SEIZURES

Question 1

Which of the following best defines status epilepticus?

A) A single seizure lasting more than 2 minutes
B) Continuous seizures or repetitive, discrete seizures with impaired consciousness in the interictal period
C) A focal seizure without loss of consciousness
D) A seizure that stops spontaneously within 30 seconds

Answer 1

Answer: B
Rationale: Status epilepticus is characterized by continuous seizures or repetitive seizures where consciousness does not return between episodes. It is a medical emergency requiring immediate treatment.

Question 2

Which of the following statements about generalized convulsive status epilepticus (GCSE) is TRUE?

A) GCSE is a benign condition that resolves on its own
B) GCSE is an emergency and must be treated immediately to prevent complications
C) GCSE is the least severe form of epilepsy
D) GCSE has no known causes

Answer 2

Answer: B
Rationale: GCSE is a medical emergency because prolonged seizures can lead to complications such as cardiorespiratory dysfunction, hyperthermia, metabolic derangements, and irreversible neuronal injury.

Question 3

Which of the following statements regarding driving restrictions for epilepsy patients is TRUE?

A) All epilepsy patients are permanently banned from driving
B) Driving is permitted if the patient has been seizure-free for a specified period (typically 3 months to 2 years)
C) Patients can drive as long as they are on medication
D) There are no driving restrictions for epilepsy patients

Answer 3

Answer: B
Rationale: Most regulations allow patients to drive if they have been seizure-free for a specified duration, usually between 3 months and 2 years, depending on local laws.

Question 4

Which of the following best describes catamenial epilepsy?

A) A form of epilepsy caused by dietary factors
B) A condition where women experience increased seizure frequency around menstruation
C) A rare childhood epilepsy syndrome
D) An epilepsy type that occurs only in men

Answer 4

Answer: B
Rationale: Catamenial epilepsy refers to a condition in which some women experience increased seizure activity around their menstrual cycles, likely due to hormonal fluctuations affecting neuronal excitability and antiseizure drug metabolism.

Question 5

Which of the following is NOT a recommended approach for managing catamenial epilepsy?

A) Increasing antiseizure drug dosages during menses
B) Hormonal therapy in some cases
C) Stopping antiseizure medication altogether
D) Monitoring hormonal influences on seizure patterns

Answer 5

Answer: C
Rationale: Stopping antiseizure medication is not a recommended approach for managing catamenial epilepsy. Instead, dosage adjustments and hormonal therapy can help control seizures.

Question 6

Which antiseizure medication is most strongly associated with teratogenic effects and fetal malformations?

A) Lamotrigine
B) Valproic acid
C) Levetiracetam
D) Carbamazepine

Answer 6

Answer: B
Rationale: Valproic acid is strongly associated with an increased risk of fetal malformations, with rates as high as 7–20%. The risk increases with higher doses and multiple medication use.

Question 7

Which of the following is a recommended strategy for pregnant women with epilepsy?

A) Using monotherapy at the lowest effective dose, especially during the first trimester
B) Stopping all antiseizure medications
C) Avoiding folate supplementation
D) Taking multiple antiseizure drugs at high doses

Answer 7

Answer: A
Rationale: The safest approach is to use monotherapy at the lowest effective dose, particularly during the first trimester, to reduce teratogenic risks while maintaining seizure control. Folate supplementation (1–4 mg/day) is also recommended.

Question 8

Which of the following statements about breastfeeding and epilepsy is TRUE?

A) Mothers with epilepsy should avoid breastfeeding
B) Breastfeeding is encouraged for mothers with epilepsy
C) Antiseizure medications make breastfeeding impossible
D) Breastfeeding worsens epilepsy

Answer 8

Answer: B
Rationale: Mothers with epilepsy can and should be encouraged to breastfeed, as the benefits outweigh potential risks. Most antiseizure drugs are present in breast milk at low concentrations that are not harmful to the infant.

Question 9

What is the first-line pharmacologic treatment for impending and early status epilepticus?

A) IV antiseizure drugs such as phenytoin or valproic acid
B) IV benzodiazepines such as lorazepam, midazolam, or clonazepam
C) IV anesthetics such as ketamine
D) Ketogenic diet and immunomodulation

Answer 9

Answer: B
Rationale: The first-line treatment for early status epilepticus is IV benzodiazepines (e.g., lorazepam, midazolam, clonazepam) due to their rapid onset and efficacy in stopping seizures.

Question 10

Which of the following is an appropriate second-line therapy after IV benzodiazepines in early status epilepticus?

A) IV anesthetics such as isoflurane
B) IV antiseizure drugs such as phenytoin, valproic acid, or levetiracetam
C) Surgery
D) Magnesium and verapamil

Answer 10

Answer: B
Rationale: If seizures persist after benzodiazepines, IV antiseizure drugs such as phenytoin, valproic acid, or levetiracetam should be administered.

Question 11

What is the recommended pharmacologic management for generalized convulsive or “subtle” status epilepticus that is resistant to first-line treatments?

A) IV midazolam or IV propofol
B) IV phenytoin only
C) Oral pregabalin
D) Electroconvulsive therapy (ECT)

Answer 11

Answer: A
Rationale: In refractory cases, continuous infusion of IV midazolam (0.2–0.6 mg/kg/h) and/or IV propofol (2–10 mg/kg/h) is recommended to control seizures.

Question 12

Which of the following is an appropriate treatment for focal-complex, myoclonic, or absence status epilepticus?

A) Further IV/PO antiseizure drugs such as valproic acid, levetiracetam, or topiramate
B) IV midazolam or IV propofol
C) IV benzodiazepines only
D) Surgery as first-line treatment

Answer 12

Answer: A
Rationale: Focal-complex, myoclonic, or absence SE may require additional IV or PO antiseizure medications such as valproic acid, levetiracetam, lacosamide, topiramate, or pregabalin.

Question 13

What is the next step in treatment for status epilepticus lasting longer than 48 hours and unresponsive to previous therapies?

A) Pentobarbital (PTB) or thiopental (THP) infusion
B) Oral phenytoin
C) Lorazepam tapering
D) Behavioral therapy

Answer 13

Answer: A
Rationale: For late refractory SE, pentobarbital (5 mg/kg → 1–5 mg/kg/h) or thiopental is used as an anesthetic to achieve burst suppression on EEG.

Question 14

Which of the following is NOT a commonly used additional therapy in late refractory SE?

A) Lidocaine
B) Ketogenic diet
C) Verapamil
D) Carbamazepine

Answer 14

Answer: D
Rationale: Other medications such as lidocaine, verapamil, magnesium, and dietary approaches like the ketogenic diet may be used. Carbamazepine is not commonly used in status epilepticus.

Question 15

Which of the following is NOT an anesthetic used in refractory SE?

A) Isoflurane
B) Desflurane
C) Ketamine
D) Clonazepam

Answer 15

Answer: D
Rationale: Clonazepam is a benzodiazepine, whereas isoflurane, desflurane, and ketamine are anesthetics used in late-stage SE management.

Question 16

Which of the following non-pharmacologic interventions can be considered in late refractory SE?

A) Vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and electroconvulsive therapy (ECT)
B) Midazolam infusion
C) Increasing benzodiazepine doses indefinitely
D) Avoiding further medical interventions

Answer 16

Answer: A
Rationale: In refractory cases, non-pharmacologic treatments such as VNS, RNS, ECT, and hypothermia may be considered when medications fail.

Question 17

Which of the following best defines a seizure?
a) A chronic neurological disease causing recurring convulsions
b) A transient occurrence of signs or symptoms due to abnormal excessive or synchronous neuronal activity in the brain
c) A condition caused only by genetic mutations in neuronal ion channels
d) A psychological disorder characterized by unconscious episodes

Answer 17

Answer: b
Rationale: A seizure is a transient event caused by abnormal neuronal activity. Epilepsy, not seizures, is a chronic condition.

Question 18

Epilepsy is best defined as:
a) A condition with two or more unprovoked seizures
b) A seizure disorder that occurs only in childhood
c) Any single seizure caused by metabolic disturbances
d) A condition that is always genetic

Answer 18

Answer: a
Rationale: Epilepsy is a chronic disorder involving recurrent, unprovoked seizures.

Question 19

Which of the following is a common cause of seizures in older adults?
a) Attention deficit hyperactivity disorder
b) Cerebrovascular disease
c) Chronic stress
d) Hyperthyroidism

Answer 19

Answer: b
Rationale: Cerebrovascular disease accounts for nearly 50% of new epilepsy cases in patients over 65.

Question 20

Focal seizures originate in:
a) Both hemispheres simultaneously
b) A single brain hemisphere
c) The brainstem only
d) The cerebellum

Answer 20

Answer: b
Rationale: Focal seizures arise in a single hemisphere, unlike generalized seizures.

Question 21

Generalized seizures differ from focal seizures in that they:
a) Are caused by metabolic disorders only
b) Originate in and rapidly engage both hemispheres
c) Always result in loss of consciousness
d) Never involve muscle movements

Answer 21

Answer: b
Rationale: Generalized seizures affect both hemispheres and often impair consciousness.

Question 22

Which type of seizure is characterized by sudden, brief lapses in consciousness without loss of postural control?
a) Generalized tonic-clonic seizure
b) Myoclonic seizure
c) Typical absence seizure
d) Atonic seizure

Answer 22

Answer: c
Rationale: Absence seizures cause brief episodes of unresponsiveness without loss of posture.

Question 23

A Jacksonian march is characterized by:
a) A spreading seizure from one part of the motor cortex to adjacent areas
b) A seizure that begins in both hemispheres at once
c) A seizure that affects vision only
d) A seizure with no physical manifestations

Answer 23

Answer: a
Rationale: A Jacksonian march describes the progressive spread of motor symptoms.

Question 24

Todd’s paralysis refers to:
a) A permanent loss of motor function after a seizure
b) A brief, temporary paralysis following a focal seizure
c) The aura preceding a seizure
d) A type of seizure that lasts more than 5 minutes

Answer 24

Answer: b
Rationale: Todd’s paralysis is a postictal weakness that resolves over time.

Question 25

Which of the following EEG findings is characteristic of typical absence seizures? a) 3-Hz spike-and-wave discharges b) High-voltage slow waves c) Continuous fast rhythms d) Unilateral spikes

Answer 25

Answer: a Rationale: Absence seizures show generalized, symmetric 3-Hz spike-and-wave discharges.

Question 26

The first-line medication for impending and early status epilepticus (SE) is: a) Phenytoin b) Lorazepam c) Valproic acid d) Levetiracetam

Answer 26

Answer: b Rationale: IV benzodiazepines (e.g., lorazepam) are the first-line treatment for SE.

Question 27

Which antiseizure drug is commonly used as a second-line agent in SE after benzodiazepines? a) Levetiracetam b) Midazolam c) Phenytoin d) Ketamine

Answer 27

Answer: c Rationale: Phenytoin is often used after benzodiazepines in SE management.

Question 28

Which neurotransmitter is primarily involved in seizure inhibition? a) Glutamate b) Acetylcholine c) GABA d) Dopamine

Answer 28

Answer: c Rationale: GABA is the main inhibitory neurotransmitter in the CNS.

Question 29

Which drug class enhances GABAergic inhibition to control seizures? a) Benzodiazepines b) NMDA antagonists c) Dopamine agonists d) Beta-blockers

Answer 29

Answer: a Rationale: Benzodiazepines enhance GABAergic inhibition, reducing seizure activity.

Question 30

Which antiseizure drug blocks voltage-gated sodium channels? a) Valproic acid b) Levetiracetam c) Phenytoin d) Gabapentin

Answer 30

Answer: c Rationale: Phenytoin blocks Na+ channels to prevent excessive neuronal firing.

Question 31

Epileptogenesis refers to: a) The formation of new neurons b) The transformation of a normal neuronal network into a hyperexcitable state c) A seizure that spreads from one hemisphere to another d) A type of genetic mutation

Answer 31

Answer: b Rationale: Epileptogenesis is the process that makes neurons hyperexcitable.

Question 32

Which of the following is NOT a mechanism of antiseizure drugs? a) Inhibiting sodium channels b) Enhancing GABA activity c) Increasing glutamate activity d) Blocking calcium channels

Answer 32

Answer: c Rationale: Antiseizure drugs generally work by reducing excitatory activity, not increasing glutamate.

Question 33

What is the electrophysiologic hallmark of typical absence seizures on EEG? A) 3-Hz, generalized, symmetric spike-and-slow-wave discharges B) Focal sharp waves in the temporal lobe C) Continuous high-frequency beta waves D) Burst suppression pattern

Answer 33

Rationale: The correct answer is A. The hallmark EEG pattern of typical absence seizures is a burst of generalized, symmetric, 3-Hz, spike-and-slow-wave discharges. This distinct pattern helps differentiate absence epilepsy from other seizure types.

Question 34

What is the primary characteristic of a typical absence seizure? A) Loss of consciousness with postictal confusion B) Sudden, brief lapses of consciousness without loss of postural control C) Generalized tonic-clonic movements D) Prolonged unconsciousness with severe disorientation

Answer 34

Rationale: The correct answer is B. Typical absence seizures are defined by sudden, brief lapses of consciousness without loss of postural control. Unlike other seizure types, they do not lead to postictal confusion or significant motor convulsions.

Question 35

How do atypical absence seizures differ from typical absence seizures? A) They have a shorter duration and more abrupt onset and cessation B) They are less common in children and more common in adults C) They have a longer duration, less abrupt onset and cessation, and more prominent motor signs D) They never involve loss of consciousness

Answer 35

Rationale: The correct answer is C. Atypical absence seizures are characterized by a longer duration, a less abrupt start and stop, and more noticeable motor signs compared to typical absence seizures.

Question 36

What EEG pattern is associated with atypical absence seizures? A) 3-Hz, symmetric spike-and-slow-wave discharges B) Generalized, slow spike-and-slow-wave pattern (≤2.5 Hz) C) High-frequency beta activity D) Focal sharp waves in the occipital lobe

Answer 36

Rationale: The correct answer is B. Atypical absence seizures show a generalized, slow spike-and-slow-wave pattern (≤2.5 Hz) on EEG, which distinguishes them from the 3-Hz pattern seen in typical absence seizures.

Question 37

What is the initial phase of a generalized tonic-clonic seizure? A) Clonic contractions of the limbs B) Tonic contraction of muscles throughout the body C) Loss of consciousness without motor involvement D) Focal limb jerking

Answer 37

Rationale: The correct answer is B. The initial phase of a generalized tonic-clonic seizure is the tonic phase, characterized by sustained muscle contraction throughout the body, leading to stiffening and symptoms such as the ictal cry and impaired respiration.

Question 38

Which of the following is a key characteristic of the clonic phase of a generalized tonic-clonic seizure? A) Prolonged muscle stiffening without relaxation B) Sudden cessation of seizure activity without transition C) Alternating periods of muscle contraction and relaxation D) Immediate return to normal consciousness

Answer 38

Rationale: The correct answer is C. The clonic phase follows the tonic phase and consists of alternating contractions and relaxations of muscles, which increase in duration until the seizure ends.

Question 39

What is a distinguishing EEG feature of the tonic phase of a generalized tonic-clonic seizure? A) 3-Hz spike-and-wave discharges B) generalized low-voltage fast activity, followed by generalized high-amplitude polyspike discharges. C) Focal sharp waves in the temporal lobe D) Burst suppression pattern

Answer 39

Rationale: The correct answer is B. The EEG during the tonic phase shows a progressive increase in generalized low-voltage fast activity, followed by generalized high-amplitude polyspike discharges.

Question 40

What underlying conditions are commonly associated with pathologic myoclonus? A) Metabolic disorders, degenerative CNS diseases, anoxic brain injury B) Migraine headaches, anxiety, sleep apnea C) Hypertension, diabetes, hypercholesterolemia D) Seasonal allergies, vitamin deficiencies, dehydration

Answer 40

Rationale: The correct answer is A. Pathologic myoclonus is often linked to metabolic disorders, degenerative CNS diseases, or anoxic brain injury and is distinct from physiologic myoclonus.

Question 41

What EEG pattern is seen in myoclonic seizures? A) 3-Hz spike-and-slow-wave discharges B) Bilaterally synchronous spike-and-slow-wave discharges immediately before the movement C) Focal sharp waves in the temporal lobe D) Burst suppression pattern

Answer 41

Rationale: The correct answer is B. Myoclonic seizures are associated with bilaterally synchronous spike-and-slow-wave discharges that appear just before the movement, confirming their cortical origin.

Question 42

Which epilepsy syndrome is most commonly associated with myoclonic seizures? A) Lennox-Gastaut syndrome B) Juvenile myoclonic epilepsy (JME) C) Childhood absence epilepsy D) Temporal lobe epilepsy

Answer 42

Rationale: The correct answer is B. Myoclonic seizures are a hallmark feature of juvenile myoclonic epilepsy (JME), a generalized epilepsy syndrome that typically begins in adolescence.

Question 43

What is a key feature of juvenile myoclonic epilepsy (JME)? A) Unilateral muscle jerking with loss of consciousness B) Bilateral myoclonic jerks, typically occurring in the morning C) Focal seizures originating in the temporal lobe D) Seizures that occur only during sleep

Answer 43

Rationale: The correct answer is B. JME is characterized by bilateral myoclonic jerks, often occurring in the morning after awakening, and consciousness is typically preserved unless the myoclonus is severe.

Question 44

In addition to myoclonic seizures, what other seizure types are commonly seen in JME? A) Complex partial seizures and atonic seizures B) Generalized tonic-clonic seizures and absence seizures C) Focal seizures with secondary generalization D) Reflex seizures triggered by sound

Answer 44

Rationale: The correct answer is B. Many patients with JME also experience generalized tonic-clonic seizures, and up to one-third have absence seizures.

Question 45

Which of the following is a defining feature of Lennox-Gastaut Syndrome (LGS)? A) Only one type of seizure, usually absence seizures B) A triad of multiple seizure types, slow spike-and-wave EEG, and cognitive impairment C) Seizures that only occur in adulthood D) A benign prognosis with full seizure remission

Answer 45

Rationale: The correct answer is B. LGS is characterized by multiple seizure types, a slow spike-and-wave EEG pattern, and cognitive impairment in most cases.

Question 46

What EEG finding is characteristic of LGS? A) 3-Hz spike-and-wave discharges B) Focal sharp waves in the temporal lobe C) Slow spike-and-wave discharges (<3 Hz) D) Continuous high-frequency beta activity

Answer 46

Rationale: The correct answer is C. LGS is associated with slow spike-and-wave discharges (<3 Hz), which distinguishes it from other epilepsy syndromes like childhood absence epilepsy.

Question 47

What is the most common epilepsy syndrome associated with focal seizures with impaired consciousness? A) Lennox-Gastaut Syndrome B) Juvenile Myoclonic Epilepsy C) Mesial Temporal Lobe Epilepsy (MTLE) D) Absence Epilepsy

Answer 47

Rationale: The correct answer is C. MTLE is the most common epilepsy syndrome associated with focal seizures that impair consciousness, often linked to hippocampal sclerosis

Question 48

Why is it important to recognize MTLE as a distinct epilepsy syndrome? A) It is a self-limiting condition that does not require treatment B) It typically responds poorly to anticonvulsants but may be treated surgically C) It is a rare and untreatable form of epilepsy D) It is caused by vitamin deficiency and can be treated with dietary changes

Answer 48

Rationale: The correct answer is B. MTLE is often resistant to anticonvulsant medications but responds well to surgical intervention, making early diagnosis crucial.

Question 49

What is a key pathologic feature associated with MTLE? A) Cortical dysplasia B) Hippocampal sclerosis C) Slow spike-and-wave discharges D) Periventricular leukomalacia

Answer 49

Rationale: The correct answer is B. Hippocampal sclerosis, which involves neuronal loss and gliosis in the hippocampus, is a key pathologic feature in many patients with MTLE.

Question 50

Which EEG finding is commonly seen in MTLE? A) Generalized spike-and-wave discharges B) Unilateral or bilateral anterior temporal spikes C) Slow spike-and-wave discharges (<3 Hz) D) Continuous high-frequency beta activity

Answer 50

Rationale: The correct answer is B. MTLE is characterized by unilateral or bilateral anterior temporal spikes on EEG, which correspond to seizure activity originating in the mesial temporal lobe.

Question 51

What MRI finding is typically associated with MTLE? A) Cortical dysplasia B) Enlarged ventricles C) Small hippocampus with increased T2 signal D) Periventricular leukomalacia

Answer 51

Rationale: The correct answer is C. MRI findings in MTLE commonly show a small hippocampus with increased T2 signal, indicating hippocampal sclerosis, which is a hallmark of the syndrome.

Question 52

What is the primary reason for increased seizure frequency in some women around the time of menstruation (catamenial epilepsy)? A) Dehydration and electrolyte imbalance B) Effects of estrogen and progesterone on neuronal excitability C) Increased dietary intake of sodium D) Higher metabolic demands during menstruation

Answer 52

Rationale: The correct answer is B. Changes in seizure frequency around menstruation are attributed to hormonal fluctuations, particularly estrogen and progesterone, which influence neuronal excitability.

Question 53

Which antiseizure medication is most strongly associated with an increased risk of fetal malformations? A) Lamotrigine B) Levetiracetam C) Valproic acid D) Gabapentin

Answer 53

Rationale: The correct answer is C. Valproic acid has been associated with a 7–20% risk of fetal malformations, making it one of the most teratogenic antiseizure drugs.

Question 54

Why is folate supplementation recommended for pregnant women with epilepsy? A) To reduce the risk of neonatal hemorrhage B) To counteract antifolate effects of antiseizure medications C) To decrease the risk of cardiovascular defects in the fetus D) To prevent gestational diabetes

Answer 54

Rationale: The correct answer is B. Many antiseizure drugs have antifolate effects, which may contribute to neural tube defects. Folate supplementation (1–4 mg/day) is recommended, though its benefits remain unproven in this setting.

Question 55

Which antiseizure medications can reduce the effectiveness of oral contraceptives? A) Valproic acid and levetiracetam B) Carbamazepine and phenytoin C) Ethosuximide and gabapentin D) Lacosamide and zonisamide

Answer 55

Rationale: The correct answer is B. Carbamazepine, phenytoin, phenobarbital, and topiramate are enzyme inducers that can enhance metabolism of oral contraceptives, reducing their efficacy.

Question 56

What is the most appropriate recommendation for pregnant women with epilepsy regarding antiseizure medication use? A) Stop all antiseizure medications to prevent fetal harm B) Continue effective monotherapy at the lowest possible dose C) Switch to multiple antiseizure medications to maximize seizure control D) Take antiseizure medications only during the third trimester

Answer 56

Rationale: The correct answer is B. The risk of uncontrolled seizures is higher than the teratogenic risks of medications, so women should remain on the lowest effective monotherapy whenever possible.

Question 57

Why is vitamin K supplementation recommended for pregnant women on enzyme-inducing antiseizure medications? A) To prevent hemorrhagic disease of the newborn B) To enhance fetal brain development C) To counteract folate deficiency D) To reduce the risk of maternal seizures

Answer 57

Rationale: The correct answer is A. Enzyme-inducing drugs (e.g., phenytoin, carbamazepine, topiramate) can cause vitamin K-dependent clotting factor deficiency in newborns, increasing the risk of neonatal hemorrhage.

Question 58

Which antiseizure drug has the highest concentration in breast milk relative to serum levels? A) Valproic acid B) Levetiracetam C) Lamotrigine D) Phenytoin

Answer 58

Rationale: The correct answer is B. Levetiracetam has a breast milk-to-serum concentration ratio of up to 300%, whereas valproic acid is only about 5%.