Common Problems in Neurology Flashcards
How are seizures classified?
Focal seizures: consciousness may or may not be impaired. Local, may generalize or propogate
Generalized seizures:
- nonconvulsive (absence)
- convulsive: myoclonic, clonic, tonic, tonic-clonic, atonic
Most likely cause of new seizure onset in patient > 65 yo
Cerebrovascular disease/stroke
Most common cause of seizures in…
- overall ages
- age > 60
- idiopathic > 62%
- stroke, brain tumor
Definition of epilepsy
chronic condition characterized by two UNPROVOKED seizures at least 24 hours apart
What factors increase risk of seizure recurrence?
- status epilepticus
- hx of brain injuty
- brain lesion on neuroimaging
- focal neuro abnormalities
- intellectual disability
- high risk seizure type: focal, absence, myoclonic or atonic
What is DRESS syndrome?
Drug Reaction with Eosinophilia and Systemic Symptoms
Definition of status epilepticus
single seizure that lasts longer that 5 minutes or recurrent seizures without return to baseline
Initial therapy in status epilepticus
- DOC: lorazepam 0.1 mg/kg IV, max 4 mg/dose
- may use midazolam IM or diazepam IV or rectally
- Urgent control therapy with Antiepileptic such as phenytoin/fosphenytoin, phenobarbital, valproate
If a patient has a seizure, when can they drive again?
3 month seizure free interval is recommended by american academy of neurology. 6 months in north carolina. Physicians not required to report to the DMV
Which are the only two anti-epileptic drugs that do not lead to hormonal contraception failure (induction of cytochrome P450)
- depakote
- keppra
Antiepileptic drugs do not interfere with depo provera or IUDs
If a woman on an antiepileptic drug is considering pregnancy what should you do?
- consider withdrawing AED 6 months prior to conception if pt has been seizure-free for > 2 years
- supplement folic acid 4 mg per day if pt on valproic acid or carbamazepine
If a woman on an antiepileptic drug becomes pregnant what should you do?
- do not change AEDs in pregnancy if patient is well controlled
- supplement folic acid 4 mg per day if pt on valproic acid or carbamazepine
- some meds may require vitamin K supplementation in last month of pregnancy
Can you breast feed while on anti-epileptic medications
Yes, all except lamotrigine
Antiepileptic drug of choice for generalized absence seizures
In < 16 yo ethosuxamide or valproic acid
SOR A
No SOR A for other age groups
Antiepileptic drug of choice for focal seizures in < 16 yo
Oxcarbazepine
SOR A
Antiepileptic drug of choice for focal seizures in > 60 yo
Gabapentin, lamotrigine
SOR A
Treatment of choice for chronic tension headaches
OTC analgesics
if needed, TCA for prophylaxis
Definition of chronic daily headaches
15 or more HA per month x 3 months
Treatment of chronic daily headaches
- stop abortive treatment, begin prophylactic treatments
- nonpharm: biofeedback, CBT (SOR B)
- Pharm:
SOR A = topiramate, valproate
SOR B=amytriptyline, gabapentin, tizanidine
No effect = SSRI, propranolol, botox
Describe cluster headaches
orbital or temporal unilateral pain with ptosis, miosis, rhinorrhea, lacrimation, or conjunctival injection.
Last 15 min - 3 hours
Treatment of cluster headaches
Acute: Oxygen and sumatriptan SQ
Preventative: verapamil is DOC.
may consider steroids, lithium, topiramate
Criteria to diagnose migraine without Aura
A. 5 attaches fulfilling criteria
B. lasts 4 -72 hrs
C. has 2+ characteristics: unilateral, pulsating, mod-severe pain, limits routine physical activity
D. at least one of the following: nausea/vomiting, photophobia/phonophobia
E. no other explanation for symptoms
What are red flags for neuroimaging?
- rapidly increasing HA frequency
- lack of coordination, abnl neuro exam, papilledema
- HA that awaken from sleep
- worst HA of life
- pts with cancer, HIV, lyme disease
- new onset > 50 yo
- rapid onset with strenuous exercise
What is the neuroimaging of choice if someone has HA that have red flag symptoms?
CT or MRI without contrast
- use contrast if immunocompromised or concern for temporal arteritis, dissection, or aneurysm
First line treatments of migraines
acetaminophen, NSAIDs
Triptans - avoid in pregnancy
Indications for preventative treatment of migraines
- HA significantly interferes with activities
- overuse of acute therapies
- adverse events with acute therapies
- patient preference
- migraine variants that mimic CVAs
Which medication is useful for abortive tx if a migraine is associated with menses?
- zolmatriptan
When should a patients migraine history limit the prescription of estrogen-containing contraceptives?
- migraines with aura at any age
- migraines over age 35
No good quality data but appears on exams
Diagnostic criteria of Multiple sclerosis
must diagnose discrete lesions in varios parts of the CNS at least 3 months apart
What is lhermitte’s sign in MS?
neck flexion results in an electric shock sensation down limbs and spine
A physical finding that indicates demyelination
What is Uhthoff’s phenomenon in MS?
worsening of symptoms with increased body temperature
Treatment of acute Multiple sclerosis exacerbations
Corticosteroids
Methylprednisolone 500-1000 mg daily for 3-7 days
In Multiple scelorsis, should DMARDS be initiated early or started once disease begins to worsen?
Should be started early
- decrease relapse rate
- decrease brain lesions on MRI
