MKSAP questions

Question 0

What are some guidelines for sport related concussions? (i.e., exclusion from sport, neuro-imaging etc)

Answer 0

Grade 1 = transient confusion without amnesia or LOC. If exam normal and asymptomatic, can rejoin at 15 minutes.
Grade 2 = transient confusion > 15min. No amnesia/LOC. If normal after 1 week, can rejoin. Consider imaging if persistent abn
Grade 3 = brief or prolonged LOC. If exam normal = home with supervision. If exam abn (includ confusion) = CT head. No sport for 1 week, unless prolonged (2 weeks!)

Question 1

What condition can cause post-infectious syndrome with sub-acute onset of weakness, sensory changes and bowel or bladder dysfunction?

Might be associated with thoracic pain level.

How do we treat?

Answer 1

Idiopathic transverse myelitis. Although recurrence might suggest MS.

The presence of a sensory spinal cord level and hyper-reflexia localises disease to the spinal cord (ruling out GBS).

After exclusion of other potential causes, treat with IV methylpred. If refractory, plasmapheresis or cyclophosphamide.

Question 2

What is the best choice of AED for reproductive age women?

Answer 2

The best is often considered to be the one that provides best control.

Carbamazepine has been shown to have low risk of foetal malformations (risk probably highest in first weeks of gestation). (2-4%)

Lamotrigine and levetiracetam are also used and thought safe.

Valproate has consistently been shown to be highest risk (6 - 17%). Phenytoin (6-14%) and phenobarbital (3-7%) also higher.

Question 3

What are options for treating post-stroke lysis hypertension?

What are our goals?

Answer 3

Ideally <180/105.

Labetalol and nicardipine are the options listed in UTD.

Nitroprusside is relatively contraindicated because of possibility of increasing intracranial pressue.

Question 4

Patient admitted with stroke and INR of 1.5. What is the most appropriate treatment?

Answer 4

Interestingly, TOAST and IST showed no benefit in preventing stroke. HAEST (Heparin in Acute Embolic Stroke Trial) showed no benefit aspirin V heparin at 14 days post acute ischaemic stroke

Acute anticoagulation is only if: 1. mechanical valve; 2. AF with small infarct post-cardiac surgery; 3. cervicocephalic dissection

Question 5

Which causes greater rates of first division pain? Trigeminal neuralgia or herpes zoster affecting CN V?

Tell me about management of both.

Answer 5

Only 5% of trigeminal neuralgia affects the ophthalmic branch, whereas zoster has much higher rates.

The pain of tic douloureux also lasts only 5 seconds to 2 minutes (by definition).

Management of trigeminal neuralgia: first line is carbamazepine, initiated at low dose and slowly uptitrated. Second line agents (limited evidence) - baclofen, gabapentin, clonazepam, lamotrigine.

There are surgical options, whereby they cut the nerve fibre

Question 6

What is the definition of episodic versus chronic migraine?

What is the definition of a migraine?

Answer 6

episodic means 15 days/month for 3 months.

Migraine can be defined as “with aura” or “without aura”.

Without aura requires >5 headaches lasting 4-72 hours;
2 of [unilateral, pulsating, aggravation on physical activity, mod-severe pain impacting daily activity];
1 of [N/v, photo/phonophobia]

with aura: 2 attacks
fully reversible aura symptoms;
one of the aura symptoms develops slowly - over more than 4 minutes
duration <60 minutes for aura;
headache after aura

Question 7

what are the treatment options for episodic migraine prevention?

Answer 7

MKSAP suggests that only topiramate and onabotulinum toxin A. Older options includes propranolol, timolol, amitriptyline and divalproex sodium.

Question 8

What are the risks with migraine and being child-bearing age female?

Answer 8

GREAT QUESTION! ahem

2-4 fold increase in stroke risk if COCP and migraine (any type)
Seems to be much higher in women with migraine with aura (recommended to avoid OCP in these women) - stats missing, but just avoid migraine w/ aura + OCP

Question 9

What are the therapeutic options for tension-type headaches?

Answer 9

Aspirin and paracetamol are the best. Addition of caffeine has also been shown to potentiate effects.

Question 10

Treatment options for cluster headaches?

Answer 10

Acute - high flow oxygen is useful in 75%; other options include sumitriptan and zolmitriptan
Transitional (short term use to prevent the ongoing attacks) - steroids
Preventative - verapamil (often in high doses!)

Question 11

An idea of the electrode numbering system with EEG?

Answer 11

If the electrode is on the right side, even numbers are used. e.g. F8-T8

Left side = odd numbers. e.g. C3-P3

Question 12

Which of the anti-epileptic drugs are most associated with Stevens-Johnson syndrome?

Answer 12

They all are, but actually rapid up-titration of lamotrigine and combination lamotrigine and valproate is higher risk.

There is theoretical increased risk of Stevens-Johnson in Asian with HLA-B*1502 allele, so may be a good idea to test before starting lamotrigine, phenytoin or carbamazepine.

Question 13

what is the definition of refractory epilepsy?

how would you manage such a patient?

Answer 13

failure to respond to 2 agents. These patients should be referred to subspecialty unit for evaluation, confirmation of diagnosis and consideration for surgery.

Question 14

Which causes greater rates of first division pain? Trigeminal neuralgia or herpes zoster affecting CN V?

Tell me about management of both.

Answer 14

Only 5% of trigeminal neuralgia affects the ophthalmic branch, whereas zoster has much higher rates.

The pain of tic douloureux also lasts only 5 seconds to 2 minutes (by definition).

Management of trigeminal neuralgia: first line is carbamazepine, initiated at low dose and slowly uptitrated. Second line agents (limited evidence) - baclofen, gabapentin, clonazepam, lamotrigine.

There are surgical options, whereby they cut the nerve fibre

Question 15

What is the definition of episodic versus chronic migraine?

What is the definition of a migraine?

Answer 15

episodic means 15 days/month for 3 months.

Migraine can be defined as “with aura” or “without aura”.

Without aura requires >5 headaches lasting 4-72 hours;
2 of [unilateral, pulsating, aggravation on physical activity, mod-severe pain impacting daily activity];
1 of [N/v, photo/phonophobia]

with aura: 2 attacks
fully reversible aura symptoms;
one of the aura symptoms develops slowly - over more than 4 minutes
duration <60 minutes for aura;
headache after aura

Question 16

what are the treatment options for episodic migraine prevention?

Answer 16

MKSAP suggests that only topiramate and onabotulinum toxin A. Older options includes propranolol, timolol, amitriptyline and divalproex sodium.

Question 17

What are the risks with migraine and being child-bearing age female?

Answer 17

GREAT QUESTION! ahem

2-4 fold increase in stroke risk if COCP and migraine (any type)
Seems to be much higher in women with migraine with aura (recommended to avoid OCP in these women) - stats missing, but just avoid migraine w/ aura + OCP

Question 18

What are the therapeutic options for tension-type headaches?

Answer 18

Aspirin and paracetamol are the best. Addition of caffeine has also been shown to potentiate effects.

Question 19

Treatment options for cluster headaches?

Answer 19

Acute - high flow oxygen is useful in 75%; other options include sumitriptan and zolmitriptan
Transitional (short term use to prevent the ongoing attacks) - steroids
Preventative - verapamil (often in high doses!)

Question 20

An idea of the electrode numbering system with EEG?

Answer 20

If the electrode is on the right side, even numbers are used. e.g. F8-T8

Left side = odd numbers. e.g. C3-P3

Question 21

Which of the anti-epileptic drugs are most associated with Stevens-Johnson syndrome?

Answer 21

They all are, but actually rapid up-titration of lamotrigine and combination lamotrigine and valproate is higher risk.

There is theoretical increased risk of Stevens-Johnson in Asian with HLA-B*1502 allele, so may be a good idea to test before starting lamotrigine, phenytoin or carbamazepine.

Question 22

what is the definition of refractory epilepsy?

how would you manage such a patient?

Answer 22

failure to respond to 2 agents. These patients should be referred to subspecialty unit for evaluation, confirmation of diagnosis and consideration for surgery.

Question 23

Which causes greater rates of first division pain? Trigeminal neuralgia or herpes zoster affecting CN V?

Tell me about management of both.

Answer 23

Only 5% of trigeminal neuralgia affects the ophthalmic branch, whereas zoster has much higher rates.

The pain of tic douloureux also lasts only 5 seconds to 2 minutes (by definition).

Management of trigeminal neuralgia: first line is carbamazepine, initiated at low dose and slowly uptitrated. Second line agents (limited evidence) - baclofen, gabapentin, clonazepam, lamotrigine.

There are surgical options, whereby they cut the nerve fibre

Question 24

What is the definition of episodic versus chronic migraine?

What is the definition of a migraine?

Answer 24

episodic means 15 days/month for 3 months.

Migraine can be defined as “with aura” or “without aura”.

Without aura requires >5 headaches lasting 4-72 hours;
2 of [unilateral, pulsating, aggravation on physical activity, mod-severe pain impacting daily activity];
1 of [N/v, photo/phonophobia]

with aura: 2 attacks
fully reversible aura symptoms;
one of the aura symptoms develops slowly - over more than 4 minutes
duration <60 minutes for aura;
headache after aura

Question 25

what are the treatment options for episodic migraine prevention?

Answer 25

MKSAP suggests that only topiramate and onabotulinum toxin A. Older options includes propranolol, timolol, amitriptyline and divalproex sodium.

Question 26

What are the risks with migraine and being child-bearing age female?

Answer 26

GREAT QUESTION! ahem

2-4 fold increase in stroke risk if COCP and migraine (any type)
Seems to be much higher in women with migraine with aura (recommended to avoid OCP in these women) - stats missing, but just avoid migraine w/ aura + OCP

Question 27

What are the therapeutic options for tension-type headaches?

Answer 27

Aspirin and paracetamol are the best. Addition of caffeine has also been shown to potentiate effects.

Question 28

Treatment options for cluster headaches?

Answer 28

Acute - high flow oxygen is useful in 75%; other options include sumitriptan and zolmitriptan
Transitional (short term use to prevent the ongoing attacks) - steroids
Preventative - verapamil (often in high doses!)

Question 29

An idea of the electrode numbering system with EEG?

Answer 29

If the electrode is on the right side, even numbers are used. e.g. F8-T8

Left side = odd numbers. e.g. C3-P3

Question 30

Which of the anti-epileptic drugs are most associated with Stevens-Johnson syndrome?

Answer 30

They all are, but actually rapid up-titration of lamotrigine and combination lamotrigine and valproate is higher risk.

There is theoretical increased risk of Stevens-Johnson in Asian with HLA-B*1502 allele, so may be a good idea to test before starting lamotrigine, phenytoin or carbamazepine.

Question 32

what is the definition of refractory epilepsy?

how would you manage such a patient?

Answer 32

failure to respond to 2 agents. These patients should be referred to subspecialty unit for evaluation, confirmation of diagnosis and consideration for surgery.

Question 33

Dural sinus venous thrombosis has a few characteristic presenting features. Please describe them. Also comment on the different sinuses and any specific presenting features.

Answer 33

Headache (severe), depressed LOC and seizures.

Fundoscopic examination can reveal papilloedema in 50% of dural sinus thrombosis.

Thrombosis of the cavernous sinus causes lesions of CNIII ,CNIV, CNV1/2 and sometimes CNVI. If the cortical veins are involved, they can get ischaemic and then haemorrhage.

Question 34

Which stroke risk factor has the greatest impact?

Answer 34

According to MKSAP, hypertension has greatest effect.

Question 35

What are the pathologic findings of Alzheimer disease? And the radiographic?

Answer 35

Includes: diffuse brain atrophy with widening of sulci and enlargement of ventricles

histologically: neurofibrillary tangles (knotted loops [strands of silver-stained material within cell bodies of neurons] and helices of hyperphosphorylated tau microtubular protein), amyloid-containing neuritic plaques, and granulovacuolar degeneration of neurons.

Question 36

What are the pharmaceutical treatment options for Alzheimer disease?

Answer 36

Focuses on acetylcholinesterase inhibitors, although galantamine also has an agonist effect on nicotine receptor.

Donepezil - AChE inhibitor;
rivastigmine - AChE inhibitor;
Tacrine - AChE inhibitor;
Galantamine - AChE inhibitor & nicotinic receptor agonist
Memantine - NMDA inhibitor

Question 37

Describe the clinical features and pathological findings in Lewy body dementia please.

How to treat? What about hallucinations and psychosis?

Answer 37

May be pattern of cognitive impairment with psychiatric features of personality change, apathy, depression and psychosis. Motor signs of parkinsonism occur and are usually poorly responsive to levodopa. Also get dream-enactment.

Pathologically widespread Lewy bodies - eosinophilic intracytoplasmic accumulations of alpha-synuclein.

Treat with AChE-inhibitors as per AD.

For hallucination Tx = avoid dopamine blockers. Good choice = clozapine.

Question 38

What is the classic triad of normal pressure hydrocephalus?

Answer 38

1. cognitive decline
2. gait impairment - broad base, short shuffling steps, characteristic hesitation/freezing on step initiation and near-normal leg function in supine/sitting position.
3. urinary urgency and incontinence

all of these are in the setting of normal CSF pressure (usually <15cm H20)

Question 39

Generally the medications that cause tardive dyskinesia are associated with blockade of a type of receptor. What is that type?

Answer 39

Is it the dopamine - type 2 (D2) receptor.

Question 40

What investigations are appropriate in patients with recurrent thunderclap headache?

Answer 40

If recurrent thunderclap headache, then reasonable to image the intracranial vasculature - as provided by angiography.

Question 41

What is the treatment of Bell’s palsy?

Answer 41

Prednisone, preferably within the first 72 hours of symptoms.

Question 42

Following thrombolysis for acute ischaemic stroke, when do we give the first dose of aspirin?

Answer 42

The trials have all withheld anti-platelet agents for 24 hours post lysis.

Question 43

If a patient is on lamotrigine and starts the OCP, what needs to happen to the medication?

Which AEDs should patients not take COCP with?

Answer 43

Oestrogen containing therapies lead to increased “glucuronidation” - reducing the levels of lamotrigine by up to 40%. Caution is also needed during the placebo weeks of the pill, as lamotrigine levels can become supratherapeutic.

Carbamazepine, phenytoin, barbiturates, topiramate - all induce enzymes leading to inadequate contraception.

Question 44

What are the differences between trigeminal neuralgia and paroxysmal hemicrania?

Recall - paroxysmal hemicrania is a type of primary headache in the same class as cluster headache

Answer 44

1. location - trigeminal neuralgia is typically V2-V3. Hemicrania usually V1.
2. Duration - trigeminal neuralgia is typically 2-3 seconds of pain then seconds - hours of painfree
   Paroxysmal hemicrania is a cluster headache-like syndrome - 15 min up many times/day
3. Associated - trigeminal neuralgia - typically none
   Paroxysmal hemicrania is often associated with autonomic symptoms (like cluster headache)
4. Treatment - trigeminal neuralgia - carbamazepine is first line
   Paroxysmal hemicrania - indomethacin is first line.

Question 45

What are the common complications of subarachnoid haemorrhage - describe as early and late.

Answer 45

Early - aneurysmal re-rupture
hydrocephalus

Late (from day 5) - arterial vasospasm (which can lead to cerebral infarction) - CT angiography is first line to assess this.

Question 46

What is Capgras syndrome?

Where is the lesion?

Answer 46

A delusional disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member has been replaced by an identical-looking impostor.

It can also occur with places/locations.

It is primarily associated with psychiatric illness, but can occur with dementia. If associated with a focal lesion = non-dominant hemisphere.

It can also occur with diffuse disease such as Alzheimer.

Question 47

What are the treatment options for status epilepticus?

Answer 47

First line = benzodiazepines. Lorazepam 0.1mg/kg IV or diazepam IV/PR (shorter acting than lorazepam)

Second line agents = phenytoin (or fosphenytoin - its prodrug) or IV valproic acid

Third line agents = no specific data exists to guide this.

Question 48

What paraneoplastic syndrome is associated with ovarian neoplasm? What is the typical radiographical finding?

Answer 48

Anti-NMDA receptor encephalitis is characterised by subacute memory disturbance, personality change, psychosis and seizures. There is also an association with oral dyskinesia.

Most commonly this syndrome is associated with unilateral or bilateral ovarian teratomas.

On brain MRI (FLAIR) - increased signal in temporal lobes (uni or bilateral).

Diagnosed by Ab found in serum or CSF.

Rx: oophopectomy + plasmapheresis/IVIg/steroids

Question 49

What are the treatment options for MS-related fatigue? (And is there anything that we need to exclude before diagnosing such?)

Answer 49

At minimum: exclusion of anaemia, sleep disorders, depression, hypothyroidism.

Treatment options are amantadine (off label use; NMDA-R antagonist) and modafinil (also used for wakefulness in sleep apnoea, MoA = unknown)

Question 50

What is apraxia, and where is the lesion usually?

Answer 50

Apraxia is the inability to perform a previously learned skilled motor task despite intact motor and sensory systems, clear comprehension and full cooperation.

The lesion is typically dominant parietal lobe

Question 51

Which migraine prophylaxis should be avoided in patients with a history of kidney stones?

Answer 51

Topiramate has a mild carbonic anhydrase inhib effect, leading to dec. prox tubule reabs of bicarb, leading to increased risk of calcium-containing renal stones.

Question 52

What has strongest benefit in a patient with symptomatic high-grade carotid stenosis - statin, aspirin, stenting or endarterectomy?

Answer 52

Carotid endarterectomy has far and away the greatest benefit. After a stroke, a patient has a 2% risk of stroke recurrence PER DAY for the first 14. NNT = 6 according to stroke lecture (Dr Read)

Stenting was shown to be equal to endarterectomy, but has greater risk of peri-op stroke.

Statins - trials haven’t investigated safety in immediate post-stroke setting.

Aspirin only small benefit compared to surgery

Question 53

What is the “best” clinical test to assess for risk of falls? (particularly backwards fall, apparently)

Answer 53

The pull test has been examined in studies (don’t ask which) and is the best way of predicting the risk of future falls in a patient with a history of BACKWARDS falls.

Basically the test is - stand behind patient, warn them, pull backwards. Normal response is small step back to recover. Abnormal is ineffectual short steps, or just plain falling.

Question 54

How do we manage multiple sclerosis related spasticity?

Answer 54

The most commonly used in Australia is baclofen. Also consider diazepam.

In the US, tizanidine (centrally acting, alpha2-R agonist) is also used.

Refractory symptoms can trial botulinum toxin injections or even intrathecal baclofen pump.

Question 55

What is most appropriate AED for partial seizures in older patients?

Answer 55

There are multiple options for partial seizures, but the side effect profile of lamotrigine makes a compelling argument for it being best in older population.

Carbamazepine and phenytoin, for example, are commonly complicated by fizziness, lethargy and gait instability. They are also hepatic enzyme inducers, making life more complicated…

Carbamazepine is also associated with hyponatraemia.

Question 56

What conditions might be associated with rapid (e.g. 5 weeks) decline to inanition. Also with evidence of myoclonus, and no other signs of trauma, intoxication, fever or any other systemic disease.

Answer 56

A paraneoplastic condition such as limbic encephalitis OR a prion disorder such as Creutzfeldt-Jakob disease.

CJD can present with similar syndrome as frontotemporal dementia, but it is much more rapid.

Question 57

Why is metoprolol not used in cocaine-associated intracranial haemorrhage?

What is our BP goal for treatment?

Answer 57

The unopposed alpha-action of cocaine can potentially lead to coronary (and possibly) cerebrovascular vaso-constriction.

Labetalol is a better choice of the beta blockers.

The goal is to bring down to < 160/90

Question 58

What are the behavioural changes that one might see with dopamine-agonist?

Answer 58

Compulsive behaviours are seen, due to dysregulation of the brain’s dopamine-dependent reward systems.

These are not the same as Lewy body dementia (dream-enactment, cognitive decline, parkinsonism, visual hallucination).

Frontotemporal dementia has features of apathy, impulsivity, perseveration, hoarding, obsessionality

Question 59

What is the first line anti-epileptic for patients with Asian background?

Answer 59

Levetiracetam is usually pretty good.

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug rash with eosinophilia and systemic symptoms (DRESS) are rare but severe idiosyncratic reactions, characterized by fever and mucocutaneous lesions that have been associated with the use of carbamazepine, oxcarbazepine, phenytoin, phenobarbital, primidone, zonisamide, lamotrigine, and (less commonly) other AEDs.

The period of highest risk is within the first two months of use. The risk may be higher in patients with HLA-B*1502 allele, which occurs almost exclusively in patients of Asian ancestry, including South Asian Indians. The FDA recommends screening such patients for this allele prior to starting carbamazepine, oxcarbazepine, and possibly phenytoin. (There is some specialists who recommend avoiding lamotrigine too)

Because cross-hypersensitivity to other AEDs is common, patients who experience this reaction should subsequently be treated with nonaromatic AEDs (eg, valproate, topiramate) which have a lower risk of this reaction. In one case series, the latter medications were well-tolerated when prescribed as alternative AEDs to patients who experienced SJS or TEN in association with an aromatic AED

Question 60

what does ABCD2 stand for?

Answer 60

Age > 60
BP > 140/90
Clinical symptom (1 = speech; 2 = hemiparesis)
Duration (1 = 10 - 59 min; 2 >/= 60 min)
DM = 1 point

Question 61

What are the side effects of the MS drug, interferon beta?

Answer 61

flulike symptoms after injection
elevated AST/ALT
lymphopenia
worsening of underlying spasticity, depression or migraines

Question 62

how do we treat spasmodic torticolis?

Answer 62

botulinium toxin injections

Question 63

Vitamin B12 deficiency can cause subacute combined degeneration of the cord. Are there any other nutritional deficiencies that can cause a similar picture?

Any infections?

Answer 63

Tabes dorsalis can present similarly.

Copper deficiency can cause a very similar picture, and can even be associated with a macrocytic anaemia!

Question 64

What is a preventative medication for tension headache?

Answer 64

Amitriptyline