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Neurology Flashcards

0
Q

Type of seizure most common in adults

A

Temporal lobe epilepsy
- virtually all are complex partial seizures (+/- secondary generalization)
Hx febrile seizures common
Partial part difficult to tx, 2ndary generalization usually responds to drugs
Psych behavioral disorders often coexist

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1
Q

Drugs that lower seizure threshold

A 
Clomipramjbe
Clozapine
Loxapine
Phenothiazine 
Bupropion
Meperidine
Inhaled anesthetics
Theophylline at level >25
Cyclosporine
Flumazenil
Quinolones
Beta lactams eg imipenem
Dalfampridine
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2
Q

Type of seizure that often requires lifelong anticonvulsant therapy

A

Juvenile myoclonic
Mixed sz types myoclonic absence and/or GTC
Ppt by stress or sleep deprivation

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3
Q

Most refractory sz disorder

A

Lennox gestault

  • heterogenous group of childhood epileptic encephalopathies
  • start before age 4 usually
  • result of brain malformations perinatal asphyxia , head injury, CNS infection
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4
Q

Another refractory syndrome

A 
Infantile spasms (west syndrome)
Attacks start before  6 months
- from cerebral dysgenesis, hypoxic ischemic injury, intrauterine infections, or idiopathic
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5
Q

Causes of single seizures

A

Withdraw from CNS depressants
Acute illness - meningitis, abscess, encephalitis
Toxicity - uremia , lead, carbon monoxide
Drugs which Lower seizure threshold
Head trauma
Hypoxia
Fever
Metabolic - hyponatremia, hypoglycemia, dehydration
Medical procedures - ECT , brain surgery, organ tx, labor and delivery

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6
Q

Chronic seizure disorder causes

A 
stroke or other vascular
Mental retardation
Neuro development or brain injury
Neoplasms 
cerebral palsy
Genetic predispo
Head trauma
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7
Q

Genetically caused sz

A

Childhood absence,
juvenile myoclonic

Mechanism:

  • mutation in ion channel function
  • mutations affecting CNS development
    - block neuronal apoptosis
    - nerve cell metabolism dysreg
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8
Q

Secure prognostic factors

A

Good prognosis : sz free x 2 or more years, successfully tx after first sz; normalized EEG

Poor prognosis: partial sz or multiple sz types in same pt, hx of status epilepticus, polypharmacy needed, traumatic brain lesion visible

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9
Q

Objective data for seizures

A

EEG - brain electrical activity- abnormalities either before or during sz may be diagnostic

CT- detect gross hemorrhaging fx or trauma, lesions
MRI - can detect smaller lesions vs CT

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10
Q

Aed most significantly associated with birth defects

A

Valproate
Phenytoin

Some case reports:
Phenobarbital
Cbz
Felbamate
All other aed have limited data - class C
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11
Q

Recommendations for pregnant and aed

A

Single drug at lowest effective dose
Oral contraceptives - may need high estrogen product due to drug intxns
Monitor aed levels due to pk changes eg altered protein biding
Ultrasound at 16-18 weeks to check for neuronal tube defects
Preconception tx with 0.4mg folic acid daily
Daily vitamin K during las 2-4 weeks of pregnancy for prevention of neonatal cerebral hemorrhaging and give vitamin k to newborn after deliv

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12
Q

Aed that can worsen psych

A

Ethosuximide
Levitiracetam
Benzos and barbiturates
Topiramate and barbiturates

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13
Q

Newly diagnosed epilepsy tx recommendations:

A
  • standard AED: CBZ , PHT, VPA, Pb

- new AED: LTG, GBP, OXC, TOP

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14
Q

Adults w treatment refractory epilepsy:

A

GBP, TOP, LTG, OXC, LVT, ZON as add-on
New AED: OXC, TOP, LTG may be used as mono therapy in tx resistant partial epilepsy
LTG in tx refractory GTC sz

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15
Q

Percent of costs from epilepsy that are indirect

A

85% due to missed work by patients and caretakers of children/elderly pts w epilepsy

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16
Q

Clinical diagnosis of Parkinson’s disease

A

2 of 3 of following:
Tremor
Rigidity
Bradykinesia

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17
Q

Non motor sx of PD

A

Psych: depression anxiety dementia hallucinations apathy
Sleep - rls
Autonomic
Speech
Sensory
Other - weight loss seborrheic dermatitis sexual dysfxn GI impaired motility

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18
Q

Hoehn and yahr scale

A

Parkinson’s dz
Stage I unilateral involvement only and minimal or no functional impairment
Stage II: bilateral involvement without impairment of balance
Stage III: postural imbalance, some reduction in activities, capable I leading independent life, mild-moderate disability
Stage IV: severely disabled must walk with assurance , marked incapacitation
Stage V: restricted to bed or wheelchair unless aided

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19
Q

How much daily carbidopa needed to block peripheral conversion of levodopa

A

75-200 mg/day

So initial carbidopa/levodopa dose is 25/100mg tid or 10/100mg qid

Titrate q 3 days PRN
If no response to 1000 mg lwop dis reconsider PD dx

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20
Q

Clinical use of anticholinergics in Parkinson’s -

A

Trihexiphenidyl and benztropine
Best in stage 1 and 2 of disease - for tremor
(With levodopa)

Inhibit muscarinic cholinergic receptors in striatum
Benztropine initial dose: 0.5-1mg qhs up to daily dose of 4-6 mg/day
Trihexyphenidyl 1-2 mg first day increase by 2mg increments q 3-5 days to 6-10 mg/day

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21
Q

Drugs to treat PD related psychosis

A

Clozapine start at 6.25mg qday and titrate slowly
Quetiapine start at 12.5 mg qday

Risperidone and olanzapine effective but reports of worsening PD

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22
Q

Migraine criteria for dx

A

At Least 5 attacks
Lasting at least 4-72 hrs (untreated or unsuccessfully treated)
2 of the following characteristics:
- unilateral location
- pulsating
- moderate or severe pain intensity
- aggravated by physical activity

23
Q

Migraine with aura

A

Attack last 4-72 hrs untreated or unsuccessfully treated

Aura - meets criteria for one of the subforms associated with aura

24
Q

Migraine scales

A

Migraine disability assessment questionnaire
(MIDAS)
- scores 0-21 with higher score indicating greater disability
- self rated - headache related disability
- both clin and research
Monitoring

Pain disability index (PDI)
Measures *pain * related disability
Monitoring for all pain(not just ha)
Scores 0-70 higher score more pain disability

25
Q

Indications for prophylactic migraine therapy

A

2 or more attacks per month that produce 3 or more days per month disability

  • failure of abortive tx
  • abortive medication use >2x/week
  • presence of uncommon migraine including hemiplegic , w prolonged aura, or migraine infarction
  • after benefit: consider taper after 6-12 months of good headache control
26
Q

Amount of time to get benefit from prophylactic migraine therapy

A

2-3 months

27
Q

Take abortive medications when?

A

Onset of headache pain (not aura)

28
Q

Pregnancy and headache meds

A

Ergot derivatives - category X !!
- due to uterine vasoconstriction causing fetal growth retardation
Triptans - category C - limited data in humans, some decreased fetal weight in animal studies

  • hold prophy therapies during pg and breast feeding
  • use prochlorperazine for nausea
29
Q

Tension headache dx (contrast with migraine)

A 
Bilateral (migraine=unilateral)
Pressing tightening (non pulsating)
Mild-moderate intensity
Not aggravated by routine physical activity

Both:
Not n/v (may be anorexia)
Possibly photo or phono phobia, not both

30
Q

Tension headache pain assessment

A

Typical scales analog for pain

31
Q

Prophy for tension headaches

A 
Amitriptyline - doc 50-100mg
SSRI (fluox, sert) * diff from migraine
Botox A * diff from migraine 
Propranolol
Bzd
32
Q

Dx criteria for cluster headache

A

At least 5 attacks fulfilling criteria
- severe or very severe
Unilateral orbital, supraorbital or temporal area lasting 15-180 min if untreated
- has to have ipsilateral facial sx or restlessness
- frequency from 1 q other day to 8/day

33
Q

Abortive tx of cluster headache

A

100% oxygen 8-10 L/min for 20 min
May be given several times per day
- sumatriptan 6mg SQ or Nasal
DHE = 2nd line abortive

34
Q

Transitional tx for cluster ha

A

short term preventive tx while awaiting full effect of prophy:
- prednisone 60-80mg per day for 3 days then taper over 14 days
DHE: daily IM injections for 1 week or 3 day IV infusion
Naratriptan 2.5mg bid

35
Q

Prophylactic therapy of cluster headache

A

Use abortive and transitional treatment while awaiting effect
- use ONLY while pt in a cluster cycle, continuous use may not prevent cluster cycles

Verapamil 120-480mg daily
Lithium 600-1500 mg/day (levels 0.3-0.8 mmol/L) - about as effective as verapamil but not as well tolerated)
Valproic 600-2000mg/day
Melatonin may reduce doses needed for other
Topiramate 50-400 mg/day

36
Q

United huntingtons disease rating scale (UHDRS)

A

Scores range from 0-128 with higher scores meaning higher motor impairment

37
Q

Huntingtons tx

A

Tetrabenazine - see card
- response in 3 weeks then full in 6 weeks

Other
Olanzapine - some evidence
Risperidone - case studies effective for motor and psych effectiveness
Clozapine - best evidence but high doses most effective but still tolerability problems

38
Q

Glasgow coma scale

A

Use in tbi
Score 14-15 more mild brain injury - full recover but may have short term memory problems and concentration difficulties
9-13 moderate - pt lethargic and stupendous
3-8 severe injury pt comatose, cannot follow commands

39
Q

Dx criteria for fibromyalgia acr

A

Widespread pain index
Symptom severity based on fatigue and waking unrefreshed
* WPI 7 and SS of 5 or WPI 3-6 and SS 9 dx fibro

40
Q

Hoehn and yahr pd scale

A

Stage I unilateral invovment no or minimal fxn impair
Stage II bilateral involvement but balance ok
Stage III evidence of postural imbalance some reduction activity but still independent life, mild-moderate disability

Stage IV severely disabled unable to stand and walk unassisted marked incapacitation

Stage V restricted to bed or wheelchair unless stated

41
Q

Beta blockers for migraine Px

A

Propranolol

Timolol

42
Q

Options for transitional tx of cluster headache

A

Prednisone 60-80mg qday x 3 days then taper over 14
DHE daily IM injectors for 1 week or 3 day IV infusion
Naratriptan 2.5mg bid

43
Q

Prophylactic therapy options

A

Verapamil
lithium 600-1500 mg/day levels 0.3-0.8 mmol/L
About as effective as verapamil but not as well tolerated
VPA
Melatonin
Topiramate

44
Q

Fastest acting triptan

A

Rizatriptan

45
Q

Longest acting triptan but slowest onset

A

Frovatriptan

46
Q

Prophy use

A

Natatriptan - has longer t1/2 but minimal recurrence slower onset (not as long acting as Frovatriptan though

47
Q

Lipophilic drug with rapid oral absorption and ODT form

A

Zolmitriptan

48
Q

Duration of Px for cluster headache

A

2 months of cluster cycle

49
Q

Fibromyalgia scale WPI widespread pain index

A

Based on number of regions that pt experiences pain (0-19)

Fibromyalgia dx:
WPI of 7 and SS of 5
Or
WPI of 3-6 and SS of 9

50
Q

SS symptom severity score for fibromyalgia

A

Presence and severity of fatigue
Waking from sleep unrefreshed
Cognitive symptoms (0-12)

51
Q

Sign and sx of fibromyalgia

A

Widespread musculoskeletal pain
Non restorative sleep and daytime fatigue
Psychological fog- depress/anxiety
Localized tenderness in 11 or more of 18 specified tender points
No apparent organic disease

52
Q

Rating scales ( different than diagnostic SS and WPI)

A

Fibro fatigue scale- clinician Fibromyalgia impact questionnaire - self rated

53
Q

Milnacipram dose

A 
Start 12.5 mg once
Day two bid
Day 4-7 25mg bid
After day 7 50mg bid
Can increase to 100mg bid based on response
54
Q

Comparing alpha 2 agonist and SGA in tx of tics in Tourette’s

A

One study shows clonidine = risperidone

Bcpp (16 decks)

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