Adult and Pediatric Epilepsy and Sleep.pdf

Adult and Pediatric Epilepsy and Sleep Question 1 If an antiepileptic drug (AED) is required in pregnancy, which of the following medications would be the best choice in terms of safety evidence? a. Phenytoin b. Carbamazepine c. Lamotrigine d. Valproic acid e. Phenobarbital Answer: c. Lamotrigine...

Adult and Pediatric Epilepsy and Sleep Question 1 If an antiepileptic drug (AED) is required in pregnancy, which of the following medications would be the best choice in terms of safety evidence? a. Phenytoin b. Carbamazepine c. Lamotrigine d. Valproic acid e. Phenobarbital Answer: c. Lamotrigine Explanation: Lamotrigine is considered safer compared to other antiepileptic drugs during pregnancy, although no AED is entirely risk-free. The choice of AED during pregnancy involves balancing the risk of seizures against the potential teratogenic effects of the medication. Lamotrigine has been associated with a lower risk of major congenital malformations compared to other AEDs like valproic acid, which has a higher teratogenic risk. It's important to monitor lamotrigine levels during pregnancy, as its clearance can increase, necessitating dosage adjustments. Question 2 Which of the following AEDs is associated with weight loss? a. Pregabalin b. Gabapentin c. Topiramate d. Carbamazepine e. Valproic acid Answer: c. Topiramate Explanation: Topiramate is known to cause weight loss in patients. This is one of its side effects and can be beneficial for patients who are overweight or have obesity-related health issues. Other AEDs like pregabalin, gabapentin, carbamazepine, and valproic acid are more commonly associated with weight gain. Question 3 A 36-year-old man with a history of herpes simplex virus (HSV) infection presents with new-onset epilepsy that you suspect is due to his prior encephalitis affecting the temporal lobes. The clinical features of seizures in mesial temporal lobe epilepsy may have all of the following characteristic symptoms, except: a. Olfactory hallucinations b. Altered consciousness c. Complex partial seizures d. Automatisms e. Tonic posturing of one limb (fencer’s posture) Answer: e. Tonic posturing of one limb (fencer’s posture) Explanation: Tonic posturing of one limb, also known as the "fencer’s posture," is associated with seizures originating from the frontal lobe, specifically the supplementary motor area. Mesial temporal lobe epilepsy commonly presents with auras like olfactory hallucinations, altered consciousness, complex partial seizures, and automatisms. Question 4 Which of the following AEDs would have the least drug–drug interactions? a. Gabapentin b. Carbamazepine c. Valproic acid d. Lamotrigine e. Phenytoin Answer: a. Gabapentin Explanation: Gabapentin is not metabolized by the liver and does not induce or inhibit hepatic enzymes, resulting in minimal drug– drug interactions. It is excreted unchanged by the kidneys. Other AEDs listed can interact with various medications due to their effects on hepatic enzyme systems. Question 5 In a young child with generalized epilepsy refractory to multiple antiepileptic medications, what would be the next best choice of treatment, if tolerated? a. Corpus callosotomy b. Ketogenic diet c. Vagus nerve stimulation d. Phenytoin e. Carbamazepine Answer: b. Ketogenic diet Explanation: The ketogenic diet has been effective in children with refractory epilepsy. It is a high-fat, low-carbohydrate diet that changes the body's energy source to ketones, which can have an antiepileptic effect. Surgical options and vagus nerve stimulation are other alternatives but are usually considered after dietary therapy. Question 6 Which of the following is the best treatment option for simple febrile seizures (FSs)? a. Intravenous (IV) lorazepam b. Rectal diazepam c. Supportive management d. Phenobarbital e. Intranasal midazolam Answer: c. Supportive management Explanation: Simple febrile seizures are typically self-limiting and do not require anticonvulsant therapy. The best approach is supportive management, which includes ensuring the safety of the child during the seizure and monitoring vital signs. Antipyretics may be used to reduce fever, but they do not prevent seizures. Question 7 Mutations in which of the following genes is most commonly associated with generalized epilepsy with febrile seizures plus (GEFS+)? a. SCN1A b. SCN1C c. SCN1B d. SCN2A e. GABRD Answer: a. SCN1A Explanation: Mutations in the SCN1A gene, which encodes the alpha subunit of a neuronal sodium channel, are most commonly associated with GEFS+. These mutations lead to altered neuronal excitability, contributing to the epilepsy phenotype. Question 8 A 13-year-old girl is being evaluated for epilepsia partialis continua. Rasmussen’s syndrome is suspected. What would be the most common finding on brain MRI in Rasmussen’s syndrome? a. Lissencephaly b. Schizencephaly c. Cortical atrophy d. Pachygyria e. Porencephaly Answer: c. Cortical atrophy Explanation: Rasmussen’s encephalitis typically shows progressive unilateral cortical atrophy on MRI due to chronic inflammation and neuronal loss. The atrophy correlates with the side affected by seizures and neurologic deficits. Question 9 A 12-year-old boy presents to your office with a history of progressively worsening frequency and severity of daily myoclonic seizures. His mitochondrial testing has so far been negative, although you suspect a progressive myoclonic epilepsy (PME) of some type. What would be the best antiepileptic medication to try first, given there are no contraindications? a. Carbamazepine b. Phenytoin c. Oxcarbazepine d. Valproic acid e. Gabapentin Answer: d. Valproic acid Explanation: Valproic acid is effective in treating myoclonic seizures and is often the first-line treatment for PME. It increases gamma-aminobutyric acid (GABA) levels in the brain and has broad-spectrum antiepileptic activity. Carbamazepine, phenytoin, and oxcarbazepine may worsen myoclonic seizures. Question 10 Which of the following choices is a characteristic associated with fosphenytoin as compared with phenytoin? a. Does not cause dizziness or nystagmus b. More cardiovascular side effects c. Achieves therapeutic plasma concentrations faster d. Faster rate of IV administration is possible e. More infiltration reactions (purple glove syndrome) Answer: d. Faster rate of IV administration is possible Explanation: Fosphenytoin can be administered intravenously at a faster rate than phenytoin because it is better tolerated and less likely to cause cardiac arrhythmias or hypotension. It is a prodrug of phenytoin and is converted to phenytoin in the body. Question 11 Which of the following is the least likely to be associated with worsening of myoclonic seizures? a. Topiramate b. Carbamazepine c. Lamotrigine d. Pregabalin e. Vigabatrin Answer: a. Topiramate Explanation: Topiramate is less likely to worsen myoclonic seizures and is sometimes used to treat them. Other medications like carbamazepine, lamotrigine, pregabalin, and vigabatrin can exacerbate myoclonic seizures and should be used with caution in patients with PME. Question 12 Which of the following antiepileptic medications is a hepatic enzyme inhibitor? a. Phenytoin b. Carbamazepine c. Valproic acid d. Phenobarbital e. Primidone Answer: c. Valproic acid Explanation: Valproic acid is a hepatic enzyme inhibitor and can increase the levels of other drugs metabolized by the liver, leading to potential drug interactions. Phenytoin, carbamazepine, phenobarbital, and primidone are hepatic enzyme inducers. Question 13 Which of the following electroencephalographic findings would be associated with the highest incidence of seizures? a. Small sharp spikes b. 6-Hz spike and wave c. Wicket spikes d. 3-Hz spike and wave e. 14 and 6 positive spikes Answer: d. 3-Hz spike and wave Explanation: The 3-Hz spike-and-wave pattern is characteristic of absence epilepsy and is associated with a high incidence of seizures. It is a diagnostic EEG finding in this type of epilepsy. Question 14 At what age do human beings attain the predominant alpha-frequency (posterior background) that is seen in adults? a. 6 to 8 years b. 8 to 10 years c. 10 to 12 years d. 12 to 14 years e. 14 to 16 years Answer: b. 8 to 10 years Explanation: By the age of 8 to 10 years, children typically develop the adult pattern of posterior dominant alpha rhythm on EEG, which ranges from 8 to 13 Hz. Question 15 A 47-year-old woman presents with confusion, fever, and seizures. Cerebrospinal fluid (CSF) studies are positive for HSV infection. What would be the most likely finding on an electroencephalogram (EEG) in this patient? a. Triphasic waves b. Wicket spikes c. Periodic lateralized epileptiform discharges d. Polyspikes e. Fast spike–wave complexes Answer: c. Periodic lateralized epileptiform discharges Explanation: Periodic lateralized epileptiform discharges (PLEDs) are often seen in patients with acute focal brain lesions such as HSV encephalitis. They are characterized by unilateral high-amplitude sharp waves occurring at regular intervals. Question 16 In a patient with absence epilepsy, which of the following antiepileptic medications is least likely to precipitate absence status epilepticus? a. Phenytoin b. Topiramate c. Carbamazepine d. Lamotrigine e. Gabapentin Answer: b. Topiramate Explanation: Topiramate is less likely to precipitate absence status epilepticus and can be used in treating absence seizures. Medications like phenytoin, carbamazepine, and gabapentin may worsen absence seizures and should be avoided. Question 17 Which of the following antiepileptic medications is the most likely to have an effect on steroid hormone concentration in the blood in patients taking oral contraceptive pills and, therefore, lead to contraceptive failure? a. Levetiracetam b. Gabapentin c. Topiramate (dose 3 years), immediate AED therapy is likely to improve the prognosis for sustained seizure remission d. The potential AED adverse effects are generally severe and some may be irreversible e. Antiepileptic drug therapy should be recommended in any patient with an unprovoked first seizure, regardless of normal or abnormal results of brain imaging or EEG Answer: a. Immediate AED therapy as compared with the delay of treatment pending a second seizure is likely to reduce seizure recurrence in the subsequent 2 years Explanation: Initiation of AED therapy after a first unprovoked seizure can reduce the risk of seizure recurrence in the next two years but may not affect long-term remission rates. The decision to initiate therapy should be individualized based on patient factors and risk-benefit analysis. Question 75 Which of the following is correct regarding the EEG in Figure 5.7? a. There is poor reactivity of the posterior background b. The patient has an occipital seizure c. The posterior background shows delta frequencies d. An eye closure is recorded during this EEG page e. The patient is sleeping Answer: d. An eye closure is recorded during this EEG page Explanation: The EEG shows posterior dominant alpha rhythm reacting to eye closure, evidenced by the synchronization of alpha activity upon eye closure. This suggests normal reactivity of the background rhythm, and the patient is awake. Question 76 Which of the following is correct regarding EEG frequencies? a. Alpha frequency is >13 Hz b. Beta frequency is 8 to 13 Hz c. Delta frequency is