Neurology - Epilepsy

Question 1

NEU - 4.1
Efficacy of pharmacotherapy in the epilepsy population:
A) 30%
B) 40%
C) 70%
D) 99%
E) 15%

Answer 1

ANSWER
C) 70%

EXPLANATION
60-70% of patients with epilepsy become seizure free by using epileptic drugs.

Question 2

NEU - 4.2
NOT a characteristic of psychogenic non-epileptic seizures:
A) closed eyes
B) variable seizure duration
C) lateral tongue biting
D) variable seizure symptoms
E) paroxysmal motor phenomena

Answer 2

ANSWER
C) lateral tongue biting

EXPLANATION
Grand mal (generalized tonic-clonic seizure) should be differentiated from convulsive syncope and the psychogenic non-epileptic seizure (pseudoseizure, „hysteric” seizure). The latter is characterized by variable seizure duration, variable seizure symptoms (semiology), and closed eyes. The lateral tongue biting is a highly specific sign of epileptic seizure.

Question 3

NEU - 4.3
Oral and manual automatisms are characteristics for:
A) absence
B) complex partial seizures
C) generalized tonic-clonic seizures
D) sensomotor Jacksonian seizure
E) tetany

Answer 3

ANSWER
B) complex partial seizures

EXPLANATION
Oral automatisms (lip smacking, chewing, or swallowing) and manual automatisms (pillrolling, finger rubbing) are the main characteristics of complex partial seizures which usually originate from the temporal lobe.

Question 4

NEU - 4.4
Epileptic aura is:
A) an antiepileptic side effect
B) a risk factor for status epilepticus
C) always accompanied by loss of consciousness
D) the first sign of a focal seizure
E) the first sign of an absence seizure

Answer 4

ANSWER
D) the first sign of a focal seizure

EXPLANATION
Epileptic aura is an epileptic seizure without objective signs (the patient has only subjective experiences during the seizure). Auras last a few seconds. Auras can also be followed by proper seizures (such as seizures with objective signs), but this is not obligatory: auras can stand alone.

Question 5

NEU - 4.5
Antiepileptic drug with a specific indication:
A) TSH
B) L-dopa
C) acetylcholine
D) ACTH
E) digitalis

Answer 5

ANSWER
D) ACTH

EXPLANATION
One of the most severe epileptic encephalopathies in infants is the West syndrome consisting of typical seizure form (BNS seizure or infantile spasm) and typical EEG sign (hypsarrhythmia). „Classical” antiepileptic drugs with exception of vigabatrin are less effective in this syndrome. Conversely, ACTH and steroid treatment can be very effective, may result in compete seizure freedom.

Question 6

NEU - 4.6
NOT effective in focal epilepsy:
A) carbamazepine
B) diphenylhydantoin
C) vigabatrin
D) ethosuximide
E) oxcarbazepine

Answer 6

ANSWER
D) ethosuximide

EXPLANATION
Some antiepileptics are more effective in focal, while others in generalized seizures. Carbamazepine is mainly useful in treating focal (or focal-onset) seizures. Ethosuximid has an effect on absence seizures only.

Question 7

NEU - 4.7
First-choice drug in idiopathic generalized epilepsy:
A) valproate
B) dyphenylhydantoin
C) diazepam
D) Vitamin B6
E) carbamazepine

Answer 7

ANSWER
A) valproate

EXPLANATION
The first-choice drug in idiopathic generalized epilepsy is the valproate. In fertile women, however, it should be avoided due to its teratogenic effect.

Question 8

NEU - 4.8
NOT a characteristic of convulsive syncope:
A) open eyes
B) jerking
C) sweating
D) pallor
E) lateral tongue biting

Answer 8

ANSWER
E) lateral tongue biting

EXPLANATION
Grand mal (generalized tonic-clonic seizure) should be differentiated from convulsive syncope and the psychogenic non-epileptic seizure (pseudoseizure, „hysteric” seizure). Convusiv syncope – like any syncope – can precede by fainting sensation, pallor, or sweating. Conversely, during the unconsciousness, a brief tonic phase, myoclonic or clonic jerking can occur. In contrast to grand mal, convulsive syncope never begins with a tonic phase (it starts with a loss of muscle tone). Tongue biting can also occur in convulsive syncope, but it never affects the lateral part of tongue, rather the tip of tongue (apical tongue biting).

Question 9

NEU - 4.9
In pregnant women taking antiepileptic drugs:
A) an abortion is recommended
B) 1000 mg/day Vitamin C is recommended
C) 1–5 mg/day folic acid is recommended
D) Vitamin K should be given during the whole pregnancy period
E) bed rest is recommended during the 3rd trimester

Answer 9

ANSWER
C) 1–5 mg/day folic acid is recommended

EXPLANATION
Pregnant women with epilepsy should receive folic acid supplementation due to potential teratogenic effects of chronic antiepileptic drug treatment. This has to start when planning a pregnancy.

Question 10

NEU - 4.10
Major fetal (congenital) malformations caused by antiepileptic drugs can be detected by:
A) measuring CPK level
B) Ultrasound examination
C) antinuclear antibody test
D) measuring estrogen level
E) measuring progesterone level

Answer 10

ANSWER
B) Ultrasound examination

EXPLANATION
Major fetal (congenital) malformations can be detected by ultrasound examinations.

Question 11

NEU - 4.11
If a grand mal seizure appears during pregnancy:
A) cesarean section is indicated
B) antiepileptic drug dosage should be reduced
C) new antiepileptic drugs should be introduced in small dosage
D) measuring serum level of antiepileptic drugs is recommended the dosage should be modified accordingly
E) bed rest is recommended

Answer 11

ANSWER
D) measuring serum level of antiepileptic drugs is recommended the dosage should be modified accordingly

EXPLANATION
Metabolism of antiepileptic drugs can be influenced by pregnancy, resulting in a less effective anti-seizure effect. This can be verified by measuring serum level of antiepileptic drugs. The dosage of antiepileptics should be modified accordingly.

Question 12

NEU - 4.12
The most frequently used type of epilepsy surgery is:
A) parietal lobectomy
B) temporal lobectomy
C) callosotomy
D) hemispherectomy
E) multiple subpial transection

Answer 12

ANSWER
B) temporal lobectomy

EXPLANATION
Most adult patients with pharmacoresistant epilepsy have temporal lobe epilepsy. The most common epilepsy surgery procedure is the temporal lobectomy.

Question 13

NEU - 4.13
Epileptic seizures are NOT characteristics of:
A) epilepsy
B) alcohol withdrawal
C) benzodiazepine withdrawal
D) sinus thrombosis
E) myasthenia gravis

Answer 13

ANSWER
E) myasthenia gravis

EXPLANATION
Epilepsy is defined by recurrent unprovoked epileptic seizures. Typical seizure provoking factors are: alcohol withdrawal and repetitive photic stimulation. Severe acute neurological disorders affecting cerebral cortex (for example sinus thrombosis) can also be accompanied by epileptic seizures. Myasthenia gravis is an autoimmune disorder of the neuromuscular junction. It does not affect the central nervous system thus it is not accompanied by epileptic seizures.

Question 14

NEU - 4.14
NOT an antiepileptic drug:
A) moclobemide
B) clobazam
C) lamotrigine
D) gabapentin
E) levetiracetam

Answer 14

ANSWER
A) moclobemide

EXPLANATION
The moclobemide is a reversible MAO-A inhibitor (RIMA), an antidepressant.

Question 15

NEU - 4.15
NOT an antiepileptic drug:
A) carbamazepine
B) vigabatrin
C) valproate
D) levetiracetam
E) alprazolam

Answer 15

ANSWER
E) alprazolam

EXPLANATION
Alprazolam is a benzodiazepin, its antiepileptic effect is infinitesimal.

Question 16

NEU - 4.16
Interictal EEG sign suggesting epilepsy:
A) vertex potential in sleep
B) 3 Hz spike-and-wave complex
C) 6–14 Hz positive discharges
D) none of them
E) all of them

Answer 16

ANSWER
B) 3 Hz spike-and-wave complex

EXPLANATION
The vertex potential on the EEG is characteristic to the light sleep. This is a physiological phenomenon. The 6-14 Hz positive spikes are normal (physiological) variations of the EEG. A 3Hz spike-and wave complex is the typical EEG sign of some genetically determined epilepsy forms, such as idiopathic generalized epilepsy including absence epilepsy.

Question 17

NEU - 4.17
Side effect of valproate:
A) hair loss
B) weight gain
C) tremor
D) all of them
E) none of them

Answer 17

ANSWER
D) all of them

EXPLANATION
Hair loss, tremor, and weight gain are the most frequent side effects of valproate treatment.

Question 18

NEU - 4.18
An epileptic patient taking antiepileptic drugs:
A) is permitted to drive a car if he/she is long-term seizure free
B) is permitted to drive a car but only after withdrawal of antiepileptic drugs
C) is not permitted to drive a car
D) is permitted to drive a car but only under supervision

Answer 18

ANSWER
A) is permitted to drive a car if he/she is long-term seizure free

EXPLANATION
Long-term seizure-free patients are permitted to have a driving license (and driving a car), regardless whether the seizure freedom has been achieved with or without antiepileptic drug treatment. The „long-term” seizure free interval is not universally defined, this interval depends on the actual country laws.

Question 19

NEU - 4.19
Which seizure type can NOT appear after a traumatic brain injury?
A) generalized tonic-clonic seizure
B) absence
C) complex partial seizure
D) focal motor seizure
E) Jacksonian seizure

Answer 19

ANSWER
B) absence

EXPLANATION
Traumatic brain injury can cause focal („posttraumatic”) epilepsy. Absence seizures occur in genetically determined epilepsy syndromes.

Question 20

NEU - 4.20
Which is NOT true for epilepsy?
A) diagnosis of epilepsy does not exclusively based on the EEG
B) focal EEG abnormality is an indication for a CT or MRI examination
C) after cessation of seizures, the antiepileptic drugs can be stopped immediately
D) the underlying etiology should also be treated in cases of symptomatic epilepsy
E) most antiepileptic drugs require a slow titration

Answer 20

ANSWER
C) after cessation of seizures, the antiepileptic drugs can be stopped immediately

EXPLANATION
Epilepsy can be considered to be cured, if the patient had become seizure-free for at least 3 years and remained seizure free for another 2 years. In some adulthood epilepsy syndromes (for example in juvenile myoclonic epilepsy), despite a complete seizure freedom, antiepileptics cannot be stopped (there is a high risk of recurrence after antiepileptic withdrawal): these epilepsy forms require a lifelong antiepileptic treatment.

Question 21

NEU - 4.21
A 55 year-old man was admitted to the emergency department due to the first epileptic seizure in his life. Neurological examination revealed a mild left-sided (central) facial paresis and left-sided hemiparesis. MRI showed a space-occupying lesion in the right frontal lobe. What is the most probable diagnosis?

A) occlusion of the right-sided internal carotid artery
B) medulloblastoma
C) cerebellar astrocytoma
D) provoked seizure due to alcohol withdrawal
E) glioma

Answer 21

ANSWER
E) glioma

EXPLANATION
Brain tumor is the underlying cause of 20-30% of adult epilepsies. Epileptic seizure is the first clinical manifestation in 1/3rd of brain tumor cases.

Question 22

NEU - 4.22
Epilepsy can be established if the patient has:
A) 1 proven epileptic seizure
B) 2 epileptic seizures 1 hour after a severe brain injury
C) 1 epileptic seizure and a family history of epilepsy
D) recurrent non-provoked epileptic seizures
E) all of the above
F) only A and B is true
G) only C and D is true

Answer 22

ANSWER
D) recurrent non-provoked epileptic seizures

EXPLANATION
The definition of an epilepsy disorder is the presence of recurrent epileptic seizures, without obvious provoking factors. In some cases, we can diagnose epilepsy after a single unprovoked seizure, if the risk of recurrence is high. For example, if a seizure appears 6 months after a stroke (post-stroke epilepsy), then we should not wait for the second seizure in order to establish the epilepsy diagnosis: these patients should receive antiepileptic drug therapy immediately because of the high risk of recurrence. In the hyper-acute phase of severe acute diseases affecting the CNS (like traumatic brain injury) epileptic seizures can also occur. In this case there is a well-defined prvovoking factor, the patient cannot be considered to be epileptic and long-term antiepileptic treatment is not required.

Question 23

NEU - 4.23
Prevalence of epilepsy in industrialized countries:
A) 0.04-0.05%
B) 0.02%
C) 0.5–1%
D) 5–6%
E) 10–12%
F) 8–10%

Answer 23

ANSWER
C) 0.5–1%

EXPLANATION
The incidence of epilepsy in industrial high-income countries is 0.04-0.1%, while the prevalence is 0.5-1%. This prevalence rate is about 3-6 times higher (ca. 3%) in some countries with limited resources due to endemic cysticercosis.

Question 24

NEU - 4.24
The following statement is NOT true for epilepsy:
A) carbamazepine is one of the first drugs of choice in epilepsy
B) monotherapy is preferred
C) surgery is one of the options in drug-resistant focal epilepsy
D) measuring serum level of antiepileptic drugs can be useful
E) epilepsy treatment is based on the EEG
F) some antiepileptic drugs in combination can reduce each other’s effects

Answer 24

ANSWER
E) epilepsy treatment is based on the EEG

EXPLANATION
The EEG is a crucial tool in establishing the diagnosis of epilepsy. It also helps in the differential diagnosis of various epilepsy syndromes (the latter is important in the choice of adequate initial treatment). Conversely, the EEG has a minimal role in monitoring the therapeutic effect. The number and severity of seizures, presence of seizure freedom, and the side effects (especially psychiatric side effects) play the leading role during the long-term therapeutic strategy.

Question 25

NEU - 4.25
Oral contraceptive drugs:
A) frequently provoke epileptic seizures
B) are not recommended in epilepsy
C) are recommended only in seizure-free epilepsy patients
D) enhance the effect of antiepileptic drugs
E) some antiepileptic drugs can reduce the effect of oral contraceptives

Answer 25

ANSWER
E) some antiepileptic drugs can reduce the effect of oral contraceptives

EXPLANATION
Some antiepileptic drugs (for example carbamazepine) can reduce the efficacy of oral contraceptives. In this case an antiepileptic drug with low interaction potential should be chosen (for example levetiracetam or lamotrigin). Oral contraceptives have generally no effect on the severity of epilepsy, but can reduce the efficacy of some antiepileptic drugs.

Question 26

NEU - 4.26
Disorder(s) which can mimic epilepsy:
A) psychogenic seizures
B) convulsive syncope
C) parasomnia
D) none of them
E) all of them

Answer 26

ANSWER
E) all of them

EXPLANATION
Grand mal (generalized tonic-clonic seizure) should be differentiated from convulsive syncope and the psychogenic non-epileptic seizure (pseudoseizure, „hysteric” seizure). Some sleep disorders (parasomnias) can mimic epilepsy. These are: sleep walking (somnambulism) and the night terror (incubus).

Question 27

NEU - 4.27
Seizures with „jamais vu” usually occur in:
A) frontal lobe epilepsy
B) temporal lobe epilepsy
C) parietal lobe epilepsy
D) occipital lobe epilepsy

Answer 27

ANSWER
B) temporal lobe epilepsy

EXPLANATION
The ”jamais vu” phenomenon (I have never seen, I have never been in this situation) is a typical epileptic dysfunction of the temporo-limbic system: a specific aura type in temporal lobe epilepsy.

Question 28

NEU - 4.28
Postictal exhaustion of the brain can manifest in:
1) tenebrosity
2) Todd-paresis
3) terminal sleep
4) aphasia

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) 2. and 4. answers are correct
D) only answer 4 is correct
E) all of the answers are correct

Answer 28

ANSWER
E) all of the answers are correct

EXPLANATION
After an epileptic seizure, the involved cerebral structures become exhausted. This can manifest in clinical symptoms. General exhaustion after grand mal can appear as postictal sleep (called terminal sleep: a postictal sopor-like state) or in postictal confusion. Due to exhaustion of limbic structures, postictal confusion can also emerge after temporal lobe seizures. Clonic seizures can be followed by transient paresis (Todd paresis). Todd paresis is caused by postictal exhaustion of the cortical motor centers. The same mechanism is responsible for postictal aphasia appearing after left-sided temporal lobe seizures.

Question 29

NEU - 4.29
An option in epilepsy treatment:
1) vagus nerve stimulation
2) ketogenic diet
3) benzodiazepines
4) deep brain stimulation

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) a 2. and 4. answers are correct
D) only answer 4 is correct
E) all 4 answers are correct

Answer 29

ANSWER
E) all 4 answers are correct

EXPLANATION
Chronic deep brain stimulation of the anterior nucleus of the thalamus (ANT-DBS) and the vagus nerve stimulation (VNS) are effective neuromodulation therapies of drug-resistant epilepsy. The ketogenic diet can be highly effective in some childhood epilepsy syndromes. Benzodiazepines are the first-choice drugs in status epilepticus, moreover, some per os benzodiazepines (clobazam, clonazepam) can also be used in chronic epilepsy treatment.

Question 30

NEU - 4.30
Hepatic enzyme inducers:
1) carbamazepine
2) levetiracetam
3) diphenylhydantoin
4) gabapentin

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) 2. and 4. answers are correct
D) only 4. answer is correct
E) all of the answers are correct

Answer 30

ANSWER
B) 1. and 3. answers are correct

EXPLANATION
Both carbamazepine and diphenylhydantoin (phenytoin) are enzyme inducers. This can be problematic in case of drug combinations due to drug-to-drug interactions.

Question 31

NEU - 4.31
Psychopathological symptoms in epilepsy can be caused by:
1) chronic epileptic dysfunction
2) underlying etiology
3) brain injuries caused by seizures
4) long-term antiepileptic treatment

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) 2. and 4. answers are correct
D) only 4. answer is correct
E) all of the answers are correct

Answer 31

ANSWER
E) all of the answers are correct

EXPLANATION
Psychiatric problems more often occur in epilepsy than in healthy population. They are caused by the original cause of epilepsy (for example brain injury), chronic epileptic activity itself, chronic drug treatment, or the socioeconomic deterioration of patients with epilepsy.

Question 32

NEU - 4.32
Life-threatening complication of epilepsy:
1) Adrenal insufficiency
2) ictal injury
3) hypoglycemic coma
4) status epilepticus

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) a 2. and 4. answers are correct
D) only answer 4 is correct
E) all 4 answers are correct

Answer 32

ANSWER
C) a 2. and 4. answers are correct

EXPLANATION
Ictal injuries, status epilepticus and the sudden death in epiepsy (SUDEP) are the main life-threatening complications of epileptic seizures.

Question 33

NEU - 4.33
Effective in status epilepticus:
1) diazepam iv.
2) clonazepam iv.
3) propofol iv.
4) diphenylhydantoin iv.

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) 2. and 4. answers are correct
D) only answer 4 is correct
E) all 4 answers are correct

Answer 33

ANSWER
E) all 4 answers are correct

EXPLANATION
The most effective first-line treatment of status epilepticus is the intravenous administration of benzodiazepines. If intravenous administration is not possible, then rectal diazepam or buccal midazolam is a reasonable alternative. If the status epilepticus continues despite benzodiazepine treatment, then intravenous diphenylhydantoin, valproate, or levetiracetam should be administrated. In refractory status epilepticus, artificial coma should be induced by propofol, short-acting barbiturates, or midazolam.

Question 34

NEU - 4.35
Effective in status epilepticus:
1) phenytoin iv.
2) diazepam iv.
3) clonazepam iv.
4) disulfiram iv.

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) a 2. and 4. answers are correct
D) only answer 4 is correct
E) all 4 answers are correct

Answer 34

ANSWER
A) 1., 2. and 3. answers are correct

EXPLANATION
The most effective first-line treatment of status epilepticus is the intravenous administration of benzodiazepines. If intravenous administration is not possible, then rectal diazepam or buccal midazolam is a reasonable alternative. If the status epilepticus continues despite benzodiazepine treatment, then intravenous diphenylhydantoin, valproate, or levetiracetam should be administrated. In refractory status epilepticus, artificial coma should be induced by propofol, short-acting barbiturates, or midazolam.

Question 35

NEU - 4.36
Characteristics of temporal lobe epilepsy:
1) psychopathological symptoms
2) good response to antiepileptic drugs in comparison with other epilepsy types
3) epileptic aura
4) 3 Hz spike-and-wave discharge on the EEG

A) 1., 2. and 3. answers are correct
B) 1. and 3. answers are correct
C) a 2. and 4. answers are correct
D) only answer 4 is correct
E) all 4 answers are correct

Answer 35

ANSWER
B) 1. and 3. answers are correct

EXPLANATION
Psychopathological alterations typically occur in temporal lobe epilepsy. Clinically observable seizures can be preceded by an epileptic aura. Temporal lobe epilepsy is very often drug-resistant: epilepsy surgery is the main option in this case. (The 3 Hz spike-and-wave pattern is characteristic to idiopathic generalized epilepsy)

Question 36

NEU - 4.37
Epileptic seizure can be provoked by:
1) some psychotropic drugs
2) sleep deprivation
3) cocoa consumption
4) alcohol withdrawal
5) infection with fever

A) All of them are correct
B) Answers 2, 4, 5 are correct
C) Answers 2, 3, 4, 5 are correct
D) Answers 1, 2, 4 are correct
E) Answers 1, 2, 4, 5 are correct

Answer 36

ANSWER
E) Answers 1, 2, 4, 5 are correct

EXPLANATION
Cocoa consumption does not cause seizures. Conversely, sleep deprivation, alcohol withdrawal, some drugs, and fever can provoke — in some susceptive individuals — epileptic seizures (called provoked seizures).

Question 37

NEU - 4.38
Mechanism of action of antiepileptic drugs:
1) GABA-receptor-antagonism
2) GABA-receptor-agonism
3) NMDA-receptor-antagonism
4) NMDA-receptor-agonism
5) serotonin-reuptake inhibition
6) serotonin-reuptake enhancement

A) Answers 1, 3 and 5 are true
B) Answers 2, 4 and 5 are true
C) Answers 2, 3 and 6 are true
D) Answers 2, 4 and 6 are true
E) Answers 2 and 3 are true

Answer 37

ANSWER
E) Answers 2 and 3 are true

EXPLANATION
The two main mechanisms of action of antiepileptic drugs are: (i) enhancing the GABAerg inhibition or (ii) blocking the glutamaterg excitation. (The serotonin-reuptake inhibition is used in affective disorders)

Question 38

NEU - 4.39
Generalized tonic-clonic seizures:
1) tetany
2) provoked epileptic seizures
3) cataplexy
4) seizures of eclampsia in pregnancy

A) Answers 1, 2, 3 are true
B) Answers 2, 3, 4 are true
C) Answers 2 and 4 are true
D) Answers 1 and 4 are true
E) all of them are true

Answer 38

ANSWER
C) Answers 2 and 4 are true

EXPLANATION
Eclampsia is a disorder of pregnancy characterized by epileptic seizures in the setting of pre-eclampsia. Tetany is caused by hypocalcaemia and not an epileptic seizure. Cataplexy (characterized by sudden loss of muscle tone) is not an epileptic seizure but one of the symptoms of narcolepsy .

Question 39

NEU - 4.40
Indication for measuring serum level of antiepileptic drug:
1) suspicion on lack of compliance/adherence
2) suspicion on drug-to-drug interaction
3) evaluation of the individual drug metabolism
4) evaluating the therapeutic effect

A) Answers 1, 2, 3 are true
B) Answers 2 and 4 are true
C) Answers 1 and 2 are true
D) Answers 1 and 4 are true
E) all of them are true

Answer 39

ANSWER
A) Answers 1, 2, 3 are true

EXPLANATION
Serum level of antiepileptic drugs provides information on (i) whether the patient takes the drug at all, (ii) whether there is a significant drug-to-drug interaction, and (iii) whether the metabolism of the drug is in the expectant range.

Question 40

NEU-4.41-4.45
Pair the matching items!
A) epilepsia partialis continua
B) Jacksonian seizure (Jacksonian march)
C) absence
D) tonic seizure
E) sleep attack

NEU - 4.41 - Lennox–Gastaut syndrome

NEU - 4.42 - 3-Hz spike-and-wave complex on the EEG

NEU - 4.43 - focal status epilepticus

NEU - 4.44 - focal seizure

NEU - 4.45 - narcolepsy

Answer 40

ANSWER
NEU - 4.41 - Lennox–Gastaut syndrome - D)

NEU - 4.42 - 3-Hz spike-and-wave complex on the EEG - C)

NEU - 4.43 - focal status epilepticus - A)

NEU - 4.44 - focal seizure - B)

NEU - 4.45 - narcolepsy - E)

Question 41

NEU - 4.50
Every patient with epilepsy had at least 1 epileptic seizure, therefore all patients with epileptic seizures have an epilepsy.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 41

ANSWER
C) first part is correct, the second is incorrect

EXPLANATION
The main feature of epilepsy is the (recurrent) unprovoked epileptic seizures. In certain biological circumstances, however, epileptic seizure can occur in healthy (non-epileptic) people: this is the provoked seizure.

Question 42

NEU - 4.51
Multiple antiepileptic drugs should be administrated if various seizure types are present, therefore a dose reduction is recommended.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 42

ANSWER
E) both parts are incorrect

EXPLANATION
During drug therapy of epilepsy, we prefer monotherapy (using only one drug). If this is not successful, we can use „rational polytherapy” where drugs with different mechanisms of actions are combined in order to maximize the antiepileptic effect.

Question 43

NEU - 4.52
Alcohol withdrawal can provoke epileptic seizures, therefore these patients had an epilepsy.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 43

ANSWER
C) first part is correct, the second is incorrect

EXPLANATION
The most severe consequences of alcohol withdrawal are: a) Provoked epileptic seizures (generalized tonic-clonic seizures), b) Delirium. People with provoked epileptic seizures do not have an epilepsy, and antiepileptic drugs are usually not indicated. By avoiding the provoking factors, we can achieve a complete long-term seizure freedom.

Question 44

NEU - 4.53
Ethosuxumide is the first drug of choice in absence epilepsy, because the EEG shows a 3-Hz spike-and-wave activity during absence seizures.

A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 44

ANSWER
B) both parts are correct, causative relation does not exist

EXPLANATION
Ethosuximide is a first-choice drug in absence epilepsy. During absence seizures, a 3-Hz spike-and-wave pattern is present on the EEG.

Question 45

NEU - 4.54
Grand mal seizure is always accompanied by enuresis, because grand mal is always accompanied by loss of consciousness.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 45

ANSWER
D) first part is incorrect, second part is correct

EXPLANATION
Characteristics of the generalized tonic-clonic (grand mal) seizure are: (i) screaming at the seizure start, (ii), tongue biting, (iii) enuresis. None of them are obligatory. Grand mal is always accompanied by loss of consciousness.

Question 46

NEU - 4.55
Pathological EEG is always a proof of epilepsy, because every epileptic patient has a pathological EEG.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 46

ANSWER
E) both parts are incorrect

EXPLANATION
The standard EEG examination shows interictal epileptiform discharges (waveforms characteristics to the epilepsy) in 30-50% of epilepsy patients. The sensitivity of the EEG is the highest within 24 hours after an epileptic seizure. If the standard EEG provides no information, the whole-night sleep-EEG or sleep-EEG after sleep deprivation can be valuable. The normal EEG does not exclude, while the pathological EEG does not prove an epilepsy. The diagnosis is mainly based on the patient history (auto- and heteroanamnestic data on the seizure, provoking factors) and clinical signs (lateral tongue biting, enuresis, postictal confusion). In some patients with epilepsy the EEG will never show epilepsy-specific waveforms. Conversely, some healthy people have a positive EEG: epilepsy-specific waveforms can occur in 2-3% of healthy (non-epileptic) children and in 0.2-0.5% of healthy adults.

Question 47

NEU - 4.56
Some of the antiepileptic drugs can be teratogenic, therefore an abortion is indicated in pregnant women with epilepsy.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 47

ANSWER
C) first part is correct, the second is incorrect

EXPLANATION
Antiepileptic drugs have a modest teratogenic effect. Some old drugs (barbiturates, phenytoin) and especially the valproate have the highest risk for inducing major congenital malformations. We can minimize the problem of teratogenicity by optimizing the antiepileptic therapy, folic acid supplementation, and screening for major congenital malformations. Consequently, most women with epilepsy can have a non-problematic pregnancy and a healthy baby.

Question 48

NEU - 4.57
Some of the antiepileptic drugs can be teratogenic, therefore folic acid substitution is recommended during and before pregnancy.
A) both parts are correct, causative relation exists
B) both parts are correct, causative relation does not exist
C) first part is correct, the second is incorrect
D) first part is incorrect, second part is correct
E) both parts are incorrect

Answer 48

ANSWER
A) both parts are correct, causative relation exists

EXPLANATION
Antiepileptic drugs have a modest teratogenic effect. Some old drugs (barbiturates, phenytoin) and especially the valproate have the highest risk for inducing major congenital malformations. We can minimize the problem of teratogenicity by optimizing the antiepileptic therapy, folic acid supplementation, and screening for major congenital malformations. Consequently, most women with epilepsy can have a non-problematic pregnancy and a healthy baby

Question 49

NEU - 4.58
Diagnosis:
A 18-year-old young man had grand mal seizures since age 14. No provoking factors were revealed. The patient reported that he also had involuntary jerking in the mornings.
A) focal epilepsy
B) juvenile myoclonic epilepsy
C) chorea major
D) psychogenic epilepsy

Answer 49

ANSWER
B) juvenile myoclonic epilepsy

EXPLANATION
Juvenile myoclonic epilepsy is one of the most frequent epilepsy syndromes in adulthood: its prevalence is ca. 0.1%. It is characterized by grand mal seizures and myoclonic jerks (usually on awakening). In 40% of patients, absence seizures can also occur. The EEG shows a 3-Hz spike-and-wave pattern. This is a genetic epilepsy, consequently, the MRI shows no epileptogenic lesion.

Question 50

NEU - 4.59
Frist drug of choice:
A 18-year-old young man had grand mal seizures since age 14. No provoking factors were revealed. The patient reported that he also had involuntary jerking in the mornings.
A) phenobarbital
B) valproate
C) clobazam
D) ethosuximide
E) carbamazepine

Answer 50

ANSWER
B) valproate

EXPLANATION
Valproate is the most effective treatment of juvenile myoclonic epilepsy. In fertile women, however, it should be avoided due to its teratogenic effect. In this case, lamotrigin or levetiracetam are the drugs of choice.

Question 51

NEU - 4.60
Follow-up and prognosis:
A 18-year-old young man had grand mal seizures since age 14. No provoking factors were revealed. The patient reported that he also had involuntary jerking in the mornings.

A) Lobectomy will never be a therapeutic option.
B) The patient should probably take antiepileptic drugs for > 10 years.
C) Taking appropriate antiepileptic drugs will probably result in complete seizure freedom.
D) in case of a long-term seizure freedom, the patient is permitted to drive a car.
E) all of them

Answer 51

ANSWER
E) all of them

EXPLANATION
Most patients with juvenile myoclonic epilepsy become seizure-free on adequate antiepileptic treatment. Conversely, due to the high risk of seizure recurrence, withdrawal of epileptic drugs are generally not recommended, even after a decade-long seizure freedom. Epilepsy surgery is not an option because this is a generalized epilepsy syndrome. Long-term seizure-free patients are permitted to have a driving license (and driving a car), regardless whether the seizure freedom has been achieved with or without antiepileptic drug treatment.