Neurology IV

Question 1

1) Define seizure
2) Give the two main categories

Answer 1

1) A transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain
2) Either focal or generalized

Question 2

How common are strokes and brain tumors as far as seizure causes go?

Answer 2

1) Stroke: ~15% overall, 49% > age 60 y/o (most common in elderly)
2) Brain tumor: ~ 6% overall, 11% > 60 y/o

Question 3

Besides idiopathic, stroke, and brain tumor, what are some other seizure etiologies?

Answer 3

1) Head trauma (TBI)
2) Intracranial infection: meningitis, encephalitis
3) Cerebral degeneration
4) Congenital brain malformations
5) Inborn errors of metabolism

Question 4

What is included in the complete H&P for a seizure patient?

Answer 4

1) Witnessed description of the event
2) Substance abuse
3) Head trauma
4) Cerebrovascular event
5) Cardiac history
6) Sleep d/o
7) Medications: tramadol, bupropion

Question 5

What 2 medications can induce seizures?

Answer 5

Tramadol and bupropion

Question 6

1) Seizure tests should include what?
2) What about for the first seizure?

Answer 6

1) Electrolytes (CMP), Glucose, HCG, ECG, EEG
2) Neuroimaging: MRI + contrast

Question 7

Seizure: Diagnostic Evaluation
1) When would you do a lumbar puncture?
2) What test is essential for diagnosis and classification?
3) What neuroimaging is preferred, MRI or CT? Why?

Answer 7

1) Only if signs of infection
2) EEG
3) MRI preferred over CT; better for identifying structural lesion
-Helps answer “Is the lesion the cause of the Sz?”

Question 8

Focal seizures:
1) What do Sx depend on?
2) How quick is the onset?
3) Give examples of Sx

Answer 8

Symptoms depend on which lobe is involved and have sudden onset (ex/ rhythmic movements – hands and feet or, hallucinations, flashing lights.)

Question 9

Focal seizures:
1) Describe temporal lobe seizures.
2) What may the pt be like after a temporal lobe seizure?
3) Is this type common?

Answer 9

1) Bland, quiet, sense of fear, lip smacking/chewing. Patient is unresponsive for a period of time.
2) Pt may be fatigued or confused, or may not remember the episode at all
3) Most common focal seizure

Question 10

Focal seizures:
1) Describe Frontal lobe seizures. Include when they may occur
2) Is the pt always unconscious?

Answer 10

1) Dramatic, often in the night; shaking of limbs, loud vocalizations.
2) Patient may remain aware throughout.

Question 11

Focal seizures:
1) Describe the Sx of occipital lobe Sz
2) Describe the Sx of parietal lobe Sz. Are they common?

Answer 11

1) Flashing colors or lights, visual hallucinations. Electrical activity may spread therefore, can be subtle or dramatic.
2) Vertigo, tingling, numbness. Uncommon.

Question 12

Focal seizures:
1) Pathophys?
2) Etiology?
3) Epidemiology?

Answer 12

1) Hyperexcitability in a neuronal population, increase in voltage, decrease in inhibitory NTs.
2) Structural brain abnormality (head injuries, birth anomalies).
3) 3/1,000 people ~10% prevalence over lifetime.
~3% go on to develop epilepsy.

Question 13

Generalized Seizures:
1) Tx?
2) Epidemiology/ demographics?

Answer 13

1) Ethosuximide, valproic acid, topiramate, carbamazepine
2) M>F; 5 mil new dx/yr globally, 3.5 mil/yr US
-0.6% children, 8% adults

Question 14

Generalized seizures:
1) What part(s) of the brain is/ are involved? Sx?
2) How are they diagnosed?
3) What are they associated with? (3 things)

Answer 14

1) Involves both hemispheres; may range from staring (absence 10-20 sec) to lightening-like jerking (myoclonic) to dramatic limb shaking and falling, usually including self injury (tonic-clonic.)
2) EEG (electroencephalogram)
3) Developmental delay, amnesia, and postictal state

Question 15

Generalized seizures:
1) What are some Sx that may or may not be present?
2) What is the pathophys?

Answer 15

1) +/- LOC, fecal/urinary incontinence, tongue biting
2) Abnormal and excessive neuronal activity

Question 16

Generalized Seizures:
1) Etiology? (hint: many)
2) DDxs?

Answer 16

1) Hyperventilation, fever, stress, menstrual cycle, trauma, infection, tumor
2) Syncope, TIA, movement disorders, convulsive concussion

Question 17

Generalized nonmotor seizures:
1) Define absence seizure (aka petit mal) and who they’re common in
2) Is consciousness always impaired? How long do they last?
3) Are they obvious? Explain

Answer 17

1) Absence seizures (AKA petit mal) – kids, “staring spell” (non-responsive)
2) Characterized by brief impairment of consciousness with abrupt start and end
-May be very brief; seconds (like, ”miss a word or two when talking”)
3) Witness may miss and patient has no recollection; no aura or postictal period

Question 18

Generalized nonmotor seizures:
1) True or false: these may have mild involuntary movements. Explain.
2) Almost always start in _____________, frequently cease by age __________, or replaced by other forms of generalized seizures.

Answer 18

1) True, but rare
2) childhood; 20 y/o

Question 19

Generalized nonmotor seizures: Tx? (2 things)

Answer 19

Valproic acid (Depakote)
+
Ethosuximide

Question 20

List the 5 different types of generalized motor seizures

Answer 20

1) Tonic
2) Clonic
3) Tonic-clonic
4) Myoclonic
5) Atonic

Question 21

1) Quick jerking without LOC describes what type of motor seizure?
2) What is a DDx for atonic seizures? Describe what these motor seizures are like

Answer 21

1) Myoclonic
2) DDx syncope; sudden drop attack, loss of muscle tone, LOC

Question 22

Motor seizures
1) What are tonic seizures? What are they the opposite of?
2) Jerking muscles, convulsions, and LOC sound like ______ seizures.
3) What are tonic-clonic seizures like?

Answer 22

1) Rigid or increased muscle tone; rigidity followed by LOC (opposite atonic)
2) clonic
3) Rigid with LOC followed by convulsions and postictal period

Question 23

Generalized motor seizures
Tonic-clonic seizure (grand mal seizures):
1) What are they like? What is the onset?
2) What is the tonic phase? How long does it last?
3) What abt the clonic phase?
4) Is there a postictal phase? Explain

Answer 23

1) Bilaterally symmetric & without focal onset
Abrupt onset: rigid, convulsions and LOC; falls to ground
2) Very stiff/rigid lasting ~10–60 seconds
3) Generalized convulsions and jerking of the limbs
4) Postictal phase w. variable Sx; confused, amnesia, HA

Question 24

Generalized motor seizures
What are some Sx of tonic-clonic seizure (grand mal seizures) besides convulsions?

Answer 24

1) Bladder and bowel release
2) Self-trauma: fall or biting self

Question 25

Status Epilepticus: 1) Define it 2) Pathophys? 3) Etiology?

Answer 25

1) 2 or more seizures without conscious recovery in between attacks. Enduring epileptic condition (> 30 min.) 2) Failure of normal inhibitory pathways (GABA) 3) N/c with anti-epileptic meds or: alcohol withdrawal, drug overdose, intracranial infections or neoplasms, metabolic disorders, fevers, strokes

Question 26

Status Epilepticus: 1) Epidemiology (incl. demographic) 2) DDx 2) Tx

Answer 26

1) Rare, 10-40/100,000/yr mostly young and elderly 2) Seizures due to hypoglycemia, electrolyte imbalance, alcohol withdrawal, cocaine, bacterial meningitis, herpes encephalitis, arrhythmias, brainstem ischemia 3) ABCs; benzos (lorazepam 4 mg IV bolus (2 mg/min)); repeat x 1 in 10 min if needed, -then may add phenytoin to maintain control; -phenobarbital if no response to benzos

Question 27

1) Define epilepsy 2) True or false: All epileptics have seizures, not all seizures develop epilepsy

Answer 27

1) Chronic condition characterized by **at least 2 unprovoked seizures** at least **24 hours apart** 2) True

Question 28

List the 3 components of epilepsy

Answer 28

1) Distinct onset and end 2) Clinical signs 3) Abnormal synchronous electrical activity of the brain

Question 29

1) _____% of population may experience a seizure during lifetime 2) What % of people develop epilepsy?

Answer 29

1) ~10% 2) ~3%

Question 30

Differentiate between provoked and unprovoked single seizure Txs

Answer 30

1) Provoked: ID and treat underlying condition (ex/drug abuse, brain tumor, stroke, fever) 2) Unprovoked single seizure: often not treated unless recurs, i.e., first single seizure not treated with anti-seizure Rx

Question 31

AEDs (Anti-Epileptic Drugs): 1) Are not necessary for who? 2) When should you Tx?

Answer 31

1) Individuals with a single new onset seizure or infrequent seizures 2) Only if there is a high risk of recurrence (EEG and or MRI +)

Question 32

AEDs (Anti-Epileptic Drugs): Immediate AED therapy (compared to delay of Tx) pending a 2nd seizure is likely to reduce ___________ risk within the first 2 years, but **not** improve __________ or prognosis over a _________ term

Answer 32

recurrence; QOL; longer term (- > 3 years)

Question 33

Epilepsy: 1) Treated patients should be seizure free for ____ years on Rx prior to consideration of medication withdrawal in appropriate patients. 2) Does withdrawal work?

Answer 33

1) ~2 years 2) Depends on epileptic syndrome; some persist for life and will have seizure after Rx withdrawn

Question 34

Epilepsy: 1) Risk of recurring seizure remains ___________ even in good candidates. 2) Surgical resection may be an option for what pts?

Answer 34

1) high (20-70%) 2) Refractory (to Rx) focal epilepsies

Question 35

Who has a High Risk of Seizure Recurrence? (7 groups)

Answer 35

1) Status epilepticus 2) History of TBI 3) Brain lesion on neuroimaging 4) Focal neurological abnormalities on exam 5) Intellectual disability 6) Abnormal EEG (with epileptiform discharges) 7) High Risk Seizure Types: Focal, absence, myoclonic or atonic seizures

Question 36

1) < _____% of MVA are attributable to seizures. 2) ____________ interval is best indicator of driving safety; longer the interval, the less likely MVA 3) The longer ________ restricted, the lower the compliance

Answer 36

1) <0.1% 2) Seizure free 3) driving

Question 37

General recommendation in TN a __________ seizure free (on treatment) interval before driving resumed, or ________ for initial license

Answer 37

1) 6-month; 12 mo

Question 38

True or false: state laws vary regarding seizures and driving **and** few states require health care providers report patients with seizure

Answer 38

1) True -Know your own state laws

Question 39

What does TDOT say about seizures and driving?

Answer 39

TDOT “shall suspend and/or not issue a DL to anyone who suffers from uncontrolled epilepsy, momentary lapse of consciousness or control due to epilepsy, cardiac syncope, DM, or other conditions until the person has remained seizure free or lapse free for 1 yr (or symptoms controlled for > 6 mo,) and then only upon receipt of a favorable medical statement from the person’s medical professional.”

Question 40

Transient Ischemic Attack (TIA): 1) Define it. How long does it typically last? 2) Pathophys? 3) Etiology?

Answer 40

1) Focal neurologic symptoms of presumed ischemic origin with the absence of infarction on brain imaging (usually resolved in minutes). 2) Transient interruption of blood flow. 3) Vascular disease, embolization (a fib, endocarditis,) hematologic (clotting disorders, Sickle cell, polycythemia).

Question 41

Transient Ischemic Attack (TIA): 1) Epidemiology: _____% of stroke patients and ____-_____% of patients with TIA will have stroke within 90d, esp older pts and pts with _______. 2) 3 DDxs? 3) Txs?

Answer 41

1) 15%; 5-15%; DM 2) Focal seizures, migraine aura, hypoglycemia 3) Treat underlying disorder (DM, HTN, hematologic disorders.): a) CEA, statin or anticoagulation if appropriate b) d/c smoking, weight reduction c) Echo, urgent neuro consult

Question 42

TIA work up should include what? (4 things)

Answer 42

1) Carotid doppler US 2) Echocardiography 3+4) ECG and Heart Rate monitor to evaluate for AF

Question 43

List the 4 features that increase risk of stroke after TIA

Answer 43

1) Age > 60 2) Diabetes 3) Speech or motor difficulties as part of presentation 4) Episode duration > 10 minutes -None of above factors = minimal risk

Question 44

AHA/ASA recommends the ABCD2 score to calculate a patient’s what?

Answer 44

Short-term risk of developing a CVA

Question 45

**Which of these medications is best to reduce risk of recurrent stroke after mild stroke or TIA?:** A. ASA B. Clopidogrel C. ASA + dipyridamole (Aggrenox) D. ASA + Clopidogrel

Answer 45

**D. ASA + Clopidogrel** (short term use) (dual therapy with aspirin and an antiplatelet)

Question 46

TIA urgent evaluation: 1) Why should you order a non-contrast CT? 2) Why should you use an MRI? 3) Why should you use neurovascular imaging?

Answer 46

1) R/o bleed 2) To determine tissue damage; negative = TIA 3) To evaluate large artery disease (Carotid artery disease = source of emboli)

Question 47

TIA urgent evaluation includes what? (4 things with different parts)

Answer 47

1) Non-contrast CT 2) MRI 3) Neurovascular imaging 4) Cardiovascular evaluation: a) ECG (enzymes as part of initial labs) b) Event monitor c) Echocardiogram

Question 48

TIA urgent evaluation: 1) Why is there are cardiovasc. eval? 2) What part of the cardiovasc. eval is a part of initial labs? 3) What part is for paroxysmal AF? 4) What are 2 reasons to use an Echocardiogram?

Answer 48

1) R/o cardiogenic source of emboli 2) ECG (enzymes as part of initial labs) 3) Event monitor 4) Thrombus, valvular disease

Question 49

What is TIA routine management?

Answer 49

Guideline directed medical management 1) HTN 2) Dyslipidemia 3) DM 4) Smoking/lifestyle modifications 5) Antiplatelet (ASA + clopidogrel) 6) Anticoagulation if appropriate – AF, valvular disease

Question 50

A patient presents to you having had a single new unprovoked motor seizure. Your first step in treatment would be? A. no medication B. start oral valproic acid C. start on AED based on type of seizure D. start IV phenytoin

Answer 50

A. no medication

Question 51

Stroke (CVA): 1) Define it and list its Sx 2) What are the 2 types?

Answer 51

1) Sudden onset of neurologic deficits from a cerebrovascular origin. -HA, vomiting, flashing lights, facial droop, unilateral weakness, vision loss, speech disruption 2) Ischemic or hemorrhagic

Question 52

1) What is the pathophys of ischemic strokes? 2) What is the pathophys of hemorrhagic strokes? Include which is more common

Answer 52

1) (87% of US strokes) thrombotic or embolic occlusion of a vessel leading to in the cerebrum 2) HTN > microaneurysms on vessels or AVMs, -hemorrhage can extend to ventricles or subarachnoid space, causing further symptoms

Question 53

What is the etiology of ischemic strokes?

Answer 53

Vascular disease, embolization (a fib, endocarditis,) hematologic (Antiphospholipid Antibody Syndrome, Sickle cell, polycythemia)

Question 54

Stroke (CVA): 1) Epidemiology? 2) DDxs? 3) Tx?

Answer 54

1) 5th leading cause of death in US and leading cause of disability 2) Seizure, infection, tumor, toxic/metabolic disorders, complicated migraines 3) 1) minimize disability, 2) prevent recurrent stroke; treat underlying cause if known

Question 55

IV thrombolytics (tPA-tissue plasminogen activator) for ischemic strokes (CVA): 1) Gives some improvement of disability at ______ days. The sooner after the stroke it is given, the _________ the results. 2) **How soon after a stroke must it be given?** 3) What is the downside?

Answer 55

1) 90; better 2) Within 3 hours 3) Many contraindications (GI bld, recent anticoagulant or ASA use… )

Question 56

Ischemic stroke Tx (besides IV thrombolytics) include what?

Answer 56

1) Embolectomy 2) Neuro consult, admit to stroke unit, tight BP control (esp first 72 hrs) 3) Early rehab 4) +/- decompressive hemi-craniotomy 5) Antiplatelet and anticoagulants

Question 57

How do you Tx a **hemorrhagic* stroke?

Answer 57

1) ABCs 2) Neurosurgery consult -admit to ICU/stroke unit 3) Lower sBP 140-180 mmHg IV labetalol or nicardipine 4) Treat underlying cause if any 5) d/c any anticoagulation and reverse any coagulopathies 6) Ventricular drainage or hematoma evacuation

Question 58

Which is the most common source of emboli resulting in stroke? A. cerebral arteries B. carotid arteries C. aortic arch D. vertebral basilar arteries E. heart

Answer 58

E. heart

Question 59

Which is the most common exam finding in a stroke patient? A. Bowel and bladder release B. LOC C. EOM dysfunction D. Unilateral weakness and speech disturbance

Answer 59

D. Unilateral weakness and speech disturbance

Question 60

H & P by experienced provider in an emergency setting has what percent sensitivity for dx of stroke and TIA?

Answer 60

92%

Question 61

Stroke: 1) What is key to diagnosis? What should you focus on? 2) Explain how timing is crucial

Answer 61

1) History/exam is key; focus on symptoms and signs of focal neurologic injury 2) Timing = last known baseline state; crucial for assessment and treatment options

Question 62

List the presentation/ Sx of stroke (6)

Answer 62

1) Acute onset with maximal focal neurologic deficit that is consistent with a vascular territory 2) Arm or leg weakness (loss of strength) 3) Speech disturbance (aphasia or dysarthria) 4) Facial weakness 5) Arm or leg paresis (sensory loss) 6) Headache or dizziness

Question 63

NIH stroke scale (NIHSS): 1) What is it? 2) How long does it take? 3) What does it do?

Answer 63

1) 15 item scale; determines severity of stroke 2) Experience provider ~5 minutes to complete 3) Helps distinguish stroke from other

Question 64

NIH stroke scale (NIHSS): What are the 3 aspects of its chief utility?

Answer 64

1) **Reliably evaluate stroke severity** (to determine whether tissue plasminogen activator administration is appropriate) 2) **Predicts prognosis** 3) **Requires training to use effectively**

Question 65

How do you interpret NIH Stroke Scale scores? **important**

Answer 65

8 or less = mild (no rtPA) 9-15 = moderate 16 + = severe

Question 66

Ischemic stroke recap: 1) What should the focused H&P include? 2) Labs?

Answer 66

1) Establish time of onset of symptoms (last witnessed asymptomatic time,) NIH stroke scale 2)Need a few to determine eligibility, others pending Glucose, CBC, coag panel

Question 67

Ischemic stroke recap: 1) What do you need to interpret within 45 mins of a pt being triaged for stroke? 2) What do you need to determine? What should you do next? 3) What do you need to review the criteria for?

Answer 67

1) STAT NCCT brain (image of brain) 2) Ischemic vs. hemorrhagic stroke -Quick re-assessment of exam findings; repeat NIH stroke scale & compare to baseline 3) rtPA (time from baseline normal is within 3 - 4.5 hours) -rtPA in appropriate patients without delay

Question 68

rTPA contraindications include what? (4 things)

Answer 68

Recent surgeries, tumors, anticoagulants, GI bleeds, ischemic stroke within past 3 months

Question 69

**CAD** 1) Carotid endarterectomy (CEA) is beneficial after stroke when _______________________ stenosis is 70% or greater. 2) Endarterectomy is reasonable with ipsilateral stenosis of _____% to _____% in patients who are at lower surgical risk. 3) What may be a reasonable alternative to endarterectomy in certain low-risk patients

Answer 69

1) ipsilateral extracranial internal 2) 50% to 69% 3) Carotid artery stenting

Question 70

Arteriovenous malformation (AVM): 1) What is it? 2) Size? 3) What can it develop? What do most do? 4) What can they cause in the brain? 5) Tx?

Answer 70

1) Congenital vascular malformations formed from a focal malformation of an arteriovenous communication without intervening capillaries. 2) Size ranges from so tiny can barely be noted to massive mass like lesions 3) Aneurysm or hemorrhage. -Most bleed at some point 3) Rec seizure, HA, mass effect, bleeds 4) If needed: surgery, embolization, cautery

Question 71

Cerebral Aneurysm Rupture: 1) What are the Sx? -What % chance of death? 2) What is the pathophys?

Answer 71

1) Severe headache, focal neurologic symptoms, coma or death. ->50% chance of death 2) Focal distortion of blood vessel wall (ex/ berry aneurysm in ant circle of willis)

Question 72

Cerebral Aneurysm Rupture: 1) Etiology? 2) Epidemiology? 3) DDxs?

Answer 72

1) HTN, developmental abnormality (but most develop over time,) smokers, females, OCP use, + FH, polycystic kidney ds 2) More common in younger patients; 30,000 cases dx in US/yr (35 mil) 3) Head trauma, SAH, cerebral arterial dissection, ruptured AVM

Question 73

Cerebral Aneurysm Rupture Tx? (7)

Answer 73

1) ABCs, emergent brain imaging, neurosurgery consult (clip or coil, but not stent) 2) Once stable, CTA = many pts have > 1 aneurysm (mirror aneurysm) 3) sBP < 130 (avoid any vasodilators that could worsen ICP) 4) Shunt for hydrocephalus 5) Frequent neuro checks 6) Prophylactic anticonvulsant meds 7) Nimodipine 60mg q4hr (improves outcomes and decreases vasospasms.) 8) Maintain euvolemia + monitor for hyponatremia

Question 74

Intracranial Hemorrhage: 1) What are the 2 kinds? What are the Sx? 2) Pathophys?

Answer 74

1) Intraparenchymal or subarachnoid; sudden onset excruciating HA (“worst HA of my life,”) focal neurologic symptoms, +/- coma, sudden death (25-50%,) can occur anytime of day/night 2) Rupture of intracerebral (berry) aneurysm or AVM

Question 75

Intracranial Hemorrhage: 1) Etiology? 2) Epidemiology? 3) DDxs?

Answer 75

1) Trauma, aneurysm rupture, HTN or developmental overtime 2) SAH 5% of all strokes, typically younger patients 3) Head trauma, arterial dissection, vasculitis

Question 76

Intracranial Hemorrhage: What is the Tx?

Answer 76

Neurosurgery consult; prevent rebleed: 1) Admit to ICU/stroke center 2) ABCs, prevent neurological complications, pain management, BP control, monitor ICP, fluids to euvolemia 3) Many patients with SAH develop hydrocephalus; drain with intraventricular catheter

Question 77

Syncope: 1) Define it 2) Pathophys 3) Etiology

Answer 77

1) Transient loss of consciousness for a few seconds 2) Excessive vagal tone or impaired control of peripheral circulation 3) Heart disease, age > 60, stress

Question 78

Syncope: 1) Epidemiology? 2) DDxs? 3) Tx?

Answer 78

1) ~30% of adults will experience at least 1 episode 2) Seizure, TIA, hypoglycemia 3) Counterpressure maneuvers (Valsalva: squat, bear down, abdominal contraction) -Treat underlying cause

Question 79

High Risk of Seizure Recurrence: What are the high risk seizure types?

Answer 79

Focal, absence, myoclonic or atonic seizures