Neurology

Question 1

Describe the management of epilepsy

Answer 1

Most neurologists now start antiepileptics following a second epileptic seizure.

NICE guidelines suggest starting antiepileptics after the first seizure if:
> neurological deficit
> brain imaging: structural abnormality
> EEG: unequivocal epileptic activity
> patient / family / carers seizure risk unacceptable

Drug treatment

• Generalised tonic-clonic seizures
  > males: sodium valproate
  > females: lamotrigine or levetiracetam
  » sodium valproate if under 10 or women unable to have children
• Focal seizures
  > first line: lamotrigine or levetiracetam
  > second line: carbamazepine, oxcarbazepine or zonisamide
• Absence seizures (Petit mal)
  > first line: ethosuximide
  > second line:
  male: sodium valproate
  female: lamotrigine or levetiracetam
  carbamazepine may exacerbate absence seizures
• Myoclonic seizures
  > males: sodium valproate
  > females: levetiracetam
• Tonic or atonic seizures
  > males: sodium valproate
  > females: lamotrigine

Question 2

describe autonomic dysreflexia

Answer 2

can only occur if spinal cord injury is above T6

features
- severe hypertension
- flushing and sweating above level of injury
- reflex bradycardia

causes
- spinal cord injury
- catheter blockage
- faecal loading

caused by excessive sympathetic response below level of injury without coordinated parasympathetic counter response

Question 3

describe Guillain-Barré syndrome

Answer 3

immune-mediated demyelination of peripheral nervous system usually post-diarrhoeal illness e.g. Campylobacter jejuni

clinical features
- back/leg pain
- progressive symmetrical ascending weakness (starting in legs)
- reflexes are reduced or absent
- sensory symptoms usually mild

other features
- respiratory muscle gastroenteritis
- respiratory muscle weakness
- cranial nerve involvement: diplopia, bilateral facial nerve palsy, oropharyngeal weakness
- autonomic involvement: urinary retention, diarrhoea

investigations
- LP: rise in protein with normal WCC
- Nerve conduction studies: decreased motor nerve conduction velocity

treatment - plasma exchange, IV immunoglobulins

Question 4

Which medications can be given for the following problems in MS?

• fatigue
• spasticity
• oscillopsia
• bladder dysfunction

Answer 4

fatigue: amantadine

spasticity: baclofen, gabapentin

oscillopsia: gabapentin

bladder dysfunction: anticholinergics

Question 5

which medications can be given to reduce the risk of relapse in MS?

Answer 5

indications
> relapsing-remitting disease + 2 relapses in past 2 years + able to walk 100m unaided
secondary progressive disease + 2 relapses in past 2 years + able to walk 10m (aided or unaided)

medications
- natalizumab: first-line

• ocrelizumab: another first-line option
• fingolimod
• beta-interferon: less effective
• glatiramer acetate: less effective

Question 6

describe hereditary sensorimotor neuropathy (HSMN) aka Charcot-Marie-Tooth

Answer 6

encompasses Charcot-Marie-Tooth disease (aka peroneal muscular atrophy)

2 common types in clinical practice
- type I: demyelinating
- type II: axonal pathology

HSMN type I
- Autosomal dominant
- due to defect in myelin-coding gene
- features start at puberty
- motor symptoms predominate
- distal muscle wasting, pes cavus, clawed toes
- foot drop and leg weakness often first features

Question 7

when can anti-epileptic drugs (AED) be stopped?

Answer 7

can be considered if seizure free for >2 years with AEDs being stopped over 2-3 months