AEDs General Uses HY

Question 1

Medications or conditions associated with interictal spikes on EEG.

Answer 1

Cefepime; lithium; tramadol; bupropion; clozapine (CeLia Transfer Busy Clothes). Thyrotoxicosis and Uremia are also associated with interictal spikes on EEG.

Question 2

BZD vs Phenobarb

Answer 2

BZD increase the frequency of opening of Cl channels and barbiturates prolong the opening time

Question 3

Antiepileptic drugs that are inducers of the hepatic cytochrome P450 enzyme system and are associated with bone loss

Answer 3

phenytoin; phenobarbital; primidone; carbamazepine

Note- Valproic acid is an inhibitor of the cytochrome P450 system but is also associated with altered bone metabolism and decreased bone mass.

Question 4

Antiepileptic drugs that can exacerbate depression

Answer 4

phenobarbital; primidone; tiagabine; vigabatrin; benzodiazepines; felbamate; levetiracetam; topiramate and zonisamide

Question 5

AEDs commonly recognized for their mood-stabilizing properties

Answer 5

carbamazepine; lamotrigine; and valproic acid

Question 6

Antidepressants best avoided in epilepsy

Answer 6

amoxapine; clomipramine; maprotiline; and bupropion; particularly at higher doses.

Question 7

For depression: first-line pharmacologic therapy

Answer 7

SSRIs with minimal effects on CYP450 isoenzymes;such as citalopram; escitalopram; and sertraline

Question 8

Iatrogenic psychosis has been described with the use of some AEDs

Answer 8

topiramate; levetiracetam; and zonisamide; and may also potentially occur when discontinuing an AED; particularly one with mood-stabilizing properties

Question 9

Medication that can cause PLEDS

Answer 9

Teophylline

Question 10

AED combination that ususally results in diplopia and dizziness

Answer 10

Phosphenytoin and CBZ

Question 11

Drugs that aggravate myoclonic or absence seizures

Answer 11

CBZ; gabapentin; Oxcarb; Pregabalin; Tiagabine. (Lamotrigine can aggravate myoclonic jerks)

Question 12

AEDs to be avoided in Dravet syndrome as they may worsen seizures

Answer 12

Lamotrigine and CBZ

Question 13

AEDs with high cognitive side effects

Answer 13

BZD; phenobarb; TPM; Zonisamide;

Question 14

AEDs with less cognitive side effects

Answer 14

LVT; Gabapentin; LMT; tiagabine

Question 15

Diagnosis of SUDEP if

Answer 15

(1) person had epilepsy; (2) death occurred suddenly; (3) death occurred unexpectedly while the person was in a reasonable state of health; (4) death occurred during normal activity; often while sleeping; (5) there was no determinable cause of death after autopsy; and (6) death was not due to SE nor accidental injury; such as falls or asphyxiation from aspiration.

Question 16

Highest risk of SUDEP

Answer 16

Uncontrolled generalized convulsive seizures (not medication non-compliance)

Question 17

Syncopes

Answer 17

The two main causes of syncope are changes in vasovagal tone and cardiac arrhythmia. Most cases of vaso-vagal syncope (91%) are associated with some type of physiologic sign or symptom; including sweating; nausea; vomiting; visual dimming; motor weakness; and palpitations. These signs and symptoms may occur in isolation or in combination. By comparison; syncopal events resulting from cardiac arrhythmia are not accompanied by prodromal symptoms in 50% of cases. When symptoms are present; diffuse weakness and dizziness are the most common symptoms. Vasovagal syncope is more common in younger patients (mean age of 40); while syncope resulting from cardiac arrhythmia is more common in older patients (mean age of 68).

Question 18

Ketogenic diet contraindications

Answer 18

Contraindicated in patients with: pancreatitis; hepatic failure; carnitine deficiency; porphyria; pyruvate carboxylase deficiency and beta-oxidation defects.

Question 19

Ketogenic diet -first line for:

Answer 19

It is the first line of treatment for GLUT1 deficiency or pyruvate dehydrogenase deficiency.

Question 20

Ketogenic diet and ICU

Answer 20

In the intensive care setting; KD is contraindicated in patients receiving proposal as it may lead to propofol infusion syndrome.

Question 21

Ketogenic diet: chances of resposding:

Answer 21

The approximate percent chance that a child will respond with a greater than 50% seizure reduction is 50%.

Question 22

Ketogenic diet ratios

Answer 22

Typically ration of 4:1 or 3:1 fat:carbohydrate.

Question 23

Ketogenic diet : ketosis

Answer 23

Ketosis is measured by the urinary ketones: 80-160mg/dl.

Question 24

Ketogenic diet: types of fat

Answer 24

Fats are usually long chain fatty acids or medium chain tryglicerides (which are better absorbed and produce more ketones).

Question 25

Ketogenic diet vs MADE

Answer 25

The effectiveness of the the MADE is comparable to the KD in children and adults.

Question 26

Ketogenic diet correlated with ketosis?

Answer 26

Seizure reduction is not correlated with the degree of acidosis or ketosis.

Question 27

NEE predictors of poor outcome

Answer 27

Predictors of poor outcome: older age; prominent motor features; lower education achievement.

Question 28

NEE predictors of good outcome

Answer 28

Predictors of good outcome: shorter duration of illness.

Question 29

Most likely to have NEEs misdiagnosed?

Answer 29

Veterans are most likely to have their psychogenic nonepileptic events mischaracterized as epileptic seizures

Question 30

Best initial choice for young female with JME

Answer 30

LVT

Question 31

Predictors of poor surgical neuropsychological outcome

Answer 31

Higher pre surgical cognitive performance; older age; lack of hippocampal atrophy on MRI; surgery on the dominant side.

Question 32

VNS and bradycardia

Answer 32

Fibers from the right vagus nerve innervate the sinoatrial node; while fibers from the left nerve innervate the atrioventricular. Stimulation of the right side is postulated to cause bradycardia; but with higher settings bradycardia can be seem with stimulation of either nerve.

Question 33

VNS baseline frequency

Answer 33

1- 20-30Hz frequency (lowering to 20Hz decreases the risk of OSA)

Question 34

VNS baseline pulse width

Answer 34

2- 200-500_s pulse width

Question 35

VNS baseline current

Answer 35

3- 0.25-0.5mA current (more current leads to cough or hoarseness; less than 0.25mA not effective)

Question 36

VNS baseline on and off times

Answer 36

4- 7-30s on-time and 5min off-time

Question 37

VNS baseline magnet settings

Answer 37

5- magnet 0.25-0.5mA current and 30-60s on-time.

Question 38

DBS - best responders?

Answer 38

Temporal lobe epilepsy

Question 39

DBS side effects

Answer 39

Memory problems; depression; hemorrhage and infection (in this order)

Question 40

Suicidaltiy

Answer 40

Increased risk of suicide is higher in patients with coexisting depression. Other risk factors; including low reported quality of life; seizure type and seizure control are not associated with higher risks.

Question 41

Medications or products that lower AEDs concentrations

Answer 41

St Johns Wort

Question 42

Medications or products that increase AEDs concentrations

Answer 42

Macrolide antibiotics; calcium channel blockers (diltiazem; verapamil); antifungals (fluconazole; ketoconazole); antivirals (indinavir; ritonavir); antidepressants (fluvoxamine; nefazodone); propoxyphene and grapefruit juice.

Muito Calor Fuja vire depressa proponha grande isolamento

Question 43

AEDS that lower OCP efficiency:

Answer 43

Phenobarbital Phenytoin CBZ Oxcarbazepine Eslicarbazepine Felbamate Topiramate

Mnemonic : Pepe coerced Felipa today.

Note: Lamotrigine is not metabolized by the hepatic enzymes, but OCPs may significantly reduce the level of lamotrigine. The dose of lamotrigine may need to be adjusted if OCPs are started or stopped during the course of AED treatment.

Question 44

AEDs that are known to have no effect on OCP efficiency

Answer 44

VPA Benzodiazepines LVT LMT Gabapentin ZNS Tiagabine

Question 45

AEDS with lowest risk of cognitive effects

Answer 45

LMT; LVT; Gabapentin

Question 46

Risk of congenital malformations

Answer 46

Carbamazepine; lamotrigine; levetiracetam; and oxcarbazepine have low overall risk of major congenital malformations. Carbamazepine has a slight risk of spina bifida; but its overall risk for malformations is low. Lamotrigine has been implicated in cleft defects; but this has not been substantiated; and its overall risk of malformations is low. Valproate has the highest risk and phenobarbital probably the next highest. Topiramate has a higher risk than several antiepileptic drugs; especially for cleft defects. Data are inadequate to determine the risks for many antiepileptic drugs (e.g.; gabapentin; lacosamide; and zonisamide).

Question 47

Drug whose levels fluctuates the most during pregnancy

Answer 47

Lamotrigine

Question 48

Medications associated with spikes on EEG

Answer 48

Cefepime; lithium; tramadol; bupropion; clozapine (CeLia Transfer Busy Clothes). Thyrotoxicosis and Uremia are also associated with interictal spikes on EEG.

Question 49

GLUT1 defficiency
(De Vivo disease)

Answer 49

GLUT1 deficiency syndrome is caused by mutations in the SLC2A1 gene -protein: glucose transporter protein type 1 (GLUT1).

Autosomal dominant - usually de novo.

90% of patients have seizures, which begin in the first month of life.

In newborns, first sign may be irregular eye movements.

Microcephaly, spasticity, complex movement disorders and developmental delay are common.

Diagnosis: low CSF lactate and glucse concentrations + genetic testing.

Ketogenic diet is very efficient

Question 50

Nonketotic Hyperglycinemia

Glycine encephalopathy

Answer 50

Mutations in the AMT and GLDC genes (which code for glycine cleavage enzyme complex) cause glycine encephalopathy.

Autosomal recessive pattern,

Appears shortly after birth with lethargy, feeding difficulties, hypotonia, abnormal jerking movements, and life-threatening problems with breathing.

Profound intellectual disability and seizures that are difficult to treat follow.

EEG: “suppression-burst” pattern in the neonatal period, changing to hypsarrhythmia during early or mid-infancy

Question 51

Occipital epilepsies

Answer 51

The association between occipital seizures and coeliac disease, with or without bilateral occipital calcifications, has been well documented.

Lafora body disease is frequently associated with occipital seizures. The diagnosis should be suspected when myoclonus and progressive mental decline are present.

Question 52

Tuberous sclerosis

Answer 52

Caused by a mutation of either of two genes, TSC1 and TSC2, which code for the proteins hamartin and tuberin respectively.
These proteins act as tumor growth suppressors.

50% have learning difficulties; 25% and 61% of affected individuals meet the diagnostic criteria for autism.

Three types of brain tumors may be associated with TSC:

1) Giant cell astrocytoma: (grows and blocks the CSF flow leading to dilatation of ventricles causing headache and vomiting)
2) Cortical tubers (are thought to represent foci of abnormal neuronal migration)
3) Sub-ependymal nodules: form in the walls of ventricles.

Some form of dermatological sign will be present in 96% of individuals with TSC:

1) Facial angiofibromas (“adenoma sebaceum”)
2) Periungual fibromas
3) Hypomelanic macules (“ash leaf spots”) - noted by UV light (Wood’s lamp)
4) Forehead plaques
5) Shagreen patches