myoclonic, clonic, tonic, tonic-clonic, atonic

Question 2

Most likely cause of new seizure onset in patient > 65 yo

Answer 2

Cerebrovascular disease/stroke

Question 3

Most common cause of seizures in…

• overall ages
• age > 60

Answer 3

• idiopathic > 62%

- stroke, brain tumor

Question 4

Definition of epilepsy

Answer 4

chronic condition characterized by two UNPROVOKED seizures at least 24 hours apart

Question 5

What factors increase risk of seizure recurrence?

Answer 5

• status epilepticus
• hx of brain injuty
• brain lesion on neuroimaging
• focal neuro abnormalities
• intellectual disability
• high risk seizure type: focal, absence, myoclonic or atonic

Question 6

What is DRESS syndrome?

Answer 6

Drug Reaction with Eosinophilia and Systemic Symptoms

Question 7

Definition of status epilepticus

Answer 7

single seizure that lasts longer that 5 minutes or recurrent seizures without return to baseline

Question 8

Initial therapy in status epilepticus

Answer 8

• DOC: lorazepam 0.1 mg/kg IV, max 4 mg/dose
• may use midazolam IM or diazepam IV or rectally
• Urgent control therapy with Antiepileptic such as phenytoin/fosphenytoin, phenobarbital, valproate

Question 9

If a patient has a seizure, when can they drive again?

Answer 9

3 month seizure free interval is recommended by american academy of neurology. 6 months in north carolina. Physicians not required to report to the DMV

Question 10

Which are the only two anti-epileptic drugs that do not lead to hormonal contraception failure (induction of cytochrome P450)

Answer 10

• depakote
• keppra

Antiepileptic drugs do not interfere with depo provera or IUDs

Question 11

If a woman on an antiepileptic drug is considering pregnancy what should you do?

Answer 11

• consider withdrawing AED 6 months prior to conception if pt has been seizure-free for > 2 years
• supplement folic acid 4 mg per day if pt on valproic acid or carbamazepine

Question 12

If a woman on an antiepileptic drug becomes pregnant what should you do?

Answer 12

• do not change AEDs in pregnancy if patient is well controlled
• supplement folic acid 4 mg per day if pt on valproic acid or carbamazepine
• some meds may require vitamin K supplementation in last month of pregnancy

Question 13

Can you breast feed while on anti-epileptic medications

Answer 13

Yes, all except lamotrigine

Question 14

Antiepileptic drug of choice for generalized absence seizures

Answer 14

In < 16 yo ethosuxamide or valproic acid
SOR A

No SOR A for other age groups

Question 15

Antiepileptic drug of choice for focal seizures in < 16 yo

Answer 15

Oxcarbazepine

SOR A

Question 16

Antiepileptic drug of choice for focal seizures in > 60 yo

Answer 16

Gabapentin, lamotrigine

SOR A

Question 17

Treatment of choice for chronic tension headaches

Answer 17

OTC analgesics

if needed, TCA for prophylaxis

Question 18

Definition of chronic daily headaches

Answer 18

15 or more HA per month x 3 months

Question 19

Treatment of chronic daily headaches

Answer 19

• stop abortive treatment, begin prophylactic treatments
• nonpharm: biofeedback, CBT (SOR B)
• Pharm:
  SOR A = topiramate, valproate
  SOR B=amytriptyline, gabapentin, tizanidine
  No effect = SSRI, propranolol, botox

Question 20

Describe cluster headaches

Answer 20

orbital or temporal unilateral pain with ptosis, miosis, rhinorrhea, lacrimation, or conjunctival injection.
Last 15 min - 3 hours

Question 21

Treatment of cluster headaches

Answer 21

Acute: Oxygen and sumatriptan SQ
Preventative: verapamil is DOC.
may consider steroids, lithium, topiramate

Question 22

Criteria to diagnose migraine without Aura

Answer 22

A. 5 attaches fulfilling criteria
B. lasts 4 -72 hrs
C. has 2+ characteristics: unilateral, pulsating, mod-severe pain, limits routine physical activity
D. at least one of the following: nausea/vomiting, photophobia/phonophobia
E. no other explanation for symptoms

Question 23

What are red flags for neuroimaging?

Answer 23

• rapidly increasing HA frequency
• lack of coordination, abnl neuro exam, papilledema
• HA that awaken from sleep
• worst HA of life
• pts with cancer, HIV, lyme disease
• new onset > 50 yo
• rapid onset with strenuous exercise

Question 24

What is the neuroimaging of choice if someone has HA that have red flag symptoms?

Answer 24

CT or MRI without contrast

- use contrast if immunocompromised or concern for temporal arteritis, dissection, or aneurysm

Question 25

First line treatments of migraines

Answer 25

acetaminophen, NSAIDs

Triptans - avoid in pregnancy

Question 26

Indications for preventative treatment of migraines

Answer 26

• HA significantly interferes with activities
• overuse of acute therapies
• adverse events with acute therapies
• patient preference
• migraine variants that mimic CVAs

Question 27

Which medication is useful for abortive tx if a migraine is associated with menses?

Answer 27

• zolmatriptan

Question 28

When should a patients migraine history limit the prescription of estrogen-containing contraceptives?

Answer 28

• migraines with aura at any age
• migraines over age 35

No good quality data but appears on exams

Question 29

Diagnostic criteria of Multiple sclerosis

Answer 29

must diagnose discrete lesions in varios parts of the CNS at least 3 months apart

Question 30

What is lhermitte’s sign in MS?

Answer 30

neck flexion results in an electric shock sensation down limbs and spine

A physical finding that indicates demyelination

Question 31

What is Uhthoff’s phenomenon in MS?

Answer 31

worsening of symptoms with increased body temperature

Question 32

Treatment of acute Multiple sclerosis exacerbations

Answer 32

Corticosteroids

Methylprednisolone 500-1000 mg daily for 3-7 days

Question 33

In Multiple scelorsis, should DMARDS be initiated early or started once disease begins to worsen?

Answer 33

Should be started early

• decrease relapse rate
• decrease brain lesions on MRI