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EEG/EPILEPSY: HIGH YIELD RITE REVIEW Your Epi Fellows PRE-TEST What medications are contraindicated in CAE? What stage of sleep suppresses 3 Hz spike and wave activity? What is the mechanism of action of felbamate? Which AEDs are not metabolized by the liver? Where are the spikes in panayiotopoulos syndrome? What is the MRI hallmark feature of Aicardi syndrome? What does this EEG show? QUESTION 1 A 10 yo boy with a hx of epilepsy and cerebral palsy is on Phenytoin, Phenobarbital, and Valproate. He transitioned to a new neurologist due refractory seizures. He was started on Lamotrigine, Topiramate, Phenobarbital and Zonisamide, with some improvement in seizure control. His vitals are 98F, pulse 75/minute, BP 100/82, he is drowsy and bedridden. Ct of the brain done recently shows generalized atrophy. Which of the following is a cause of his skin rash? A . Topiramate B. Zonisamide C. Lamotrigine D. Phenobarbital E. Phenytoin withdrawal LAMOTRIGINE ~10% patient develop erythema and maculopapular rash. Develops during the first 2 -8 weeks of therapy Serious rashes—SJS, TEN, angioedema in 1% of cases. QUESTION 2 22 yo man evaluated for seizures. Head CT shows widespread rounded lesions: What is the treatment? A. Acyclovir B. Steroids C. Aspirin D. Interferon E. Albendazole QUESTION 3 Same 10 yo boy came in due to worsening seizures. He is on Phenytoin, phenobarbital, and topiramate. Felbamate is started. What is the concern with starting this medication? A. Drowsiness B. Dizziness and ambulatory difficulty C. Pancreatic dysfunction D. Aplastic anemia E. QRS prolongation and heart block FELBAMATE NMDA blocker; potentiates GABA Partial seizures, approved in 1993 Bad side effects: fulminant liver failure and aplastic anemia Other side effects: mild drowsiness, ataxia, nystagmus, tachycardia, N/V [anorexia] QUESTION 4 40 yo man w a hx of seizures described as “flashes of light” from his right hemifield followed by GTC. Current medications include lamotrigine, HAART meds and multivitamins. What is the next best medication to add: A. Phenobarbital B. Levetiracetam C. Valproate D. Tiagabine E. Topiramate LEVETIRACETAM If it’s a choice, it’s usually the answer No drug interactions Okay in pregnancy [as is lamotrigine] What is not okay in pregnancy??? AEDS BAD IN PREGNANCY Valproic acid Spinal cord issues Phenytoin Topiramate Fetal hydantoin syndrome Oral/cleft lip/palate Phenobarbital Low IQ AEDS BAD IN PREGNANCY Valproic acid Spinal cord issues Phenytoin Topiramate Fetal hydantoin syndrome Oral/cleft lip/palate Phenobarbital Low IQ METABOLISM Metabolized p450 Topiramate Tiagabine Phenobarbital P450 inhibitors Valproic acid P450 inducer Phenobarbital Liver: betaoxidation/glucuronidation Valproic acid METABOLISM Metabolized p450 Topiramate Tiagabine Phenobarbital P450 inhibitors Valproic acid P450 inducer Phenobarbital Liver: betaoxidation/glucuronidation Valproic acid Non liver AEDs: - Gabapentin - Keppra QUESTION 5 55 yo woman here for f/u after being started on carbamazepine for localization -related epilepsy. She initially had no seizures for the first 2 months, but then started having seizures 2 weeks ago. Why did this happen? A. she needs higher doses of carbamazepine given its level likely decreased after initial stabilization B. Her epilepsy is becoming refractory to carbamezapine. C. She needs the addition of a second AED. CARBAMAZEPINE Auto-induces itself Typically occurs 15-30 days after onset of treatment Plasma clearance doubles Pearl: Don’t restart someone’s carbamazepine at the same dose when it was held Doesn’t apply to oxcarb or esclicarb QUESTION 6 CHILDHOOD ABSENCE EPILEPSY (CAE) Treat with ethosuximide Less ef ficacious are lamotrigine and valproic acid Induced by hyperventilation Was asked about 5 times on my boards What meds are contraindicated? CHILDHOOD ABSENCE EPILEPSY (CAE) Treat with ethosuximide Less ef ficacious are lamotrigine and valproic acid Induced by hyperventilation Was asked about 5 times on my boards What meds are contraindicated? Carbamazepine, oxcarb, tiagabine, vigabatrin CHILDHOOD ABSENCE EPILEPSY (CAE) Treat with ethosuximide Less ef ficacious are lamotrigine and valproic acid Induced by hyperventilation Was asked about 5 times on my boards What meds are contraindicated? Carbamazepine, oxcarb, tiagabine, vigabatrin QUESTION 7 A 6 yo girl presents due to occasional episodes of waking up, producing strange gurgling noises and hemifacial twitching. What is the next step in management? A . Psychiatry B. Sleep study C. Brain MRI D. Reassurance E. 24-EEG monitor BENIGN CHILDHOOD EPILEPSY WITH CENTROTEMPORAL SPIKES: BECTS/BRE One of the many childhood epilepsy syndromes where there is an↑ in discharges during sleep Depending on % increase and where the spikes localize, you can get a dif ferent syndrome/phenotype BRE/BCECTS LandauKleffner Panayiotopoulos Generalized + regression: CSWS QUESTION 8 A 3 yo girl presents to the ED with her fifth febrile seizure over the past year. Each is described as a GTC which self resolved within 5 minutes. Her mother also had a history of 1 febrile seizure. What is the next step in management? A. Start Keppra B. Reassurance because the child will likely not develop epilepsy. C. DNA testing for SCN1A mutations D. MRI brain E. Routine EEG FEBRILE SEIZURES Simple febrile sz: <15 minutes, does not recur within 24 hours, no focality Complex: does not fit above criteria Still low risk of developing epilepsy (2%) Though related to sodium channel mutations, typically not tested at this point and would not change management QUESTION 9 Which of the following suppressed 3 Hz spike and wave activity on EEG? A . Alkalosis B. Hyperventilation C. Hypoglycemia D. Drowsiness E. REM sleep QUESTION 9 Which of the following suppressed 3 Hz spike and wave activity on EEG? A . Alkalosis B. Hyperventilation C. Hypoglycemia D. Drowsiness E. REM sleep [all of the above increase 3 Hz EEG activity] QUESTION 10 A 10 yo child suf fered a TBI 2 days ago and remains unresponsive. An EEG was obtained at 2 uV. What is the most likely interpretation? A . Brain death B. The electrode box is disconnected. C. This patient is on benzos D. This person likely has focal seizures. E. There is some residual cortical activity, although the prognosis is poor. QUESTION 10 A 10 yo child suf fered a TBI 2 days ago and remains unresponsive. An EEG was obtained at 2 uV. What is the most likely interpretation? A . Brain death B. The electrode box is disconnected. C. This patient is on benzos D. This person likely has focal seizures. E. There is some residual cortical activity, although the prognosis is poor. QUESTION 11: WHAT IS THE TREATMENT FOR THIS? Phenobarbital Phenytoin ACTH Carbamezepine Lamotrigine QUESTION 12 Regarding the pharmacokinetics of phyntoin, which of the following is correct? A . It is renally metabolized B. It is exclusively metabolized in the liver C. It has zero-order (nonlinear) kinetics D. It is a hepatic enzyme inhibitor E. It has first-order kinetics QUESTION 12 Regarding the pharmacokinetics of phyntoin, which of the following is correct? A . It is renally metabolized B. It is exclusively metabolized in the liver C. It has zero-order (nonlinear) kinetics D. It is a hepatic enzyme inhibitor E. It has first-order kinetics QUESTION 13 What is the MOA for benzos? A . Chloride channel antagonism B. Chloride channel agonism C. GABAa antag D. GABAa agonist E. GABAb agonism QUESTION 13 What is the MOA for benzos? A . Chloride channel antagonism B. Chloride channel agonism C. GABAa antag D. GABAa agonist E. GABAb agonism QUESTION 14 Where does the figure 4 localize? A. Mesial temporal lobe B. Occipital lobe C. Motor cortex D. Supplementary motor cortex E. Frontal lobe QUESTION 14 Where does the figure 4 localize? A. Mesial temporal lobe B. Occipital lobe C. Motor cortex D. Supplementary motor cortex E. Orbitofrontal lobe QUESTION 15 In a patient with CSF -positive HSV encephalitis, what would you find on their EEG? A . Triphasic waves B. Wicket spikes C. Periodic lateralized epileptiform discharges (PLEDs) D. Polyspikes E. Fast spike-wave complexes QUESTION 15 In a patient with CSF -positive HSV encephalitis, what would you find on their EEG? A . Triphasic waves B. Wicket spikes C. Periodic lateralized epileptiform discharges (PLEDs) D. Polyspikes E. Fast spike-wave complexes QUESTION 15 In a patient with CSF -positive HSV encephalitis, what would you find on their EEG? A . Triphasic waves B. Wicket spikes C. Periodic lateralized epileptiform discharges (PLEDs) D. Polyspikes E. Fast spike-wave complexes JME Myoclonic seizures GTCs Tx “life long”: Keppra, VPA, Lamotrigine QUESTION 16 12 yo boy with frequent falls, clumsiness, drops objects and has frequent GTCs. Has a history of infantile spasms. A . Landau-Kleffner B. Lennox-Gastaut C. Myoclonic epilepsy D. Doose syndrome E. JME QUESTION 16 12 yo boy with frequent falls, clumsiness, drops objects and has frequent GTCs. Has a history of infantile spasms. A . Landau-Kleffner B. Lennox-Gastaut C. Myoclonic epilepsy D. Doose syndrome E. JME QUESTION 17 What is the mechanism of action of lacosamide? A. Selectively enhances fast inactivation of voltage -dependent sodium channels B. Stabilizes hyperexcitable neuronal membranes C. Inhibits repetitive neuronal firing D. Enhances slow inactivation of voltage -dependent sodium channels E. Binds to the collapsin response mediator protein 2 (CRMP2) QUESTION 17 What is the mechanism of action of lacosamide? A. Selectively enhances fast inactivation of voltage -dependent sodium channels B. Stabilizes hyperexcitable neuronal membranes C. Inhibits repetitive neuronal firing D. Enhances slow inactivation of voltage -dependent sodium channels E. Binds to the collapsin response mediator protein 2 (CRMP2) QUESTION 18 A 2 month old girl has blindness, infantile spasms, and an abnormal retinal examination. Her brain MRI shows agenesis of the corpus callosum. What is the most likely cause? A . West syndrome B. Ohtahara syndrome C. Severe myoclonic epilepsy of infancy ( Dravet) D. Aicardi syndrome E. Myoclonic-astatic epilepsy (Doose) QUESTION 18 A 2 month old girl has blindness, infantile spasms, and an abnormal retinal examination. Her brain is below. What is the most likely cause? A . West syndrome B. Ohtahara syndrome C. Severe myoclonic epilepsy of infancy ( Dravet) D. Aicardi syndrome E. Myoclonic-astatic epilepsy (Doose) POST-TEST What medications are contraindicated in CAE? What stage of sleep suppresses 3 Hz spike and wave activity? What is the mechanism of action of felbamate? Which AEDs are not metabolized by the liver? Where are the spikes in panayiotopoulos syndrome? What is the MRI hallmark feature of Aicardi syndrome? What does this EEG show? POST-TEST What medications are contraindicated in CAE? The carbs- oxcarb, carb, esclicarb What stage of sleep suppresses 3 Hz spike and wave activity? REM What is the mechanism of action of felbamate? NMDA blocker, so helps GABA Which AEDs are not metabolized by the liver? Keppra, gabapentin Where are the spikes in panayiotopoulos syndrome? Occipital What is the MRI hallmark feature of Aicardi syndrome? Agenesis of the corpus callosum What does this EEG show? BRE/BECTs