Medicine Marrow Pg No 597-606 (Neurology)
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Questions and Answers

Which of the following is NOT a feature of trigeminal autonomic cephalgias?

  • Short-lasting headache
  • Severe, unilateral headache
  • Throbbing pain (correct)
  • Ipsilateral ANS symptoms

    • Cluster headaches typically occur more frequently in females than males.

    False

    What is the duration range of a typical cluster headache attack?

    15 minutes to 3 hours

    Cluster headaches are often associated with _________ ANS symptoms.

    <p>ipsilateral</p> Signup and view all the answers

    Match the types of trigeminal autonomic cephalgias with their characteristics:

    <p>Cluster headaches = Severe unilateral headaches with nocturnal attacks Paroxysmal hemicrania = Headaches occurring several times a day SUNCT = Short-lasting unilateral headache with conjunctival congestion Hemicrania continua = Continuous headache with variable intensity</p> Signup and view all the answers

    What is the fastest type of hypersynchronous neuronal motor activity?

    <p>Myoclonic</p> Signup and view all the answers

    Pseudo seizures primarily occur in adults.

    <p>False</p> Signup and view all the answers

    What does 'LOC' stand for in seizure classification?

    <p>Loss of Consciousness</p> Signup and view all the answers

    An atonic seizure is characterized by _____ motor activity.

    <p>slowest</p> Signup and view all the answers

    Match the types of seizures with their characteristics:

    <p>Focal = Loss of consciousness - Aware Generalized = Includes loss of consciousness and other symptoms Unknown = Seizures of uncertain origin Clonic = Rhythmic muscle jerking</p> Signup and view all the answers

    What is the most common treatment option for managing increased intracranial pressure?

    <p>Acetazolamide</p> Signup and view all the answers

    Pulsatile tinnitus is the most common type of tinnitus.

    <p>False</p> Signup and view all the answers

    What type of headache is characterized as orthostatic and worsens in the morning?

    <p>Orthostatic headache</p> Signup and view all the answers

    The best option for repeated lumbar puncture can extract up to ____ ml of cerebrospinal fluid.

    <p>20-30</p> Signup and view all the answers

    Match the symptoms with their appropriate descriptions:

    <p>Transient visual obscuration = Seconds to minutes duration Tinnitus = Unilateral &gt; bilateral Headache = Worse in the morning Lumber puncture = Up to 20-30 ml extraction</p> Signup and view all the answers

    What type of seizure involves impaired awareness or dyscognition?

    <p>Complex Partial Seizure</p> Signup and view all the answers

    Simple Partial seizures exhibit loss of consciousness.

    <p>False</p> Signup and view all the answers

    What types of seizures may be classified as generalized onset?

    <p>Tonic clonic, Myoclonic, Atonic, Clonic</p> Signup and view all the answers

    A diagnosis of epilepsy requires at least ______ unprovoked seizures separated by a minimum of 24 hours.

    <p>two</p> Signup and view all the answers

    Match the following types of seizures with their characteristics:

    <p>Tonic Clonic = Motor: Tonic, Clonic Myoclonic = Motor: Myoclonic Atonic = Motor: Atonic Typical Absent = Non-Motor: Typical absent</p> Signup and view all the answers

    What is the main treatment option for trigeminal neuralgia?

    <p>Carbamazepine</p> Signup and view all the answers

    Trigeminal neuralgia can present with unilateral pain due to compression on the inferior cerebellar artery.

    <p>False</p> Signup and view all the answers

    What is tic douloureux in the context of trigeminal neuralgia?

    <p>Wincing due to pain</p> Signup and view all the answers

    In benign intracranial hypertension, the __________ is often performed to assess brain abnormalities.

    <p>MRI brain</p> Signup and view all the answers

    Match the following conditions with their features:

    <p>Trigeminal neuralgia = Paroxysms of intense unilateral pain Glossopharyngeal neuralgia = Pain at the tonsil bed and throat Benign intracranial hypertension = Increased intracranial pressure without a mass Carbamazepine = First-line treatment for trigeminal neuralgia</p> Signup and view all the answers

    What does a normal MRI indicate in the evaluation of papilledema?

    <p>Possible benign intracranial hypertension or Idiopathic intracranial hypertension</p> Signup and view all the answers

    Bradycardia is a condition often associated with papilledema.

    <p>True</p> Signup and view all the answers

    What is the opening pressure in a lumbar puncture that indicates papilledema?

    <p>greater than 25 cm of H₂O</p> Signup and view all the answers

    ________ can occur as a secondary cause of papilledema due to drug use.

    <p>Tetracycline</p> Signup and view all the answers

    Match the secondary causes of papilledema with their categories:

    <p>Danazol = Drugs Steroid withdrawal = Endocrine Tamoxifen = Drugs Growth hormone = Endocrine</p> Signup and view all the answers

    What is the primary characteristic of focal seizures without dyscognition?

    <p>Motor onset</p> Signup and view all the answers

    Focal seizures with dyscognition often involve loss of consciousness.

    <p>True</p> Signup and view all the answers

    Name one structural lesion that can cause focal seizures.

    <p>Brain tumors</p> Signup and view all the answers

    The most common localization for focal seizures with dyscognition is the _____ lobe.

    <p>medial temporal</p> Signup and view all the answers

    Match the following seizure types with their characteristics:

    <p>Focal Seizures Without Dyscognition = Consciousness remains intact Focal Seizures With Dyscognition = LOC +, post ictal disorientation Todd's Palsy = Transient palsy lasting up to 24 hours Jacksonian March = Migration of motor activity from distal to proximal</p> Signup and view all the answers

    What is the typical age range for childhood absence seizures?

    <p>4-10 years</p> Signup and view all the answers

    Post-ictal confusion is often present in typical childhood absence seizures.

    <p>False</p> Signup and view all the answers

    What is associated with genetically determined epilepsy in childhood?

    <p>Typical childhood absence seizures</p> Signup and view all the answers

    The EEG findings for generalized seizures in the temporal lobe show __________ spikes.

    <p>temporal lobe</p> Signup and view all the answers

    Match the following seizure types with their characteristics:

    <p>Typical childhood absence seizure = Good prognosis with remission by age 12 Atypical juvenile absence seizure = More complex features than typical</p> Signup and view all the answers

    What is the primary treatment for typical juvenile absent seizures?

    <p>Valproate</p> Signup and view all the answers

    Atypical juvenile absent seizures are characterized by a normal EEG pattern.

    <p>False</p> Signup and view all the answers

    What is the age range associated with juvenile myoclonic epilepsy?

    <p>6-25 years</p> Signup and view all the answers

    The aggravating factor for absent-mindedness and loss of focus in seizures is __________.

    <p>hyperventilation</p> Signup and view all the answers

    Match the seizure types with their characteristics:

    <p>Typical Absence Seizure = 3Hz spike &amp; wave pattern Atypical Absence Seizure = Longer duration of unconsciousness Juvenile Myoclonic Epilepsy = Sleep deprivation triggers Generalized Tonic-Clonic Seizures = GTCS in 90% of cases</p> Signup and view all the answers

    What is the primary treatment for paroxysmal hemicrania?

    <p>Indomethacin</p> Signup and view all the answers

    SUNT is characterized by unilateral, orbital or temporal pain with a high frequency of attacks.

    <p>True</p> Signup and view all the answers

    What is the recommended dose of oxygen for acute treatment?

    <p>12-15 L/min for 10-20 mins</p> Signup and view all the answers

    The best long-term prevention treatment for cluster headaches is __________.

    <p>Verapamil</p> Signup and view all the answers

    Match the types of headache disorders with their characteristics:

    <p>Paroxysmal Hemicrania = Severe stabbing pain, 1-20 attacks/day SUNT = Stabbing/throbbing, 3-200 attacks/day Hemicrania Continua = Continuous unilateral headache with episodic features SUNCT = Unilateral orbital pain, frequent attacks</p> Signup and view all the answers

    Study Notes

    Trigeminal Autonomic Cephalgias

    • Includes: Cluster headaches, Paroxysmal hemicrania, SUNCT, Hemicrania continua
    • Features:
      • Short-lasting, severe, unilateral, neuralgic headaches
      • Ipsilateral autonomic nervous system (ANS) symptoms including: conjunctival congestion/lacrimation, nasal congestion/rhinorrhea, eyelid edema, and forehead and facial sweating

    Cluster Headache

    • More common in young males
    • Features:
      • Unilateral periorbital non-throbbing pain
      • Stabbing, boring, non-throbbing pain
      • Excruciating pain
      • Ipsilateral ANS symptoms
      • Nocturnal headaches
      • Frequency: 1-8 attacks/day
      • Symptom duration: 8-10 weeks followed by symptom-free period
      • Attack duration: 15 minutes - 3 hours (average 30 minutes)
      • Photophobia may be seen
      • 20% cases are chronic
      • Triggers: Alcohol
      • Other symptoms: Forehead and facial flushing, sensation of fullness in ear, miosis and/or ptosis
    • Treatment:
      • Weight loss
      • Acetazolamide (DOC)
      • Topiramate
      • Repeated lumbar puncture (up to 20-30 ml): Best option
      • Surgery: Optic nerve sheath fenestrations, shunting

    Paroxysmal Hemicrania

    • Females = males
    • Headache type: Throbbing, boring, stabbing
    • Severity: Excruciating
    • Frequency: 1-20 attacks/day
    • Attack duration: 2-30 minutes (average 5 minutes)
    • ANS symptoms present
    • Treatment: Indomethacin (reduces frequency of attacks)

    SUNCT

    • Males = females
    • Unilateral orbital or temporal pain
    • Headache type: Stabbing/throbbing
    • Frequency: 3-200 attacks/day
    • Management:
      • Treatment: IV lignocaine
      • Prevention: Lamotrigine or topiramate

    Hemicrania Continua

    • More common in elderly females
    • Continuous unilateral background headache with episodic TAC
    • Migrainous features and ANS symptoms present
    • Responsive to indomethacin

    Management of Acute Increased Intracranial Pressure

    • Elevate the head
    • Administer mannitol
    • Sedation
    • Hyperventilation
    • Pressor therapy to maintain Cerebral Perfusion Pressure (CPP) > 60 mmHg

    Trigeminal Neuralgia

    • Females > males, age 50-60 years
    • Paroxysms of intense unilateral pain due to compression on superior cerebellar artery
    • Bilateral pain due to demyelination (multiple sclerosis)
    • Brief, electric, shock-like superficial pain
    • Wincing due to pain (tic douloureux)
    • Maxillary (V2) and mandibular (V3) division of trigeminal nerve
    • No objective sensory loss
    • Cutaneous trigger present, followed by a refractory period
    • Investigation: Specialized MRI
    • Treatment:
      • Carbamazepine (most effective) >> lamotrigine
      • HLA B-1502 testing before administration of carbamazepine
      • Subcutaneous botulinum toxin
      • Microvascular decompression in medical refractory cases

    Glossopharyngeal Neuralgia

    • Also known as Eagle syndrome
    • Due to elongation of styloid process
    • Sudden, severe, short-lasting, recurrent bouts of pain
    • Pain location: Tonsil bed, throat & angle of jaw
    • Aggravation factors: Coughing, yawning, swallowing
    • Associated with cardiac conduction abnormalities

    Benign Intracranial Hypertension (Idiopathic Intracranial Hypertension)

    • Often seen with hypertension, bradycardia, and bradypnoea
    • Evaluation protocol: Papilledema and no neurological signs except possible 6th nerve paresis
    • Diagnostic tests:
      • MRI: Normal findings indicate possible benign intracranial hypertension or IIH
      • CT/MRI: Normal results
      • LP (Lumbar Puncture): Opening pressure greater than 25 cm of H₂O, normal CSF biochemistry and cytology
    • Modified Dandy Criteria:
      • Symptoms consistent with increased intracranial pressure
      • No localizing signs other than possible 6th nerve palsy
      • Normal CT and MRI findings

    Papilledema

    • Primary Empty Sella Syndrome: Benign intracranial hypertension with intact pituitary gland
    • Secondary Causes:
      • Drugs: Outdated tetracycline, nalidixic acid, NSAIDs, retinol, danazol, tamoxifen
      • Endocrine: Steroid withdrawal, growth hormone, anabolic steroids

    Seizure Semiology

    • Definition: signs and symptoms of seizure activity
    • Seizure: Transient occurrence of signs and/or symptoms due to abnormal excessive hypersynchronous neuronal activity in the brain
    • Hypersynchronous neuronal motor activity:
      • Myoclonic (fastest)
      • Clonic
      • Tonic
      • Atonic (slowest)

    Pseudo seizure

    • Most common in adolescents
    • Increased axial thrust movements
    • Increased attention-seeking actions
    • Pupils: Low sympathetic activity → Less dilation

    Classification (ILAE 2017)

    • Based on onset: Focal, Generalized (with/without loss of consciousness), Unknown
    • Focal Onset (Partial):
      • Complex Partial: Impaired awareness, automatisms, non-motor symptoms
      • Simple Partial: Absent (absence of loss of consciousness), tonic, clonic, atonic, myoclonic, hyperkinetic, epileptic spasm (rare)
    • Generalized Onset:
      • Motor: Tonic clonic, clonic, tonic, myoclonic, atonic
      • Non-motor: Typical absent, atypical absent, myoclonic

    Epilepsy

    • Evaluation:
      • MRI
      • EEG
      • Type of onset
      • Loss of consciousness
    • Epilepsy Syndrome:
      • At least two unprovoked seizures separated by at least 24 hours without an identifiable cause
      • Single episode seizure with evidence suggestive of epileptiform syndrome on MRI/EEG with a risk of subsequent seizure >60%
    • Investigation of TAC:
      • MRI brain
      • Polysomnography
      • Pituitary function test

    Focal Seizures

    • Without Dyscognition: Simple partial seizure, focal motor onset, aware, no epileptiform syndrome
    • With Dyscognition: Complex partial seizure, focal motor or non-motor onset, impaired consciousness, post-ictal disorientation, epileptiform syndrome present, medial temporal lobe is the most common location
    • Etiology:
      • Structural lesion (frontal/fronto-parietal lobe) → Opposite side brain irritation → Seizure
      • Tuberculoma
      • Neurocysticercosis
      • Brain tumors
      • Post-stroke seizure (elderly)
      • Motor (Tonic > Tonic clonic) > sensory (flashing light) / Autonomic
    • Presentation:
      • Clonic movements: 2-3 Hz
      • Abnormal facial movements synchronized with limbs
      • Todd's palsy: Post-ictal (transient) palsy lasting up to 24 hours
      • Jacksonian march: Motor activity migration (Distal to proximal)
      • Epilepsia partialis continua: Continuous activity lasting hours to days
      • Aura: Rare
    • MRI: Determine etiology, Normal results may indicate transient abnormality → Not diagnostic
    • EEG: Not an indication for anti-epileptics
    • Treatment:
      • Most common type of complex partial seizure
      • Family history present
      • History of febrile seizures in childhood
      • EEG: Temporal spikes
    • Other Observations:
      • Family history present
      • Aura: Subjective internal event not observed by others, Abdominal (Feeling of fullness → Regurgitation) > visual > auditory
      • Behavioral arrest: Motionless stare
      • Automatisms: Coordinated motor activity resembling movement (e.g., Lip smacking, chewing)
      • Anterograde amnesia
      • Hippocampal sclerosis
      • Temporal spikes
      • Antiepileptics: Lifelong

    Generalized Seizures

    • Absent Seizures: Non-motor, Epileptiform syndromes: Typical childhood absence seizure (remission by 12 years, good prognosis), Atypical juvenile absence seizure
      • Typical childhood absent seizures:
        • Age: 4-10 years
        • Gender: Boys > Girls
        • Presentation:
          • Consciousness: Sudden brief lapse (No loss of postural control)
          • Post-ictal confusion: Absent
        • MRI: Hippocampal sclerosis
        • EEG: Temporal lobe spikes
      • Atypical Juvenile Absent Seizure:
        • Age: 9-13 years
        • Presentation:
          • Loss of consciousness: Longer duration
          • Loss of postural control
          • Status epilepticus
        • EEG: Asymmetrical slow spike and wave pattern, abnormal interictal background
      • Treatment: Antiepileptic drugs (lifelong), Valproate (preferred), ethosuximide
    • Generalized Tonic Clonic Seizures:
      • Juvenile Myoclonic Epilepsy
        • Age: 6-25 years
        • Gender: Females > males
        • Associations: Sleep deprivation (upon awakening), GTCS in 90%, Absence seizure in 1/3rd cases

    Active Space Management

    • Treatment: 100% Oxygen (treatment of choice), 12-15 L/min for 10-20 minutes, Sumatriptan 6 mg s/c
    • Prevention:
      • Short-term: Steroids (DOC), Verapamil, Galcanezumab, Greater occipital nerve injection
      • Long-term: Verapamil (best), Topiramate, Lithium

    Neurology

    • Active Space:
      • IQ: Normal
      • Daydreaming, absentmindedness, loss of focus
      • Motor activity: Pause/stare > automatisms > eye movement
      • Aggravating factor: Hyperventilation
    • Investigations:
      • MRI: Normal
      • EEG: 3Hz spike & wave pattern
    • Treatment:
      • Antiepileptic drugs until age 12 (remission, good prognosis)
      • Valproate (preferred), ethosuximide

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    Test your knowledge on trigeminal autonomic cephalgias, including cluster headaches and their unique symptoms. This quiz covers characteristics, triggers, and treatment options related to these severe headache disorders. Dive into the specifics of these conditions and enhance your understanding.

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