Neurology Quiz: Seizure Disorders

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Questions and Answers

A 25-year-old woman with no significant medical history presents with recurrent episodes of staring spells. Each spell lasts for 15–20 seconds, during which she is unresponsive to verbal stimuli. Witnesses describe her blinking repetitively during the events, followed by immediate recovery with no confusion. The spells occur multiple times a day, predominantly during periods of inactivity. Neurological examination is normal. MRI brain is normal. Routine EEG shows frequent generalized 3 Hz spike-and-wave discharges, particularly during hyperventilation. What is the most likely diagnosis and the best initial treatment?

  • Juvenile myoclonic epilepsy, trial of valproate
  • Absence seizures, trial of ethosuximide (correct)
  • Temporal lobe epilepsy, consider surgical evaluation
  • Complex partial seizures, trial of levetiracetam
  • Psychogenic non-epileptic events, referral for psychotherapy

A 60-year-old man presents with sudden-onset jerking of his right arm that lasts for 2–3 minutes, followed by weakness of the same arm for 30 minutes. He remains fully conscious during the events. He reports three such episodes in the past two weeks, all occurring while awake. Neurological examination shows mild right arm weakness. MRI brain reveals an area of gliosis in the left motor cortex. EEG shows focal sharp waves in the left central region. What is the most likely diagnosis and the next step in management?

  • Ischemic stroke with seizure-like activity, consider thrombolysis
  • Psychogenic non-epileptic events, psychiatric evaluation
  • Focal seizures with postictal paresis, trial of levetiracetam (correct)
  • Epilepsia partialis continua, urgent ICU admission
  • Motor tics, trial of dopamine receptor blockers

A 45-year-old woman presents with a 3-week history of episodic confusion and unresponsiveness lasting several minutes. She has no recollection of the events but reports headache and mild fatigue afterward. Family members report lip-smacking and chewing movements during the episodes. Neurological examination is normal. MRI brain shows mild hippocampal atrophy on the left. EEG reveals interictal sharp waves in the left temporal region. What is the most likely diagnosis and the best next step?

  • Sleep-related parasomnia, consider polysomnography
  • Psychogenic non-epileptic events, refer to psychiatry
  • Frontal lobe epilepsy, proceed with surgical consultation
  • Temporal lobe epilepsy, start anti-seizure medication (correct)
  • Transient ischemic attacks, initiate aspirin therapy

A 34-year-old man presents with brief episodes of sudden head nodding and bilateral arm jerking. The events occur primarily in the morning within 1–2 hours of waking and are triggered by sleep deprivation. There is no loss of consciousness. Neurological examination is normal. MRI brain is normal. EEG shows generalized polyspike-and-wave discharges, most prominent during photic stimulation. What is the most likely diagnosis and initial management?

<p>Juvenile myoclonic epilepsy, start valproate (E)</p> Signup and view all the answers

A 50-year-old man presents with episodes of sudden, transient inability to move or speak, lasting 10-15 seconds. He remains aware during the events and describes a feeling of being "frozen in place." The episodes occur predominantly when he is lying in bed and are often preceded by auditory hallucinations. Neurological examination and MRI brain are normal. EEG shows rhythmic sharp waves over the right frontal region during sleep. What is the most likely diagnosis and next step in management?

<p>Frontal lobe epilepsy, initiate anti-seizure therapy (E)</p> Signup and view all the answers

A 29-year-old woman presents with episodes of prolonged staring, during which she exhibits automatisms like fumbling with her hands and lip-smacking. The events last 2–3 minutes and are followed by confusion for 15–20 minutes. She also describes a rising epigastric sensation before the episodes. These have been occurring for years but are increasing in frequency. Neurological examination is normal. MRI shows hippocampal sclerosis on the right. EEG reveals interictal right temporal sharp waves and rhythmic 5 Hz activity over the right temporal region during events. What is the most likely diagnosis and next step in management?

<p>Temporal lobe epilepsy, consider anti-seizure medication and epilepsy surgery evaluation (C)</p> Signup and view all the answers

A 38-year-old man presents with nocturnal events where he suddenly sits up in bed, screams, and thrashes his arms. These episodes last 30–60 seconds and occur 2–3 times per week. He denies daytime symptoms or memory of the episodes. Neurological examination is normal. MRI brain is normal. EEG during wakefulness is unremarkable, but sleep EEG shows bursts of rhythmic fast activity over the frontal regions during events. What is the most likely diagnosis and management approach?

<p>Nocturnal frontal lobe epilepsy, trial of anti-seizure medication (B)</p> Signup and view all the answers

A 42-year-old woman presents with recurrent episodes of a "sudden surge of energy," during which she vocalizes unintelligible sounds and exhibits rapid, forceful movements of her arms. The episodes last 10–20 seconds and occur unpredictably, often during the day. Neurological examination is normal. MRI brain is normal. Video EEG monitoring captures an event with hyperkinetic movements and preserved awareness, accompanied by rhythmic fast activity in the left frontocentral region. What is the most likely diagnosis?

<p>Frontal lobe epilepsy, start anti-seizure medication (C)</p> Signup and view all the answers

A 55-year-old man with a history of hypertension presents with sudden right-sided weakness lasting 3–4 minutes, followed by complete resolution. He denies loss of consciousness, speech difficulty, or other symptoms. Neurological examination and MRI brain are normal. EEG shows periodic lateralized epileptiform discharges (PLEDs) over the left hemisphere. What is the most likely diagnosis and best next step?

<p>Focal seizures with motor symptoms, start anti-seizure medication (D)</p> Signup and view all the answers

A 19-year-old college student reports episodes of sudden head drops and brief loss of postural tone lasting 1-2 seconds, occurring multiple times daily. These began at age 12 but were dismissed as clumsiness. He also has generalized tonic-clonic seizures occurring every few months. MRI brain is normal. EEG shows generalized polyspike-and-wave discharges, especially during sleep deprivation. What is the most likely diagnosis and appropriate treatment?

<p>Atonic seizures in generalized epilepsy, start valproate (C)</p> Signup and view all the answers

A 65-year-old woman with diabetes presents with episodic confusion lasting several hours, during which she exhibits lip-smacking and repetitive swallowing movements. These episodes occur 1-2 times per month. Neurological examination is normal. MRI brain shows age-appropriate atrophy. EEG reveals periodic lateralized epileptiform discharges (PLEDs) over the left temporal region. What is the most likely diagnosis and next step?

<p>Focal seizures, start anti-seizure medication (C)</p> Signup and view all the answers

A 47-year-old man presents with episodic jerking of his left hand that occasionally spreads to involve the arm and face. The episodes last 1–2 minutes, followed by a transient speech difficulty. Neurological examination is normal between events. MRI brain reveals a small lesion in the right precentral gyrus. EEG shows frequent sharp waves over the right central region. What is the most likely diagnosis and best next step?

<p>Focal epilepsy, initiate anti-seizure medication (B)</p> Signup and view all the answers

A 26-year-old woman presents with recurrent episodes of involuntary pelvic thrusting, vocalizations, and complex limb movements lasting 5–10 minutes. These occur only in the presence of others and are preceded by a “warning” of vague discomfort. Neurological examination and MRI brain are normal. EEG during events shows no epileptiform activity or ictal changes. What is the most likely diagnosis and management?

<p>Psychogenic non-epileptic events, referral to psychotherapy (A)</p> Signup and view all the answers

A 62-year-old woman with a history of hypertension presents with frequent episodes of brief right-sided face and arm twitching. She remains fully conscious during the events, which last 30–60 seconds. MRI brain shows an old left middle cerebral artery infarct. EEG reveals sharp waves over the left central region. What is the most likely diagnosis and treatment?

<p>Focal seizures, start anti-seizure medication (D)</p> Signup and view all the answers

A 30-year-old man presents with recurrent episodes of sudden head turning to the left, accompanied by grunting sounds. Each episode lasts 15–30 seconds and occurs multiple times per week. He remains aware during the events. Neurological examination is normal. MRI brain is normal. EEG shows ictal rhythmic theta activity over the right frontal region during events. What is the most likely diagnosis and treatment?

<p>Frontal lobe epilepsy, start anti-seizure medication (A)</p> Signup and view all the answers

Flashcards

Absence Seizures

Characterized by brief periods of staring and unresponsiveness, often with repetitive blinking, that occur multiple times a day, particularly during periods of inactivity. Typically involves 3 Hz spike-and-wave discharges on EEG during hyperventilation.

Ethosuximide

Anti-seizure medication commonly used for absence seizures, known for its effectiveness in controlling generalized spike-and-wave discharges.

Focal Seizures

Seizures originating in a specific area of the brain, often resulting in localized symptoms, such as weakness or paralysis, in the corresponding body part.

Postictal Paresis

A brief period of weakness or paralysis following a seizure, often affecting the same body part involved in the seizure.

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Levetiracetam

Anti-seizure medication commonly used for focal seizures, including those with postictal paresis.

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Focal Seizures with Secondary Generalization

Seizures with a focal onset that spread to involve both hemispheres of the brain, often resulting in a generalized tonic-clonic seizure.

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Juvenile Myoclonic Epilepsy

Seizures characterized by sudden jerky movements, especially in the morning upon waking or after sleep deprivation, often triggered by flashing lights. Usually associated with generalized polyspike-and-wave discharges on EEG.

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Valproate

Anti-seizure medication commonly used for juvenile myoclonic epilepsy, known for its effectiveness in controlling both myoclonic seizures and generalized tonic-clonic seizures.

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Temporal Lobe Epilepsy

Seizures originating in the temporal lobe, often characterized by complex symptoms such as confusion, automatisms (lip-smacking, fumbling), and altered awareness.

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Frontal Lobe Epilepsy

Seizures originating in the frontal lobe, often characterized by sudden, involuntary movements, changes in behavior, or altered awareness. May involve rhythmic fast activity on EEG.

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Nocturnal Frontal Lobe Epilepsy

Seizures that occur exclusively during sleep, often characterized by behavioral changes, such as sitting up in bed, screaming, or thrashing.

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Frontal Lobe Seizures

Episodes of sudden, transient inability to move or speak, lasting seconds, with preserved awareness. Often associated with feelings of being 'frozen in place', sometimes with preceding auditory hallucinations.

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Complex Partial Seizures

A type of focal seizure characterized by prolonged staring, automatisms (lip-smacking, fumbling), and altered awareness. Often associated with hippocampal sclerosis on MRI and interictal temporal sharp waves on EEG.

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Frontal Lobe Seizures

Episodes of sudden, excessive energy, with vocalizations, rapid movements, and preserved awareness. Often associated with rhythmic fast activity in the frontal region on EEG.

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Periodic Lateralized Epileptiform Discharges (PLEDs)

Periodic Lateralized Epileptiform Discharges (PLEDs) are abnormal electrical activity in the brain that can be seen on an EEG. They are often seen in people with epilepsy, especially those with focal seizures.

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Atonic Seizures

Characterized by brief episodes of sudden loss of muscle tone (going limp), often occurring multiple times daily. Often associated with generalized spike-and-wave discharges on EEG, especially during sleep deprivation.

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Focal Seizures

Episodes of episodic confusion lasting several hours, often with automatisms (lip-smacking, repetitive swallowing), typically associated with PLEDs over the temporal lobe on EEG.

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Focal Seizures

Seizures characterized by involuntary jerking movements, typically involving a localized area of the body, such as the hand or arm, often with transient speech difficulty. Often associated with sharp waves over the corresponding brain region on EEG.

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Psychogenic Non-epileptic Events

Episodes of involuntary pelvic thrusting, vocalizations, and complex limb movements occurring only in the presence of others, suggesting a non-epileptic origin. Often associated with no epileptiform changes on EEG.

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Focal Seizures

Episodes of brief right-sided face and arm twitching, often associated with an old infarct in the opposite hemisphere on MRI and sharp waves on EEG, suggesting a focal seizure.

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Frontal Lobe Epilepsy

Seizures characterized by sudden head turning and vocalizations, often associated with rhythmic theta activity in the frontal region on EEG.

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Focal Seizures

Episodes of sudden, transient weakness lasting 3-4 minutes, with complete resolution. Often associated with periodic lateralized epileptiform discharges (PLEDs) on EEG, suggesting a focal seizure.

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Atonic Seizures

Seizures characterized by sudden head drops and brief loss of postural tone (atonia), often associated with generalized polyspike-and-wave discharges on EEG, especially during sleep deprivation.

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Generalized Tonic-Clonic Seizures

Seizures characterized by generalized tonic-clonic convulsions, often preceded by myoclonic jerks, suggesting a generalized epilepsy syndrome.

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Carbamazepine

Anti-seizure medication commonly used for generalized seizures, including tonic-clonic seizures and myoclonic seizures.

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Lamotrigine

Anti-seizure medication commonly used for both focal and generalized epilepsy, particularly for myoclonic seizures.

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Lennox-Gastaut Syndrome

A rare epilepsy syndrome characterized by both tonic-clonic seizures and a specific type of seizure called 'atonic' seizures, often associated with developmental delay and cognitive impairment.

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Valproate

Anti-seizure medication commonly used for various epilepsy syndromes, including Lennox-Gastaut syndrome and juvenile myoclonic epilepsy.

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Benign Familial Neonatal Seizures

A type of neonatal seizure that is often benign and self-limiting, often involving repetitive facial twitching and jerking movements, with a normal MRI and multifocal sharp waves on EEG.

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Infantile Spasms

A type of seizure that occurs in clusters, often after waking, characterized by brief flexing movements of the neck, arms and legs, with a diffuse cortical atrophy on MRI and a characteristic EEG pattern called hypsarrhythmia.

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Childhood Absence Seizures

A type of seizure characterized by staring episodes, with repetitive blinking and a loss of responsiveness, typically triggered by hyperventilation, with a characteristic EEG finding of generalized 3 Hz spike-and-wave discharges.

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Nocturnal Frontal Lobe Seizures

A type of seizure that often occurs during sleep, with involuntary movements, such as sitting up, screaming, or thrashing, often associated with rhythmic fast activity in the frontal region of the brain on EEG.

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Burst Suppression Pattern

EEG pattern commonly seen during therapeutic hypothermia, which involves periods of suppression of brain activity followed by bursts of electrical activity.

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Generalized Periodic Discharges (GPDs)

EEG pattern observed after therapeutic hypothermia, consisting of repetitive, slow-wave discharges occurring at a frequency of 1 Hz, often indicating a poor prognosis.

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Return of Spontaneous Circulation (ROSC)

A medical term for the re-establishment of spontaneous circulation after successfully resuscitating a person from cardiac arrest.

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Therapeutic Hypothermia

A treatment involving cooling the body temperature to 32-34 degrees Celsius for 24-48 hours after cardiac arrest, with the goal of improving neurological outcomes.

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Nocturnal Frontal Lobe Seizures

Seizures that occur primarily during sleep, with various involuntary movements, such as sitting up, screaming, or thrashing. Often associated with rhythmic fast activity in the frontal region of the brain on EEG.

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Return of Spontaneous Circulation (ROSC)

A medical term for the re-establishment of spontaneous circulation after successfully resuscitating a person from cardiac arrest. A key marker of successful CPR.

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Therapeutic Hypothermia

A treatment involving cooling the body temperature down to a specific range for a specific duration after cardiac arrest, in the hopes of protecting the brain from damage. The goal is to improve neurological outcomes.

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Focal Seizures with Motor Symptoms

A type of seizure characterized by sudden involuntary movements, typically involving a localized area of the body like the hand or arm, often accompanied by transient speech difficulty. Associated with sharp waves over the corresponding brain region on EEG.

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Frontal Lobe Seizures with Hyperactivity

A type of seizure characterized by sudden, excessive energy, with vocalizations, rapid movements, and preserved awareness. Often associated with rhythmic fast activity in the frontal region of the brain on EEG.

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Frontal Lobe Seizures with Akinesia

A type of seizure characterized by episodes of sudden, transient inability to move or speak, lasting seconds, with preserved awareness. Often associated with feelings of being "frozen in place", sometimes with preceding auditory hallucinations.

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Frontal Lobe Seizures with Head Turning

A type of seizure characterized by sudden head turning and vocalizations, often associated with rhythmic theta activity in the frontal region of the brain on EEG.

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Focal Seizures with Facial and Arm Twitching

A type of seizure characterized by brief right-sided face and arm twitching, often associated with an old infarct in the opposite hemisphere on MRI and sharp waves on EEG, suggesting a focal seizure.

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Focal Seizures with Transient Weakness

A type of seizure characterized by episodes of sudden, transient weakness lasting 3-4 minutes, with complete resolution. Often associated with periodic lateralized epileptiform discharges (PLEDs) on EEG, suggesting a focal seizure.

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Study Notes

Question 1

  • Patient: 25-year-old woman with recurrent staring spells.
  • Spell Duration: 15-20 seconds.
  • Symptoms: Unresponsive to verbal stimuli, repetitive blinking, immediate recovery.
  • Frequency: Multiple times a day, predominantly during inactivity
  • Normal neurological exam: Neurological examination came back normal.
  • Normal MRI: MRI of the brain was normal.
  • EEG: Frequent generalized 3 Hz spike-and-wave discharges, particularly during hyperventilation.
  • Most likely diagnosis: Absence seizures
  • Initial treatment: Trial of ethosuximide.

Question 2

  • Patient: 60-year-old man with jerking episodes.
  • Symptom Duration: 2-3 minutes, followed by arm weakness for 30 minutes.
  • Episode Frequency: Three episodes in the past two weeks
  • Patient Consciousness: Fully conscious during the episodes, awake.
  • Neurological Exam: Mild right arm weakness.
  • MRI Brain: Area of gliosis in the left motor cortex.
  • EEG: Focal sharp waves in the left central region.
  • Most likely diagnosis: Focal seizures with postictal paresis.
  • Next Step: Trial of levetiracetam.

Question 3

  • Patient: 45-year-old woman with episodic confusion.
  • Symptoms: Episodic confusion, headache, fatigue, lip-smacking, chewing.
  • Neurological Exam: Normal.
  • MRI Brain: Mild hippocampal atrophy on the left.
  • EEG: Interictal sharp waves in the left temporal region.
  • Most likely diagnosis: Temporal lobe epilepsy.
  • Next Step: Start anti-seizure medication.

Question 4

  • Patient: 34-year-old man with brief episodes of head nodding and arm jerking.
  • Episode Trigger: Sleep deprivation
  • Symptoms: Head nodding, bilateral arm jerking.
  • Consciousness Loss: No loss of consciousness.
  • Neurological Exam: Normal.
  • MRI Brain: Normal.
  • EEG: Generalized polyspike-and-wave discharges, most prominent during photic stimulation.
  • Most likely diagnosis: Juvenile myoclonic epilepsy.
  • Initial management: Start valproate.

Question 5

  • Patient: 50-year-old man with episodes of sudden inability to move or speak.
  • Duration: 10-15 seconds
  • Awareness during episodes: Aware during events.
  • Feeling: Frozen in place.
  • Episodes occur: Predominantly when lying in bed, preceded by auditory hallucinations.
  • Neurological Exam: Normal.
  • MRI Brain: Normal.
  • EEG: Rhythmic sharp waves over the right frontal region during sleep.
  • Most likely diagnosis: Frontal lobe epilepsy.
  • Next step: Initiate anti-seizure therapy.

Question 6

  • Patient: 29-year-old woman with prolonged staring episodes.
  • Symptoms: Prolonged staring, automatisms (fumbling with hands, lip-smacking), confusion following the episodes(15-20 minutes), rising epigastric sensation beforehand.
  • Duration: 2-3 minutes.
  • Frequency: Increasing frequency.
  • Neurological Exam: Normal.
  • MRI: Hippocampal sclerosis on the right.
  • EEG: Ictal right temporal sharp waves and rhythmic 5 Hz activity over the right temporal region during events.
  • Most likely diagnosis: Temporal lobe epilepsy.
  • Next step: Consider anti-seizure medication and/or epilepsy surgery evaluation.

Question 7

  • Patient: 38-year-old man with nocturnal events of sitting up, screaming, and thrashing his arms.
  • Episode Duration: 30-60 seconds.
  • Frequency: 2-3 times per week.
  • Awareness during episodes: Does not remember the events.
  • Neurological Exam: Normal
  • MRI Brain: Normal
  • EEG: Bursts of rhythmic fast activity over the frontal regions during events.
  • Most likely diagnosis: Nocturnal frontal lobe epilepsy.
  • Management Approach: Trial of anti-seizure medication.

Question 8

  • Patient: 42-year-old woman describing "sudden surge of energy."
  • Symptoms: Rapid, forceful movements of her arms, vocalizing unintelligible sounds.
  • Duration: 10-20 seconds.
  • Neurological Exam: Normal
  • MRI Brain: Normal
  • Video EEG: Hyperkinetic movements, preserved awareness, rhythmic fast activity in the left frontocentral region.
  • Most likely diagnosis: Frontal lobe epilepsy

Question 9

  • Patient: 55-year-old man with right-sided weakness.
  • Symptom Duration: 3-4 minutes.
  • Neurological Exam: Normal
  • MRI Brain: Normal
  • EEG: Periodic lateralized epileptiform discharges (PLEDS) over the left hemisphere.
  • Most likely diagnosis: Focal seizures with motor symptoms.
  • Next Step: Start anti-seizure medication.

Question 10

  • Patient: 19-year-old college student with head drops lasting 1-2 seconds.
  • Symptoms: Head drops, brief loss of postural tone.
  • Frequency: Multiple times daily.
  • History: Generalized tonic-clonic seizures every few months (at age 12 or more; previously wrongly diagnosed as clumsiness).
  • MRI Brain: Normal
  • EEG: Generalized polyspike-and-wave discharges, especially during sleep deprivation.
  • Most Likely Diagnosis: Juvenile myoclonic epilepsy.
  • Treatment: Initiate valproate.

Question 11

  • Patient: 65-year-old woman with episodic confusion, lip-smacking, and repetitive swallowing.

  • Episodes frequency: 1-2 times per month.

  • Neurological Exam: Normal

  • MRI brain: Age-appropriate atrophy

  • EEG: Periodic lateralized epileptiform discharges (PLEDs) over the left temporal region

  • Most probable diagnosis: Focal seizures

  • Next treatment: Start anti-seizure medication

Question 12

  • Patient: 47-year-old man with episodic jerking of left hand, face, and speech difficulty.

  • Episode duration: 1-2 minutes.

  • MRI brain: Small lesion in the right precentral gyrus

  • EEG: Frequent sharp waves on the right central region.

  • Most probable diagnosis: Focal epilepsy

  • Next treatment: Initiate anti seizure medication

Question 13

  • Patient: 26-year-old woman with involuntary pelvic thrusting , vocalizations, complex limb movements,
  • Duration: 5-10 minutes.
  • Neurological Exam: Normal
  • MRI brain: Normal.
  • EEG: No epileptiform activity during events.
  • Most probable diagnosis: Psychogenic non-epileptic events.
  • Management: Referral to psychotherapy.

Question 14

  • Patient: 62-year-old woman with right-sided face and arm twitching.
  • Episode duration: 30-60 seconds
  • MRI brain: Old left middle cerebral artery infarct
  • EEG: Sharp waves over the left central region.
  • Most probable diagnosis: Focal seizures
  • Treatment: Start anti-seizure medication

Question 15

  • Patient: 30-year-old man with sudden head turning to the left, grunting sounds
  • Episode duration: 15-30 seconds
  • Neurological Exam: Normal
  • MRI Brain: Normal
  • EEG: Ictal rhythmic theta activity on right frontal region during events
  • Most likely diagnosis: Frontal lobe epilepsy
  • Treatment: Start anti-seizure medication

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