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RACP Written Exam 2021 > Neurology > Flashcards

Neurology Flashcards

1
Q

In AF what, apart from anticoagulation can you do to reduce the stroke risk?

A

Reduce blood pressure, aim SBP <133

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2
Q

Which investigation has the highest specificity for detecting AF?

A

Implantable loop recorder

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3
Q

Which of the NOAC’s carries a high risk of GI bleed?

A

Rivaroxaban and Dabigatran (150 but not 110).

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4
Q

How do the NOACS and warfarin compare for stroke risk reduction in AF?

A

All non inferior to warfarin for stroke and systemic embolism prevention
All NOACS significantly reduce hemorrhagic stroke

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5
Q

Are NOACS useful for primary and secondary stroke prevention?

A

Yes

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6
Q

Which renal function measure should you use when prescribing NOACs?

A

Cockroft-Gault Equation

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7
Q

In a systematic review for prevention of stroke in AF which NOAC had the highest expected incremental net benefit?

A

Apixaban 5mg BD

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8
Q

In patients post embolic stroke of unknown source (no confirmed AF) is rivoroxaban better than aspirin?

A

No primary outcome of stroke or other embolic event and major bleeding higher in the Rivoroxaban group compared to aspirin

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9
Q

What are some early findings on CTB non contrast in an ischaemic stroke?

A

1) Hyperdense artery (White section of artery)

2) Loss of grey/white matter differentiation due to hypodensity of great matter.

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10
Q

How does the ischaemic area appear on MRI brain DWI?

A

Ischaemic areas appear bright

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11
Q

What are the key metrics used to determine ischaemic core and penumbral size on CT perfusion scan?

A

1) Mean transit time
2) Tmax
3) Cerebral blood volume
4) Cerebral blood flow

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12
Q

Diagnostic Tests in seizure

A

EEG

MRI - on all patients apart from children with genetic epileptic disorder

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13
Q

Mesial temporal sclerosis on MRI

A

Flair + high signal in the temporal region

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14
Q

What is the treatment for absence seizures (PBS)

A

Ethosuxamide

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15
Q

Treatment for focal seizures (PBS)

A

Carbemazepine

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16
Q

What percentage of patients become seizure three on mono therapy AED

A

50% (90% on low to moderate doses)

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17
Q

Best anti-epileptic to use in women of child bearing age

A

Lamotrigine and leviteracetam (the L’s)

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18
Q

Drug resistant epilepsy

A

Seizures despite two, appropriate, anti-epileptic drugs

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19
Q

Diagnostic studies to consider in a patient who may be candidate for epilepsy surgery

A 
MRI 
Spect (Interictal and Ictal) 
SISCOM
FDG-PET 
Functional MRI (to identify eloquent cortext to avoid in surgery) 
Intracranial EEG
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20
Q

Novel therapies for drug resistant epilepsy

A

Vagus nerve stimulation
Deep brain stimulation (anterior nucleus of the thalamus)
Ketogenic Diet

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21
Q

Prevalence of epilepsy

A

1 in 26 = approx 4% of the population

22
Q

When does childhood absence seizures typically onset?

A

During primary school age

23
Q

Investigations in new onset seizure

A 
Early EEG (within 24 hours) 
MRI (note 15% of findings missed on CT scan)
24
Q

Treatment for benzo refractory status?

A

Leviteracetam = phenytoin = valproate

25
Q

Best drug for generalised seizures? (PBS)

A

Valproate

+: Mood enhancer
-: Teratogenic (do not use in young women)

26
Q

Best drug for mycolonus? (PBS)

A

Clonazepam

27
Q

Lamotrigine uses and adverse effects

A

Generalised epilepsy
- Alternative to Valproate in young women and obese
Lennox Gastaut

A/E
Rash when used with valproate
Dizzy when used with carbamezpine

28
Q

Leviteracetam uses and adverse effects

A

Focal epilepsy
- Alternative for pregnant women

Adverse effects
- Mood disturbances

29
Q

Topiramate

A

Use
- Focal epilepsy add on therapy

Adverse effects

  • CNS fog
  • Renal stones as carbonic anhydrase inhibitor
  • Weight loss
  • Teratogenic ?
30
Q

Perampenel

A

Uses
- Focal epilepsy add on

Adverse effects

  • CNS effects: somnolence/dizziness/agression
  • Slow titration
  • Teratogenecity
31
Q

MOA of vigabatrin?

A

Elevates brain GABA (prevents the breakdown)

32
Q

Leviteracetam MOA

A

Binds to synaptic vesicular protein SV2A

33
Q

Perampanel MOA

A

Blocks post synaptic AMPA (glutamate) receptors. Therefore down regulates excitatory action

34
Q

Carbemazepime and SJS

A

HLA_B*1502
Predominant in Han Chinese or SE Asian descent

Therefore if treating these patients need to tests for HLA-B*1502

35
Q

Carbemazepime and DRESS

A

HLA-A*31:01

36
Q

Phenytoin related Dress/SJS

A

CYP2C9*3

37
Q

Autoimmune limbic encephalitis

A

Anti LGl1: Anti potassium channel antibody (Older men)

Anti NMDA: Antibody to NMDA (young woman with teratoma)

38
Q

EEG findings in liver failure

A

Triphasic waves

39
Q

EEG finding in CJD

A

Biphasic synchronous waves approx 1 per second

40
Q

Carbemazepime MOA

A

Blocks voltage gated and use dependent sodium channels.

41
Q

Pyramidal weakness

A

Legs: Flexors weaker
Arms: extensors weaker

42
Q

Gold standard of vertebral imaging

A

CT Angiogram

43
Q

Hyper-acute stroke therapy

A

IV thrombolysis: 0-4.5 hours (within 9 hours from recent study)
Endo-vascular therapy: 12 hours (24 hours for posterior stroke with salvageable penumbra)
- Up to 12 hours NNT is 2.6!

Based on salvageable penumbra

44
Q

TIA definition

A

Symptoms <1 hr with no evidence of damage on imaging

20% of patients with acute stroke will have TIA in the weeks to months prior to event.

Most risk within 7-10 days
8% mortality at 6 months

45
Q

Indication for carotid enderartectomy

A

Symptomatic carotid stenosis
> 50-69% (moderate) recommended in men
> 70-99% (severe) recommenced within 14 weeks with an ARR of 30%

Criteria for CEA

  • Ipsilateral stroke or TIA
  • Life expectancy >5 years
  • Accesible lesion

Note stenting: data worse only useful if poor surgical candidate i.e restenosis post CEA or radiation induced stenosis.
Peri-procedural death/stroke rate is higher

46
Q

Hyper-acute stroke therapy

A

IV thrombolysis: 0-4.5 hours (within 9 hours from recent study)
Endo-vascular therapy: 12 hours (24 hours for posterior stroke with salvageable penumbra)
- Up to 12 hours NNT is 2.6!

Extending the time frames is based on salvageable penumbra

47
Q

Indications for reduced dose of Apixaban to 2.5 BD

A

two of three

1) Age >80
2) Weight <60
3) Cr >133

48
Q

DOAC with increased risk of bleeding?

A

Rivaroxaban

49
Q

What to consider in a patient with stroke/AF with high bleeding risk

A

Consider left atrial appendage occlusion devices i.e watchman/amulet device

Prague 17 study
Head to head of Watchmann vs Apixaban
11% vs 13% of embolic stroke/complications

Other option would be surgical closure during cardiac surgery

50
Q

When to consider PFO closure?

A

Patients = 60 yoa
Embolic stroke without other risk factors (esp AF)

Note risks of AF post procedure = 4-6%

RACP Written Exam 2021 (18 decks)

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