Ch 24: Nervous System Disorders

Question 1

What are the essentials of diagnosis for migraine?

Answer 1

Headache, usually pulsation, lasting 4 - 72 hours.
Pain is typically, but not always, unilateral.
Nausea, vomiting, photophobia, and phonophobia are common accompaniments.
Pain is aggravated with routine physical activity.
An aura of transient neurologic symptoms (commonly visual) may precede head pain.
Commonly, head pain occurs with no aura.

Question 2

Ophthalmoplegic migraine is _____ and a diagnosis of _________.

Answer 2

rare, exclusion

p. 978

Question 3

There are 4 categories of pharmacologic prophylaxis of migraine. What are they?

Answer 3

Antiepileptics
Cardiovascular drugs
Antidepressants
Other

Question 4

What population is predominantly affected by cluster headaches?

Answer 4

Middle-aged men

p. 979

Question 5

The term “epilepsy” denotes any disorder characterized by…

Answer 5

…recurrent unprovoked seizures.

p. 983

Question 6

There is no evidence that prophylactic anticonvulsant drug treatment reduces the incidence of _____________ epilepsy.

Answer 6

posttraumatic

p. 983

Question 7

What are the two types of focal seizures?

Answer 7

Seizures WITHOUT impairment of consciousness (simple partial) and seizures WITH impairment of consciousness (complex partial).

(p. 984)

Question 8

What are the key features of a focal seizure?

Answer 8

Involvement of only a restricted part of brain; may evolve to a bilateral, convulsive seizure.

(p. 984)

Question 9

What is the key feature of a generalized seizure?

Answer 9

Diffuse involvement of brain at onset.

p. 984

Question 10

What are the 6 categories of generalized seizures?

Answer 10

absence (petit mal)
atypical absence
myoclonic
tonic
clonic
tonic-clonic (grand mal)

(p. 984)

Question 11

What are the key features of an absence (petit mal) seizure?

Answer 11

consciousness impaired briefly; patient often unaware of the attacks

(p. 984)

Question 12

What are the other characteristics of an absence (petit mal) seizure?

Answer 12

They may have clonic, tonic, or atonic components, autonomic components or accompanying automatisms.
They almost always begin in childhood and frequently cease by age 20.

(p. 984)

Question 13

What are the key features of an atypical absence seizure?

Answer 13

They may be more gradual in onset and termination than a typical absence seizure.

(p. 984)

Question 14

What are the other characteristics of an atypical absence seizure?

Answer 14

There may be more marked changes in tone.

p. 984

Question 15

What are the key features of a myoclonic seizure?

Answer 15

Single or multiple myoclonic jerks.

p. 984

Question 16

What are the key features of a tonic seizure?

Answer 16

bilaterally increased tone and stiffening of limbs with associated loss of consciousness

(p. 984)

Question 17

What are the key features of a clonic seizure?

Answer 17

Bilateral rhythmic jerking with associated loss of consciousness

(p. 984)

Question 18

What are the key features of a tonic-clonic (grand mal) seizure?

Answer 18

Tonic phase: sudden loss of consciousness, with rigidity and arrest of respiration, lasting < 1 minute
Clonic phase: jerking, usually for < 2 - 3 minutes
Flaccid coma: variable duration

May be accompanied by tongue biting, incontinence, or aspiration; commonly followed by postical confusion variable in duration

(p. 984)

Question 19

What are the key features of an atonic seizure?

Answer 19

Sudden loss of tone, very brief (< 2 seconds), and often result in recurrent falls; also known as epileptic drop attacks

(p. 984)

Question 20

What are the key features of status epilepticus?

Answer 20

Repeated seizures without intervening recovery of consciousness; a fixed and enduring epileptic condition lasting > or = to 30 minutes

(p. 984)

Question 21

The aura that precedes a generalized seizure is itself a part of the seizure, indicating _____ _____ from a restricted part of the brain.

Answer 21

focal onset

p. 985

Question 22

What is the term for seizures that are provoked by flashing lights?

Answer 22

photosensitive epilepsy

p. 985

Question 23

How can a serum prolactin level help to distinguish between a psychogenic nonepileptic seizure (PNES) and a true seizure?

Answer 23

elevation of serum prolactin level to at least twice the upper limit of normal can be seen between 10 and 20 minutes after a seizure or syncopal event, but not after a PNES.

(p. 986)

Question 24

Drug therapy for epilepsy is usually continued until there have been no seizures for at least…

Answer 24

…2 years.

p. 986

Question 25

Treatment of seizures with more than 2 drugs is almost always unhelpful unless....

Answer 25

...the patient is having seizures of different types. | p. 986

Question 26

All antiepileptics are potentially...

Answer 26

...teratogenic. | p. 986

Question 27

What is the initial treatment for status epilepticus?

Answer 27

Maintenance of airway. 50% dextrose in case hypoglycemia is the cause. If seizures continue, IV bolus of lorazepam, 4 mg, at a rate of 2 mg/min; repeat this again after 10 minutes if necessary. An alternative to lorazepam is midazolam IM, or diazepam gel rectally. (p. 989)

Question 28

Regardless of the response to lorazepam or midazolam, one of what 2 drugs should be given to initiate long-term seizure control?

Answer 28

fosphenytoin or phenytoin | p. 989

Question 29

What dose of fosphenytoin should be given?

Answer 29

18 - 20 mg [phenytoin equivalents] /kg at a rate of 50 mg/min (p. 989)

Question 30

If seizures continue after lorazepam and fosphenytoin, what drug(s) is/are given next?

Answer 30

phenobarbital, 10 - 20 mg/kg In addition to or instead, valproate can be given, 25 - 30 mg/kg. (p. 989)

Question 31

What is the therapeutic serum drug level for valproic acid (Valproate)?

Answer 31

50 - 100 mcg/mL | p. 987

Question 32

What is the therapeutic serum drug level for carbamazepine (Tegretol)?

Answer 32

4 - 8 mcg/mL | p. 987

Question 33

What is the therapeutic serum drug level for phenytoin (Dilantin)?

Answer 33

10 - 20 mcg/mL | p. 987

Question 34

What are the essentials of diagnosis for TIA?

Answer 34

Focal neurologic deficit of acute onset. Clinical deficit resolves completely within 24 hours. Risk factors for vascular disease often present. (p. 991)

Question 35

About __% of patients with stroke have a history of TIAs and 5 - 10% of patients with TIAs will have a stroke within __ days.

Answer 35

30%; 90 | p. 991

Question 36

Hematologic causes of TIA include...

Answer 36

...polycythemia, sickle cell disease, hyperviscosity syndromes, and the antiphospholipid antibody syndrome. (p. 992)

Question 37

The subclavian steal syndrome may lead to...

Answer 37

...transient vertebrobasilar ischemia. | p. 992

Question 38

A CT or MRI of the brain is indicated with __ hours of TIA symptom onset.

Answer 38

24 | p. 992

Question 39

All patients with TIA in whom anticoagulation is not indicated should be treated with ____________ _______ to reduce the frequency of TIAs and the incidence of stroke.

Answer 39

antiplatelet therapy | p. 993

Question 40

What is the ABCD2 score used to determine?

Answer 40

it is a assessment of TIA/stroke recurrence risk. ABCD2 score of 4 points or more warrants a hospital admission.

Question 41

Use of natalizumab is generally restricted to those in whom....

Answer 41

...JC virus antibodies are negative. | p. 1024

Question 42

What drug is FDA-approved to treat fatigue in patients with MS?

Answer 42

modafinil (Provigil) | p. 1025

Question 43

What therapy can be done for MS patients with corticosteroid-refractory relapses?

Answer 43

plasmapheresis | p. 1024

Question 44

Mitoxantrone can be given once every 3 months, and has a maximum...

Answer 44

...lifetime dose of 140 mg/m2. | p. 1024

Question 45

The maximum dose for mitoxantrone is related to its...

Answer 45

...risk of causing cardiomyopathy.

Question 46

For myasthenia gravis, anticholinesterase drugs provide symptomatic benefit without...

Answer 46

....influencing the course of the disease. | p. 1045

Question 47

The term concussion is often used synonymously with...

Answer 47

...mild TBI. | p. 1029

Question 48

Grades of TBI are traditionally defined by the....

Answer 48

...Glasgow Coma Scale measured 30 minutes after injury. | p. 1029

Question 49

Mild TBI is indicated by a GCS of...

Answer 49

...13 to 15. | p. 1029

Question 50

Moderate TBI is indicated by a GCS of...

Answer 50

...9 to 12. | p. 1029

Question 51

Severe TBI is indicated by a GCS of...

Answer 51

... < or = to 8. | p. 1029

Question 52

What types of head injuries may present with normal neurologic findings shortly after injury (lucid interval), but then rapidly deteriorate thereafter?

Answer 52

epidural and subdural hematoma | p. 1029

Question 53

What are the common acute symptoms of a concussion?

Answer 53

headache, nausea, vomiting, confusion/disorientation, dizziness, and imbalance, and possibly a period of amnesia encompassing the traumatic event; may present with or without loss of consciousness (p. 1029)

Question 54

What are some signs of a basilar skull fracture?

Answer 54

bruising around the eyes (raccoon sign), blood in the external auditory meatus (Battle sign), and leakage of CSF from the ear or nose (CSF can be identified by its glucose or beta-2-transferrin content) (p. 1029)

Question 55

Current recommendations are that head CT be performed in patients with concussion and any of the following:

Answer 55

``` GCS score less than 15 focal neurologic deficit seizure coagulopathy age 65 or older skull fracture persistent headache or vomiting retrograde amnesia exceeding 30 minutes intoxication soft tissue injury of the head or neck ``` (p. 1030)