Medicine Marrow Pg No 607-616 (Neurology)

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Questions and Answers

What is the most common clinical feature associated with acute presentations of neurological infections?

Petechiae

Cerebral infarction

Focal neurological signs

Severe headache (correct)

Which of the following signs indicates meningeal irritation?

Trousseau's sign

Hoffmann's sign

Bouchard's sign

Brudzinski's sign (correct)

What is the primary endotoxin associated with meningococcal infections?

Peptidoglycan

Lipopolysaccharide (correct)

Lipid A

Lipoteichoic acid

Which condition is associated with the clinical signs of petechiae and palpable purpura?

Meningococcus Signup and view all the answers

Which of the following conditions is a relative contraindication for a lumbar puncture?

Immunocompromised state Signup and view all the answers

What characterizes the initial compensatory phase of a generalized tonic-clonic seizure?

Increased cardiac output and increased lactate Signup and view all the answers

What is a potential consequence during the decompensation phase of generalized tonic-clonic seizures?

Multiple Organ Dysfunction Syndrome (MODS) Signup and view all the answers

What is the primary treatment option for individuals with myoclonic seizures?

Levetiracetam Signup and view all the answers

What is the recommended action if seizures do not stop after administering IM midazolam?

Achieve IV access and prepare for further treatment Signup and view all the answers

Which drug should be administered if seizures persist after the second dose of IV lorazepam?

A third line drug such as propofol or thiopentone Signup and view all the answers

Which characteristic EEG pattern is commonly associated with myoclonic seizures?

Polyspike & wave pattern Signup and view all the answers

What is a defining feature of atonic seizures?

Sudden loss of muscle tone Signup and view all the answers

What is indicated if seizures continue beyond 20 minutes after initial treatment?

Check for subtherapeutic drug levels Signup and view all the answers

Which of the following is NOT associated with Lennox Gastaut syndrome?

Myoclonic seizures Signup and view all the answers

What age group is most commonly affected by atonic seizures?

Children Signup and view all the answers

What is the primary focus when constructing the stem of a question?

Presenting a clear and definite problem Signup and view all the answers

Which of the following is a guideline for constructing options in a multiple-choice question?

Options should be mutually exclusive Signup and view all the answers

What should distractors in a multiple-choice question represent?

Common student misconceptions Signup and view all the answers

How should the correct answer be determined for a given question?

It should be based on content knowledge that is widely accepted Signup and view all the answers

What is a key requirement regarding the wording of multiple-choice options?

Options should be clearly stated and concise Signup and view all the answers

Which metabolic condition is NOT associated with the causes of Generalized Tonic-Clonic Seizures (GTCS)?

Increased potassium levels Signup and view all the answers

What is the recommended treatment for HSV-1 encephalitis?

Acyclovir Signup and view all the answers

Which type of syncope is characterized by a sudden drop in blood pressure often due to emotional triggers?

Vasovagal syncope Signup and view all the answers

Which of the following drugs is associated with withdrawal seizures?

Benzodiazepines Signup and view all the answers

Which of the following conditions is NOT listed as a cause of Generalized Tonic-Clonic Seizures (GTCS)?

Hypercalcemia Signup and view all the answers

Which syndrome is associated with the most significant challenges in children?

Dravet's Syndrome Signup and view all the answers

Which of the following features is not typically associated with Rolandic Seizures?

Mental retardation Signup and view all the answers

Which type of childhood seizure is characterized by West Syndrome?

Infantile spasms Signup and view all the answers

Which of the following statements about Lafora's disease is true?

It leads to significant cognitive decline. Signup and view all the answers

In which age group are Dravet's Syndrome seizures typically observed?

Birth to 2 years Signup and view all the answers

Which organism is most commonly associated with CNS infections?

Staphylococcus aureus Signup and view all the answers

What microscopic feature is indicative of pneumococcus?

Swollen capsule after antiserum addition Signup and view all the answers

Which predisposing factor increases the risk of meningitis in individuals over 65 years of age?

Age over 65 years Signup and view all the answers

Which of the following is a characteristic of pneumolysin?

It forms pores in the cell membrane. Signup and view all the answers

In which age group are individuals most likely to experience CNS infections only in an immunocompromised state?

20-50 years Signup and view all the answers

What is the most common organism causing acute meningitis in adults?

Streptococcus pneumoniae Signup and view all the answers

Which of the following antibodies is associated with small cell lung cancer?

Anti Na Antibody Signup and view all the answers

What is considered a favorable condition for an organism in acute meningitis?

Release of endotoxins and other toxic acid substances Signup and view all the answers

In patients younger than 2 months, which organism is the most common cause of acute meningitis?

Escherichia coli Signup and view all the answers

Which symptoms indicate involvement of brain parenchyma in acute meningitis?

Meningoencephalitis Signup and view all the answers

What is the onset of symptoms for bacterial meningitis?

24-48 hours Signup and view all the answers

Which clinical feature is most commonly associated with viral encephalitis?

Refractory status epilepticus Signup and view all the answers

What is the severity of viral meningitis?

Benign Signup and view all the answers

Which of the following causative organisms is most common in viral meningitis?

Enterovirus type 7 Signup and view all the answers

What is a notable feature of the CSF analysis in bacterial meningitis?

Nil RBC count Signup and view all the answers

Which condition involves complete altered behavior or personality changes?

Viral encephalitis Signup and view all the answers

What is the typical outcome if bacterial meningitis is left untreated?

100% mortality rate Signup and view all the answers

Which MRI finding is consistent with viral encephalitis?

Hyperintensity in the medio-temporal region Signup and view all the answers

Which antiepileptic drug is considered the least teratogenic during pregnancy?

Lamotrigine Signup and view all the answers

What is the classification of seizures when they last for 5 minutes or longer without regaining consciousness?

Convulsive status epilepticus Signup and view all the answers

Which side effect is associated with Levetiracetam?

Suicidal ideation Signup and view all the answers

What is a significant risk associated with prolonged seizures beyond 30 minutes?

Increased likelihood of brain damage Signup and view all the answers

Which of the following drugs is NOT known to cause cognitive slowing?

Levetiracetam Signup and view all the answers

Study Notes

Neurology - Active Space - Clinical Presentation

Large purpuric rash, shock, and adrenal hemorrhage are key features.
A carrier state exists in 70-90% of cases.
Lipopolysaccharide is the most common endotoxin.
Penicillin is effective against both pneumococcus and meningococcus.
Acute presentation occurs within 1-2 days.
Severe headache is the most common symptom.
The triad of fever (high grade), headache, and stiff neck are classic signs.

Neurology - Active Space - Other Features

Lymphadenopathy can suggest TB.
Focal neurological signs or seizures might indicate encephalitis.
Rash is a potential sign of meningococcus.
Cerebral infarction could be caused by pneumococcus.
Seizures with ataxia or cerebral nerve palsy are possible with Listeria infection.
Petechiae and palpable purpura are associated with meningococcus.
High-grade fever may be present in malaria and dengue.

Signs of Meningeal Irritation

Brudzinski's sign: Flexion of hips and knees occurs when the neck is flexed.
Kernig's sign: Resistance to leg extension is observed when the hip is flexed.

Lumbar Puncture (LP)

LP is used to diagnose meningitis.
Relative contraindications to LP include immunocompromised individuals and papilloedema without a space-occupying lesion (SOL) or abscess.

Generalized Tonic-Clonic Seizure (GTCS)

The initial compensatory phase involves increased cardiac output, blood pressure, blood sugar, and lactate levels.
The decompensation phase can lead to cardiac arrest, rhabdomyolysis, acute tubular necrosis, electrolyte imbalances (decreased calcium, decreased phosphate, increased potassium), MODS, increased intracranial pressure, and hyperthermia.

Generalized Tonic-Clonic Seizure (GTCS) - Management

Continuous EEG monitoring is crucial.
Comatose patients should undergo a 48-hour neurocritical care services evaluation (NCSE).

Status Epilepticus Management

Rapid intravenous (IV) access is essential, ideally with at least two lines.
First-line: Lorazepam or diazepam are administered intravenously.
Second-line: Valproate, phenytoin, fosphenytoin, or levetiracetam are administered intravenously, if seizures continue.
Third-line: Propofol, phenobarbital, or thiopentone are used if seizures persist.

Seizure Semiology

Myoclonic seizures: sudden brief shock-like contractions involving generalized, face, trunk, and limbs.
Normal IQ is usually associated with these types of seizures.
Anti-epileptic therapy with drugs like levetiracetam, valproate, lamotrigine, and topiramate is the treatment.

Atonic Seizures

A sudden loss of muscle tone is characteristic.
Children are more susceptible.
Atonic seizures are associated with Lennox Gastaut syndrome, which also includes tonic, drop attacks, and absent seizures.

EEG Findings

Myoclonic seizures have a characteristic EEG pattern with polyspike & wave activity.

Pediatric Epileptic Encephalopathies

These are severe, rare, and often intractable forms of childhood epilepsy.
Lennox Gastaut syndrome, West syndrome, Dravet syndrome, and multiple seizure types with childhood refractory epilepsy are examples.

Generalized Tonic-Clonic Seizure (GTCS) Causes and Syncope

Causes of GTCS

Metabolic: Hypoglycemia, electrolyte imbalances (low sodium, high sodium, low calcium, low calcium with high phosphate, low magnesium, high magnesium).
Encephalopathy: Hepatic, uremic.
Encephalitis: Viral (HSV-1, treated with acyclovir), autoimmune (anti-NMDA antibody), paraneoplastic.
Brain injury: Remote or long-standing, post stroke.
Drug withdrawal: Alcohol, barbiturates, benzodiazepines.
Drug-induced: Theophylline, imipenem, cefepime, quinolones, lithium, TCAs.

Syncope

Types: Vasovagal, cardiac, orthostatic hypotension, situational.

Neurology - Acute Meningitis

Treatment should start with antibiotics, even if encephalitis is suspected.

Etiology of Meningitis

Adults: Streptococcus pneumoniae is the most common cause. Neisseria meningitidis and Listeria are also significant, particularly in individuals over 50 years old.
Under 2 months: Enterobacteriaceae (E. coli) is most common. Streptococcus agalactiae and Listeria are other causes.
2 months to 1 year: Streptococcus agalactiae is the most common cause. E. coli and Listeria are also possible.
Immunodeficient patients: Streptococcus pneumoniae, Neisseria meningitidis, Listeria, and Haemophilus influenzae (Hib) are more prevalent.

CNS Infections

Common in patients with post-head injury, post craniotomy, post-CSF rhinorrhea, or a shunt or Omaya reservoir.
Staphylococcus aureus, E. coli, and Pseudomonas are common pathogens.

Streptococcus pneumoniae Features

Gram-positive, catalase-positive, α-hemolytic on blood agar.
Bile-soluble, optochin-sensitive, and inulin-fermenter.
Capsule helps evade phagocytosis.

Streptococcus pneumoniae Pathogenesis

Colonizes the nasopharyngeal wall.
Serotype-3 invades.
Most commonly enters the CSF through the choroid plexus.
Spread occurs through CSF circulation.

Pneumococcal Meningitis and Age

Under 20 and over 50: infection can occur in both immunocompetent and immunocompromised individuals.
20-50: infection typically occurs only in immunocompromised individuals.

Common Features of CNS Infections

Altered blood-brain barrier (BBB) permeability.
Activation of WBCs.
Vasogenic edema.
Increased exudate in CSF.
Blockage of CSF flow.
Interstitial edema.

Specific Features of Streptococcus pneumoniae

Quellung reaction: Rapid identification technique based on the capsule swelling after adding antiserum.

Predisposing Factors for Meningitis

Age over 65 years.
Sickle cell disease.
Celiac disease.
CSF leak.

Meningococcal Meningitis

Predisposing factors: C- deficiency (late complement), hypogammaglobulinemia, hyposplenism, HIV, diabetes mellitus (DM), cochlear implant patients.

Bacterial Meningitis vs Viral Meningitis vs Viral Encephalitis

Bacterial Meningitis: Acute, catastrophic onset; high fever, stiff neck, vomiting, severe headache, photophobia, altered mental status; typically seen within 24-48 hours.
Viral Meningitis: Benign, gradual onset; peaks initially with fever and headache that last 1-2 days; nausea, vomiting, photophobia, stiff neck, discomfort, distracted, confused, lethargic; typically develops within 3-5 days.
Viral Encephalitis: Severe, involves brain parenchyma; refractory status epilepticus, complete behavior/personality changes, confusion, speech defects, focal neurological deficits; onset typically within 1-2 days.

Etiology of Meningitis and Encephalitis

Bacterial Meningitis: Not specified in the provided table.
Viral Meningitis: Enterovirus type 7, HSV-2.
Viral Encephalitis: HSV-1, Japanese encephalitis virus (JE) in India, Nipah virus (rare).

Investigations

CSF Analysis: Sugar, protein, cell count (WBC, RBC), antibodies (HSV, JE).
MRI: May reveal possible hyperintensity in the medio-temporal, orbito-frontal, and insula regions consistent with HSV or JE encephalitis.

Neurology - Epilepsy and Anti- Epileptic Drugs (AEDs)

The document contains critical information about AEDs, their side effects, and their use during pregnancy.
Lamotrigine is considered the best option in pregnancy due to its lower teratogenicity compared to other AEDs.
Folic acid supplementation is vital for patients already on AEDs during pregnancy.

Side Effects of AEDs

Carbamazepine: Steven Johnson Syndrome (SJS), high risk of SIADH (low sodium levels), Hemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS).
Oxcarbazepine: Similar side effects to carbamazepine, also high risk of SIADH and HLH/MAS.
Lamotrigine: SJS, HLH/MAS.
Levetiracetam: Suicidal ideation, alopecia.
Valproate: Pancreatitis, thrombocytopenia, liver abnormalities, increased ammonia (NH3), renal stones, weight gain.
Topiramate: Cognitive slowing, weight loss.
Zonisamide: Cognitive slowing.
Felbamate: Aplastic anemia, increased PR interval.
Lacosamide: Cognitive slowing.

Status Epilepticus

Definition: Continuous seizure lasting 5 minutes or more, or two or more discrete seizures without regaining consciousness between them.
Time: 0-5 minutes (TI) is considered the initial phase; 30 minutes (T2) is the point where brain damage becomes more likely if seizures are not controlled.
Classification: Convulsive status epilepticus (CSE), non-convulsive SE (NCSE), refractory SE (unresponsive to AEDs and benzodiazepines).
NORSE (New Onset Refractory Status Epilepticus) is often viral in origin, unless proven otherwise.

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Description

Test your knowledge on the clinical presentations in neurology, including key features such as purpuric rash, shock, and the symptoms of meningitis. This quiz emphasizes important signs and associated conditions, making it essential for understanding neurological emergencies.