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Neurology Flashcards

0
Q

Type of seizure most common in adults

A

Temporal lobe epilepsy
- virtually all are complex partial seizures (+/- secondary generalization)
Hx febrile seizures common
Partial part difficult to tx, 2ndary generalization usually responds to drugs
Psych behavioral disorders often coexist

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1
Q

Drugs that lower seizure threshold

A 
Clomipramjbe
Clozapine
Loxapine
Phenothiazine 
Bupropion
Meperidine
Inhaled anesthetics
Theophylline at level >25
Cyclosporine
Flumazenil
Quinolones
Beta lactams eg imipenem
Dalfampridine
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2
Q

Type of seizure that often requires lifelong anticonvulsant therapy

A

Juvenile myoclonic
Mixed sz types myoclonic absence and/or GTC
Ppt by stress or sleep deprivation

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3
Q

Most refractory sz disorder

A

Lennox gestault

  • heterogenous group of childhood epileptic encephalopathies
  • start before age 4 usually
  • result of brain malformations perinatal asphyxia , head injury, CNS infection
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4
Q

Another refractory syndrome

A 
Infantile spasms (west syndrome)
Attacks start before  6 months
- from cerebral dysgenesis, hypoxic ischemic injury, intrauterine infections, or idiopathic
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5
Q

Causes of single seizures

A

Withdraw from CNS depressants
Acute illness - meningitis, abscess, encephalitis
Toxicity - uremia , lead, carbon monoxide
Drugs which Lower seizure threshold
Head trauma
Hypoxia
Fever
Metabolic - hyponatremia, hypoglycemia, dehydration
Medical procedures - ECT , brain surgery, organ tx, labor and delivery

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6
Q

Chronic seizure disorder causes

A 
stroke or other vascular
Mental retardation
Neuro development or brain injury
Neoplasms 
cerebral palsy
Genetic predispo
Head trauma
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7
Q

Genetically caused sz

A

Childhood absence,
juvenile myoclonic

Mechanism:

  • mutation in ion channel function
  • mutations affecting CNS development
    - block neuronal apoptosis
    - nerve cell metabolism dysreg
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8
Q

Secure prognostic factors

A

Good prognosis : sz free x 2 or more years, successfully tx after first sz; normalized EEG

Poor prognosis: partial sz or multiple sz types in same pt, hx of status epilepticus, polypharmacy needed, traumatic brain lesion visible

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9
Q

Objective data for seizures

A

EEG - brain electrical activity- abnormalities either before or during sz may be diagnostic

CT- detect gross hemorrhaging fx or trauma, lesions
MRI - can detect smaller lesions vs CT

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10
Q

Aed most significantly associated with birth defects

A

Valproate
Phenytoin

Some case reports:
Phenobarbital
Cbz
Felbamate
All other aed have limited data - class C
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11
Q

Recommendations for pregnant and aed

A

Single drug at lowest effective dose
Oral contraceptives - may need high estrogen product due to drug intxns
Monitor aed levels due to pk changes eg altered protein biding
Ultrasound at 16-18 weeks to check for neuronal tube defects
Preconception tx with 0.4mg folic acid daily
Daily vitamin K during las 2-4 weeks of pregnancy for prevention of neonatal cerebral hemorrhaging and give vitamin k to newborn after deliv

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12
Q

Aed that can worsen psych

A

Ethosuximide
Levitiracetam
Benzos and barbiturates
Topiramate and barbiturates

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13
Q

Newly diagnosed epilepsy tx recommendations:

A
  • standard AED: CBZ , PHT, VPA, Pb

- new AED: LTG, GBP, OXC, TOP

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14
Q

Adults w treatment refractory epilepsy:

A

GBP, TOP, LTG, OXC, LVT, ZON as add-on
New AED: OXC, TOP, LTG may be used as mono therapy in tx resistant partial epilepsy
LTG in tx refractory GTC sz

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15
Q

Percent of costs from epilepsy that are indirect

A

85% due to missed work by patients and caretakers of children/elderly pts w epilepsy

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16
Q

Clinical diagnosis of Parkinson’s disease

A

2 of 3 of following:
Tremor
Rigidity
Bradykinesia

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17
Q

Non motor sx of PD

A

Psych: depression anxiety dementia hallucinations apathy
Sleep - rls
Autonomic
Speech
Sensory
Other - weight loss seborrheic dermatitis sexual dysfxn GI impaired motility

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18
Q

Hoehn and yahr scale

A

Parkinson’s dz
Stage I unilateral involvement only and minimal or no functional impairment
Stage II: bilateral involvement without impairment of balance
Stage III: postural imbalance, some reduction in activities, capable I leading independent life, mild-moderate disability
Stage IV: severely disabled must walk with assurance , marked incapacitation
Stage V: restricted to bed or wheelchair unless aided

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19
Q

How much daily carbidopa needed to block peripheral conversion of levodopa

A

75-200 mg/day

So initial carbidopa/levodopa dose is 25/100mg tid or 10/100mg qid

Titrate q 3 days PRN
If no response to 1000 mg lwop dis reconsider PD dx

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20
Q

Clinical use of anticholinergics in Parkinson’s -

A

Trihexiphenidyl and benztropine
Best in stage 1 and 2 of disease - for tremor
(With levodopa)

Inhibit muscarinic cholinergic receptors in striatum
Benztropine initial dose: 0.5-1mg qhs up to daily dose of 4-6 mg/day
Trihexyphenidyl 1-2 mg first day increase by 2mg increments q 3-5 days to 6-10 mg/day

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21
Q

Drugs to treat PD related psychosis

A

Clozapine start at 6.25mg qday and titrate slowly
Quetiapine start at 12.5 mg qday

Risperidone and olanzapine effective but reports of worsening PD

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22
Q

Migraine criteria for dx

A

At Least 5 attacks
Lasting at least 4-72 hrs (untreated or unsuccessfully treated)
2 of the following characteristics:
- unilateral location
- pulsating
- moderate or severe pain intensity
- aggravated by physical activity

23
Q

Migraine with aura

A

Attack last 4-72 hrs untreated or unsuccessfully treated

Aura - meets criteria for one of the subforms associated with aura

24
Migraine scales
Migraine disability assessment questionnaire (MIDAS) - scores 0-21 with higher score indicating greater disability - self rated - *headache* related disability - both clin and research Monitoring Pain disability index (PDI) Measures *pain * related disability Monitoring for all pain(not just ha) Scores 0-70 higher score more pain disability
25
Indications for prophylactic migraine therapy
2 or more attacks per month that produce 3 or more days per month disability - failure of abortive tx - abortive medication use >2x/week - presence of uncommon migraine including hemiplegic , w prolonged aura, or migraine infarction - after benefit: consider taper after 6-12 months of good headache control
26
Amount of time to get benefit from prophylactic migraine therapy
2-3 months
27
Take abortive medications when?
Onset of headache pain (not aura)
28
Pregnancy and headache meds
Ergot derivatives - category X !! - due to uterine vasoconstriction causing fetal growth retardation Triptans - category C - limited data in humans, some decreased fetal weight in animal studies - hold prophy therapies during pg and breast feeding - use prochlorperazine for nausea
29
Tension headache dx (contrast with migraine)
``` Bilateral (migraine=unilateral) Pressing tightening (non pulsating) Mild-moderate intensity Not aggravated by routine physical activity ``` Both: Not n/v (may be anorexia) Possibly photo or phono phobia, not both
30
Tension headache pain assessment
Typical scales analog for pain
31
Prophy for tension headaches
``` Amitriptyline - doc 50-100mg SSRI (fluox, sert) * diff from migraine Botox A * diff from migraine Propranolol Bzd ```
32
Dx criteria for cluster headache
At least 5 attacks fulfilling criteria - severe or very severe Unilateral orbital, supraorbital or temporal area lasting 15-180 min if untreated - has to have ipsilateral facial sx or restlessness - frequency from 1 q other day to 8/day
33
Abortive tx of cluster headache
100% oxygen 8-10 L/min for 20 min May be given several times per day - sumatriptan 6mg SQ or Nasal DHE = 2nd line abortive
34
Transitional tx for cluster ha
short term preventive tx while awaiting full effect of prophy: - prednisone 60-80mg per day for 3 days then taper over 14 days DHE: daily IM injections for 1 week or 3 day IV infusion Naratriptan 2.5mg bid
35
Prophylactic therapy of cluster headache
Use abortive and transitional treatment while awaiting effect - use ONLY while pt in a cluster cycle, continuous use may not prevent cluster cycles Verapamil 120-480mg daily Lithium 600-1500 mg/day (levels 0.3-0.8 mmol/L) - about as effective as verapamil but not as well tolerated) Valproic 600-2000mg/day Melatonin may reduce doses needed for other Topiramate 50-400 mg/day
36
United huntingtons disease rating scale (UHDRS)
Scores range from 0-128 with higher scores meaning higher motor impairment
37
Huntingtons tx
Tetrabenazine - see card - response in 3 weeks then full in 6 weeks Other Olanzapine - some evidence Risperidone - case studies effective for motor and psych effectiveness Clozapine - best evidence but high doses most effective but still tolerability problems
38
Glasgow coma scale
Use in tbi Score 14-15 more mild brain injury - full recover but may have short term memory problems and concentration difficulties 9-13 moderate - pt lethargic and stupendous 3-8 severe injury pt comatose, cannot follow commands
39
Dx criteria for fibromyalgia acr
Widespread pain index Symptom severity based on fatigue and waking unrefreshed * WPI 7 and SS of 5 or WPI 3-6 and SS 9 dx fibro
40
Hoehn and yahr pd scale
Stage I unilateral invovment no or minimal fxn impair Stage II bilateral involvement but balance ok Stage III evidence of postural imbalance some reduction activity but still independent life, mild-moderate disability Stage IV severely disabled unable to stand and walk unassisted marked incapacitation Stage V restricted to bed or wheelchair unless stated
41
Beta blockers for migraine Px
Propranolol | Timolol
42
Options for transitional tx of cluster headache
Prednisone 60-80mg qday x 3 days then taper over 14 DHE daily IM injectors for 1 week or 3 day IV infusion Naratriptan 2.5mg bid
43
Prophylactic therapy options
Verapamil lithium 600-1500 mg/day levels 0.3-0.8 mmol/L About as effective as verapamil but not as well tolerated VPA Melatonin Topiramate
44
Fastest acting triptan
Rizatriptan
45
Longest acting triptan but slowest onset
Frovatriptan
46
Prophy use
Natatriptan - has longer t1/2 but minimal recurrence slower onset (not as long acting as Frovatriptan though
47
Lipophilic drug with rapid oral absorption and ODT form
Zolmitriptan
48
Duration of Px for cluster headache
2 months of cluster cycle
49
Fibromyalgia scale WPI widespread pain index
Based on number of regions that pt experiences pain (0-19) Fibromyalgia dx: WPI of 7 and SS of 5 Or WPI of 3-6 and SS of 9
50
SS symptom severity score for fibromyalgia
Presence and severity of fatigue Waking from sleep unrefreshed Cognitive symptoms (0-12)
51
Sign and sx of fibromyalgia
Widespread musculoskeletal pain Non restorative sleep and daytime fatigue Psychological fog- depress/anxiety Localized tenderness in 11 or more of 18 specified tender points No apparent organic disease
52
Rating scales ( different than diagnostic SS and WPI)
Fibro fatigue scale- clinician Fibromyalgia impact questionnaire - self rated
53
Milnacipram dose
``` Start 12.5 mg once Day two bid Day 4-7 25mg bid After day 7 50mg bid Can increase to 100mg bid based on response ```
54
Comparing alpha 2 agonist and SGA in tx of tics in Tourette's
One study shows clonidine = risperidone

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