Ch 5 Epilepsy

Question 1

The prevalence of congenital malformations in offspring of women on an AED is?

Answer 1

4-10% which is 2-4x increase from the expected prevalence of the general population

Question 2

Which AED has lower risk of teratogencity and should be considered to use during pregnancy?

Answer 2

Lamotrigine

Question 3

How are lamotrigine levels affected during pregnancy?

Answer 3

The clearance of lamotrigine increases during pregnancy, so the dose should be adjusted during this time

Question 4

Which AED has some of the highest fetal malformation rates and should be avoided during pregnancy?

Answer 4

Valproate (2-3x higher than carbamazepine or lamotrigine)

It also has dose dependent cognitive adverse events

Question 5

What is the fencer’s posture associated with?

Answer 5

Frontal lobe epilepsy and indicates epileptic activation of the supplemental motor area

Question 6

Which AED can worsen generalized epilepsy (especially myoclonic epilepsy)?

Answer 6

Gabapentin

Question 7

Which AED has he least potential interactions with any other medication?

Answer 7

Gabapentin (it’s neither an enzyme inducer nor inhibitor)

Question 8

In cases of epilepsy of childhood that is refractory to multiple AEDs, what is the next step?

Answer 8

the ketogenic diet (initiated in the hospital by starvation for 1-2 days followed by strict diet)

Question 9

Define simple febrile seizure (6)?

Answer 9

< 15 mins, generalized seizure, lack of focality, normal neuro exam, no persistent deficits, negative family history

Question 10

Define complex febrile seizure (6)?

Answer 10

> 15 mins, focal features, abnormal neuro exam, seizure recurrence in < 24 hours, postictal sign (Todd’s paralysis), more likely due to meningitis/encephalitis or underlying seizure d/o

Question 11

How to treat simple febrile seizure?

Answer 11

supportive care

Question 12

How to treat complex febrile seizure?

Answer 12

short term ppx: diazepam and antipyretics

long term ppx: phenobarbital or valproic acid

Question 13

What is generalized epilepsy with febrile seizure plus (GEFS+)?

Answer 13

patients in whom febrile seizures continue past the defined upper limit of age (febrile seizures occur 6mo to 5 yrs old)

Question 14

What is the mutation of GEFS+?

Answer 14

SCN1A

Question 15

What is Rasmussen’s syndrome?

Answer 15

Severe inflammatory brain d/o characterized by progressive unilateral hemisphereic atrophy, progressive neurologic dysfunction (hemiparesis and cognitive deterioration), intractable focal seizures (epilepsia partialis continua).

Question 16

What is the treatment of Rasmussen’s syndrome?

Answer 16

heispherectomy

Question 17

What are the first line and second line therapies for progressive myoclonic epilepsies?

Answer 17

1st line: Valproic acid (caution: pt with mitochondrial mutation may develop fulminant hepatic failure while on valproic acid)
2nd line: Clonazepam, Levetiracetam, Topiramate, Zonisamide

Question 18

What is the advantage of fosphenytoin over phenytoin (4)?

Answer 18

Compared to phenytoin, fosphenytoin is (1) not associated w purple glove syndrome (2) can be given rapidly IV (3) lower occurrence of cardiovasc side effects (4) can be given IM

Question 19

Common side effects of phenytoin (3)?

Answer 19

dizziness, nystagmus, drowsiness

Question 20

What AEDs are known to exacerbate some myoclonic epilepsies?

Answer 20

Lamotrigine, Gabapentin, Carbamazepine, Pregabalin, and Vigabatrin

Question 21

Out of the following, name which medications are hepatic enzyme inducers and which are hepatic enzyme inhibitors: phenytoin, carbamazepine, valproic acid, phenobarbital, primidone

Answer 21

hepatic enzyme inhibitor: valproic acid

hepatic enzyme inducers: phenytoin, carbamazepine, phenobarbital, primidone

Question 22

what are the main first line and second line agents in the treatment of absence seizures?

Answer 22

First line: ethosuximide
2nd line: valproic acid, topiramate, zonisamide and lamotrigine (although lamotrigine can actually cause aggravation of absence seizures on rare occasions)

Question 23

The adult pattern of normal posterior dominant alpha rhythm in older children and adults is usually seen by the age of?

Answer 23

8 to 10 years

Question 24

In a patient with HSV encephalitis, what abnormality could you expect to find on EEG?

Answer 24

PLEDs (periodic lateralizing epileptiform discharges). Can also be seen in any destructive process such as anoxia, HSV encephalitis, stroke, and tumor

Question 25

Which AEDs have been associated with aggravation of absense seizures (4)?

Answer 25

phenytoin, carbamazepine, gabapentin, lamotrigine

Question 26

Which AEDs have minimal oral contraceptive interaction (7)?

Answer 26

Valproic acid, Gabapentin, Pregabalin, Levetiracetam, Zonisamide, Tigabine, and Topiramate

Question 27

What does the EEG show for JME?

Answer 27

4-6Hz polyspike and wave discharges interictally (can be triggered by photicstimulaton

Question 28

1st line treatment of JME?

Answer 28

Valproic acid

avoidance of triggers such as alcohol intake and lack of sleep

Question 29

2nd line treatment of JME?

Answer 29

lamotrigine, levetiracetam, topiramate, and zonisamide

Question 30

What AEDs to avoid in JME because it can make JME worse?

Answer 30

carbamazepine and phenytoin (similar to the worsening of childhood absence epilepsy seen with these agents)

Question 31

A patient is on valproic acid. Another physician wants to know if lamotrigine can be added. What is the interaction between these two medications?

Answer 31

Valproic acid is a hepatic enzyme inhibitor. It will significantly increase the half-life of lamotrigine.

Question 32

In general, phenytoin approaches zero-order kinetics at what total levels?

Answer 32

total levels > 10 to 15ug/mL, at which point small dose increments can potentially cause large increases in serum levels