Neurology

Question 1

In AF what, apart from anticoagulation can you do to reduce the stroke risk?

Answer 1

Reduce blood pressure, aim SBP <133

Question 2

Which investigation has the highest specificity for detecting AF?

Answer 2

Implantable loop recorder

Question 3

Which of the NOAC’s carries a high risk of GI bleed?

Answer 3

Rivaroxaban and Dabigatran (150 but not 110).

Question 4

How do the NOACS and warfarin compare for stroke risk reduction in AF?

Answer 4

All non inferior to warfarin for stroke and systemic embolism prevention
All NOACS significantly reduce hemorrhagic stroke

Question 5

Are NOACS useful for primary and secondary stroke prevention?

Answer 5

Yes

Question 6

Which renal function measure should you use when prescribing NOACs?

Answer 6

Cockroft-Gault Equation

Question 7

In a systematic review for prevention of stroke in AF which NOAC had the highest expected incremental net benefit?

Answer 7

Apixaban 5mg BD

Question 8

In patients post embolic stroke of unknown source (no confirmed AF) is rivoroxaban better than aspirin?

Answer 8

No primary outcome of stroke or other embolic event and major bleeding higher in the Rivoroxaban group compared to aspirin

Question 9

What are some early findings on CTB non contrast in an ischaemic stroke?

Answer 9

1) Hyperdense artery (White section of artery)

2) Loss of grey/white matter differentiation due to hypodensity of great matter.

Question 10

How does the ischaemic area appear on MRI brain DWI?

Answer 10

Ischaemic areas appear bright

Question 11

What are the key metrics used to determine ischaemic core and penumbral size on CT perfusion scan?

Answer 11

1) Mean transit time
2) Tmax
3) Cerebral blood volume
4) Cerebral blood flow

Question 12

Diagnostic Tests in seizure

Answer 12

EEG

MRI - on all patients apart from children with genetic epileptic disorder

Question 13

Mesial temporal sclerosis on MRI

Answer 13

Flair + high signal in the temporal region

Question 14

What is the treatment for absence seizures (PBS)

Answer 14

Ethosuxamide

Question 15

Treatment for focal seizures (PBS)

Answer 15

Carbemazepine

Question 16

What percentage of patients become seizure three on mono therapy AED

Answer 16

50% (90% on low to moderate doses)

Question 17

Best anti-epileptic to use in women of child bearing age

Answer 17

Lamotrigine and leviteracetam (the L’s)

Question 18

Drug resistant epilepsy

Answer 18

Seizures despite two, appropriate, anti-epileptic drugs

Question 19

Diagnostic studies to consider in a patient who may be candidate for epilepsy surgery

Answer 19

MRI 
Spect (Interictal and Ictal) 
SISCOM
FDG-PET 
Functional MRI (to identify eloquent cortext to avoid in surgery) 
Intracranial EEG

Question 20

Novel therapies for drug resistant epilepsy

Answer 20

Vagus nerve stimulation
Deep brain stimulation (anterior nucleus of the thalamus)
Ketogenic Diet

Question 21

Prevalence of epilepsy

Answer 21

1 in 26 = approx 4% of the population

Question 22

When does childhood absence seizures typically onset?

Answer 22

During primary school age

Question 23

Investigations in new onset seizure

Answer 23

Early EEG (within 24 hours) 
MRI (note 15% of findings missed on CT scan)

Question 24

Treatment for benzo refractory status?

Answer 24

Leviteracetam = phenytoin = valproate

Question 25

Best drug for generalised seizures? (PBS)

Answer 25

Valproate +: Mood enhancer -: Teratogenic (do not use in young women)

Question 26

Best drug for mycolonus? (PBS)

Answer 26

Clonazepam

Question 27

Lamotrigine uses and adverse effects

Answer 27

Generalised epilepsy - Alternative to Valproate in young women and obese Lennox Gastaut A/E Rash when used with valproate Dizzy when used with carbamezpine

Question 28

Leviteracetam uses and adverse effects

Answer 28

Focal epilepsy - Alternative for pregnant women Adverse effects - Mood disturbances

Question 29

Topiramate

Answer 29

Use - Focal epilepsy add on therapy Adverse effects - CNS fog - Renal stones as carbonic anhydrase inhibitor - Weight loss - Teratogenic ?

Question 30

Perampenel

Answer 30

Uses - Focal epilepsy add on Adverse effects - CNS effects: somnolence/dizziness/agression - Slow titration - Teratogenecity

Question 31

MOA of vigabatrin?

Answer 31

Elevates brain GABA (prevents the breakdown)

Question 32

Leviteracetam MOA

Answer 32

Binds to synaptic vesicular protein SV2A

Question 33

Perampanel MOA

Answer 33

Blocks post synaptic AMPA (glutamate) receptors. Therefore down regulates excitatory action

Question 34

Carbemazepime and SJS

Answer 34

HLA_B*1502 Predominant in Han Chinese or SE Asian descent Therefore if treating these patients need to tests for HLA-B*1502

Question 35

Carbemazepime and DRESS

Answer 35

HLA-A*31:01

Question 36

Phenytoin related Dress/SJS

Answer 36

CYP2C9*3

Question 37

Autoimmune limbic encephalitis

Answer 37

Anti LGl1: Anti potassium channel antibody (Older men) | Anti NMDA: Antibody to NMDA (young woman with teratoma)

Question 38

EEG findings in liver failure

Answer 38

Triphasic waves

Question 39

EEG finding in CJD

Answer 39

Biphasic synchronous waves approx 1 per second

Question 40

Carbemazepime MOA

Answer 40

Blocks voltage gated and use dependent sodium channels.

Question 41

Pyramidal weakness

Answer 41

Legs: Flexors weaker Arms: extensors weaker

Question 42

Gold standard of vertebral imaging

Answer 42

CT Angiogram

Question 43

Hyper-acute stroke therapy

Answer 43

IV thrombolysis: 0-4.5 hours (within 9 hours from recent study) Endo-vascular therapy: 12 hours (24 hours for posterior stroke with salvageable penumbra) - Up to 12 hours NNT is 2.6! Based on salvageable penumbra

Question 44

TIA definition

Answer 44

Symptoms <1 hr with no evidence of damage on imaging 20% of patients with acute stroke will have TIA in the weeks to months prior to event. Most risk within 7-10 days 8% mortality at 6 months

Question 45

Indication for carotid enderartectomy

Answer 45

Symptomatic carotid stenosis > 50-69% (moderate) recommended in men > 70-99% (severe) recommenced within 14 weeks with an ARR of 30% Criteria for CEA - Ipsilateral stroke or TIA - Life expectancy >5 years - Accesible lesion Note stenting: data worse only useful if poor surgical candidate i.e restenosis post CEA or radiation induced stenosis. Peri-procedural death/stroke rate is higher

Question 46

Hyper-acute stroke therapy

Answer 46

IV thrombolysis: 0-4.5 hours (within 9 hours from recent study) Endo-vascular therapy: 12 hours (24 hours for posterior stroke with salvageable penumbra) - Up to 12 hours NNT is 2.6! Extending the time frames is based on salvageable penumbra

Question 47

Indications for reduced dose of Apixaban to 2.5 BD

Answer 47

two of three 1) Age >80 2) Weight <60 3) Cr >133

Question 48

DOAC with increased risk of bleeding?

Answer 48

Rivaroxaban

Question 49

What to consider in a patient with stroke/AF with high bleeding risk

Answer 49

Consider left atrial appendage occlusion devices i.e watchman/amulet device Prague 17 study Head to head of Watchmann vs Apixaban 11% vs 13% of embolic stroke/complications Other option would be surgical closure during cardiac surgery

Question 50

When to consider PFO closure?

Answer 50

Patients = 60 yoa Embolic stroke without other risk factors (esp AF) Note risks of AF post procedure = 4-6%