Neuro - Session 13 - Group Work [WRONG DECK]

Question 1

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
a) What type of epilepsy does he have? Discuss your reasoning.

Answer 1

Partial complex seizure (likely to originate in the temporal lobe)
- in this instance we’d say seizure until we know other investigations or another episode

Associated with

• people who have had a seizure when they were young
• associated with auras

Question 2

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
b) What investigations are indicated and what might they show?

Answer 2

• EEG (increased temporal lobe activity)
• MRI (increased activity)

Can do ECG and bloods to rule out any other systemic causes.

Question 3

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
c) What drugs might be effective?

Answer 3

o Lamotrigine (more commonly used in generalised)
o Topiramate
o Gabapentin
o Phenytoin
o CARBAMAZEPINE (first line in partial seizures)

First line drugs
Absence - ethosuxamide
Partial - carbamazepine
Generalised - sodium valproate/lamotrigine

Question 4

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
d) Explain the proposed mechanism of action of carbamazepine and suggest the predicted side effects specifically through the cerebellum and brainstem. What about the heart?

Answer 4

Sodium channel blocker

Symptoms
Ataxia - affects coordination (wouldn’t really say bradykinesia)
Diplopia - double vision

Signs
Dysdiachokinesia
Bradycardia - depression of the AVN

so
DANISH

Question 5

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
e) Most antiepileptic agents have a dosing range. How would you typically go about initiating a new agent?

Answer 5

Start low and titrate up to reduce side effects

If already on a drug and ineffective, so trying a new drug, then you slowly wean off other drug but titrate up new drug until you get to middle therapeutic and then

Question 6

1) A 24-year-old man presents as a referral with recent onset of funny turns. He experiences a warning aura consisting of a smell of burning rubber and a sensation of butterflies rising out of his stomach. He then becomes unresponsive for several minutes during which he plucks idly at his clothing and makes smacking movements of his lips. As a child he suffered several prolonged convulsions during febrile illnesses.
f) If the drug that you prescribe is tolerated but fails to be effective what questions do you need to ask?

Answer 6

• Are you taking it? If no, why not
• Other medications?
• Age and lifestyle
• Psychiatric history
• Driving
• If female, pregnancy

Question 7

2) An 18-year-old woman presents after suffering a generalised tonic-clonic seizure shortly after getting out of bed. CT and EEG are normal. She has a further seizure after returning to the ward following initial scans. This does not appear to be self-terminating.
a) What immediate action would you take (before medicating)?

Answer 7

Full ABCDE

Recovery position

Question 8

2) An 18-year-old woman presents after suffering a generalised tonic-clonic seizure shortly after getting out of bed. CT and EEG are normal. She has a further seizure after returning to the ward following initial scans. This does not appear to be self-terminating.
b) What first line pharmacological treatment would you recommend?

Answer 8

IV Lorazepam (hospital)
or
Buccal or PR Midazolam (pre-hospital)
(to stop the seizure)
*Slide 47 - mistake, other way around

After the seizure:
Sodium valproate (except for pregnancy) or lamotrigine

Question 9

2) An 18-year-old woman presents after suffering a generalised tonic-clonic seizure shortly after getting out of bed. CT and EEG are normal. She has a further seizure after returning to the ward following initial scans. This does not appear to be self-terminating.
c) Why is this preferred over diazepam?

Answer 9

Lorazepam has a longer duration of action than diazepam, and decreased respiratory-cardiac side effects

Question 10

2) An 18-year-old woman presents after suffering a generalised tonic-clonic seizure shortly after getting out of bed. CT and EEG are normal. She has a further seizure after returning to the ward following initial scans. This does not appear to be self-terminating.
d) What would be recommended as an additional agent and what monitoring would be specifically required?

Answer 10

Phenytoin: this needs blood monitoring bc it has a narrow therapeutic index

Dose needs to be monitored for BMI

Question 11

2) An 18-year-old woman presents after suffering a generalised tonic-clonic seizure shortly after getting out of bed. CT and EEG are normal. She has a further seizure after returning to the ward following initial scans. This does not appear to be self-terminating.

This patient is likely to need to take long term antiepileptic monotherapy.

e) What considerations would you discuss with her regarding contraception and about if and when she wishes to start a family?

Answer 11

Phenytoin is teratogenic, therefore must be advised not to get pregnant.

If she is on contraception she might need to up her oestrogen dose to actually have a contraceptive effect (carbamazepine)

Question 12

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.
a) What differential diagnoses would you also consider and need to rule out in this patient?

Answer 12

Lewy body dementia
Depression/anxiety 
Thyroid
Myasthenia gravis
Space-occupying lesion

Question 13

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.
b) What features of these differential diagnoses distinguish them from classical Parkinson’s disease?

Answer 13

Other symptoms or additional symptoms not included.

Question 14

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.
c) She is prescribed co-careldopa. Describe the constituent parts of this preparation and why this is prescribed.

Answer 14

This is levadopa with its decarboxylase inhibitor, preventing the peripheral conversion of L-DOPA to dopamine, allowing more of it to cross the blood brain barrier.

Question 15

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.
d) What advice would you give this lady about taking this medication?

Answer 15

It has prominent side effects, e.g. sedation, hallucinations, risk of neuroepileptic malignant syndrome (side effect of antipsychotic due to extra dopamine, giving you fever, rigidity and confusion).

• If lady still drives, she MUST inform the DVLA.

Question 16

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.

Following two years of managed treatment, the efficacy of the L-DOPA has decreased in this patient and dyskinesia has become a significant problem for her. In discussion with her neurologist it is decided that her medication should be changed to a drug with the brand name Stalevo(R).

e) What does this preparation contain and by what mechanisms is it hoped that it will improve control of her symptoms.

Answer 16

Carbidopa levodopa and entacapone. Entacoapone increased levels of Levodopa in the body by inhibiting COMT.

Question 17

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.

Following two years of managed treatment, the efficacy of the L-DOPA has decreased in this patient and dyskinesia has become a significant problem for her. In discussion with her neurologist it is decided that her medication should be changed to a drug with the brand name Stalevo(R).

f) Why would you avoid prescribing metoclopramide to this patient? What alternative antiemetic would be a suitable alternative? Comment on its mechanism and site of action.

Answer 17

It is a dopamine antagonist and so this will exacerbate the effects of the low dopamine in the brain. Ondesetron serotonin receptor antagonist.

Question 18

3) A 66-year-old fine artist was diagnosed with Parkinson’s disease 6 months ago. She had reported symptoms which included significant disruption to sleep, mild urinary incontinence and her partner had reported that she was suffering from fluctuating mood. On examination there was slowness of gait and fine motor skills were reduced. There was no tremor.

Following two years of managed treatment, the efficacy of the L-DOPA has decreased in this patient and dyskinesia has become a significant problem for her. In discussion with her neurologist it is decided that her medication should be changed to a drug with the brand name Stalevo(R).

g) Is a catechol-O-methyltransferase inhibitor appropriately prescribed as a single agent for the treatment of Parkinson’s disease? Explain your reasoning.

Answer 18

No, they are usually used as an adjuvant therapy with use with carbidopa and levodopa.

Question 19

4) A 44 year-year-old female been referred to a neurologist with symptoms that fit a diagnosis of myasthenia gravis. In untreated patients an i.v. injection of the short acting acetylcholinesterase inhibitor edrophonium will produce clinical improvement lasting about 5 minutes.
a) What initial class of drugs would be recommended if a clinical diagnosis is confirmed? How do they relieve symptoms?

Answer 19

Acetylcholinerase inhibitor, they reduce breakdown of acetylcholine.

Question 20

4) A 44 year-year-old female been referred to a neurologist with symptoms that fit a diagnosis of myasthenia gravis. In untreated patients an i.v. injection of the short acting acetylcholinesterase inhibitor edrophonium will produce clinical improvement lasting about 5 minutes.
b) Her medical history suggests that she has essential hypertension which is well managed therapeutically. Why may this be of concern to the prescribing neurologist?

Answer 20

Beta blockers and ACE inhibitors exacerbate myasthenia gravis (make them worse)