Seizure Multiple Choice Questions

1. What is the 2017 ILAE terminology for seizures previously known as Complex partial seizures?

a) Focal seizure

b) Partial epilepsy

c) Focal seizure with impaired awareness

d) Focal seizure with secondary generalization

REFERENCE: Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by

the International League Against Epilepsy: Position Paper of the ILAE Commission for

Classification and Terminology. Epilepsia. 2017;58(4):522-530. doi:10.1111/epi.13670

2. A 40 years old gentleman developed sudden onset involuntary tonic posturing of left upper limb followed by versive head turn towards the left and tonic-clonic movements of all four limbs with accompanying loss of consciousness. What is this type of seizure classified as in the 2017 ILAE classification?

a) Generalized tonic-clonic seizures (GTCS)

b) Focal seizure with impaired awareness

c) Focal seizure with secondary generalization

d) Focal to bilateral tonic-clonic seizure

REFERENCE: Fisher RS, Cross JH, French JA, et al. Operational classification of seizure types by

the International League Against Epilepsy: Position Paper of the ILAE Commission for

Classification and Terminology. Epilepsia. 2017;58(4):522-530. doi:10.1111/epi.13670

3. A 65 years old gentleman with history of poorly controlled diabetes mellitus for the past 20 years, experienced sudden onset lightheadedness on getting up from supine position which was associated with diaphoresis, jerky movements of upper limbs for 5-10 seconds followed by loss of consciousness. He recovered from this whole episode to an alert state in less than a minute. Which of the following is the most likely diagnosis?

a) Syncope

b) Stroke

c) Seizure

d) Hypoglycemia

REFERENCE: Crompton DE, Berkovic SF. The borderland of epilepsy: clinical and molecular

features of phenomena that mimic epileptic seizures. Lancet Neurol. 2009;8(4):370-381.

doi:10.1016/S1474-4422(09)70059-6

4. A patient has chewing and lip-smacking automatisms during the seizure episode. Where is the lesion most likely to be located?

a) Frontal lobe

b) Temporal lobe

c) Parietal lobe

d) Occipital lobe

EXPLANATION: “Automotor movements involving the mouth and tongue (oral automatisms)

include mastication, swallowing, lip smacking, blowing, whistling, and kissing. Awareness is

generally impaired except in seizures restricted to the nondominant temporal lobe.”

REFERENCE: Foldvary-Schaefer N, Unnwongse K. Localizing and lateralizing features of auras and

seizures. Epilepsy Behav. 2011;20(2):160-166. doi:10.1016/j.yebeh.2010.08.034

5. Which of the following is not a classical feature of Lennox-gastaut syndrome?

a) Multiple seizure types

b) Interictal EEG showing generalized slow spike-and-wave discharges (< 2.5 Hz)

c) Visual symptoms

d) Cognitive dysfunction

EXPLANATION: “Lennox-Gastaut syndrome (LGS) is considered an epileptic encephalopathy and

is defined by a triad of multiple drug-resistant seizure types, a specific EEG pattern showing

bursts of slow spike-wave complexes or generalized paroxysmal fast activity, and intellectual

disability.”

REFERENCE: Asadi-Pooya AA. Lennox-Gastaut syndrome: a comprehensive review. Neurol Sci.

2018;39(3):403-414. doi:10.1007/s10072-017-3188-y

6. A 45 years old wife of a farmer presents to a primary health center with recent onset seizures since the last 2 months. She does not give history of any epilepsy risk factors. She has been on 10 mg OD of Amlodipine for essential hypertension and has been taking it irregularly for 3 years. Her husband witnessed 1 of her 3 seizures and describes a generalized tonic clonic seizure. No focal onset has been noted either by the husband or the lady. Which of the following should be advised immediately?*

a) Plain CT brain

b) CECT brain

c) MRI brain

d) MRI brain epilepsy protocol

EXPLANATION: In a middle aged female patient with new onset recent seizures without any

epilepsy risk factors, the possibility of a structural lesion as the etiology is high and should be

ruled out. A CT/MRI brain with contrast is better suited for ruling out the same. However, at the

primary healthcare level, obtaining an MRI brain is most of the times not possible due to

financial and accessibility limitations. Therefore in such setting, a CT brain with contrast should

be the most appropriate next step of evaluation.

7. A 21 years old college student had a generalized tonic-clonic seizure in the morning. This is the first seizure he has ever had. The previous evening, he had been having fever of 102-103 degree celsius and all through the preceding night, he had repeated episodes of vomiting and a couple of loose stools. At presentation to the ER, his serum sodium was 115 meq /l and his random blood sugar was 100 g/dl. He probably has:

a) Febrile seizure

b) Idiopathic generalized epilepsy

c) Acute generalized epilepsy

d) Acute symptomatic seizure

EXPLANATION: “An acute symptomatic seizure is defined as a clinical seizure occurring at the

time of a systemic insult or in close temporal association with a documented brain insult.

Suggestions are made to define acute symptomatic seizures as those events occurring within 1

week of stroke, traumatic brain injury, anoxic encephalopathy, or intracranial surgery; at first

identification of subdural hematoma; at the presence of an active central nervous system (CNS)

infection; or during an active phase of multiple sclerosis or other autoimmune diseases. In

addition, a diagnosis of acute symptomatic seizure should be made in the presence of severe

metabolic derangements (documented within 24 h by specific biochemical or hematologic

abnormalities), drug or alcohol intoxication and withdrawal, or exposure to well-defined

epileptogenic drugs”

REFERENCE: Ettore Beghi et al. Recommendation for a definition of acute symptomatic seizure.

Epilepsia, 51(4):671–675, 2010 doi: 10.1111/j.1528-1167.2009.02285

8. Which of the following in your opinion is most useful for making a diagnosis of epilepsy and determining if it is focal or generalized onset?

a) Clinical history and examination

b) EEG

c) MRI brain

d) PET scan

REFERENCE: Scheffer, I.E., Berkovic, S., Capovilla, G., Connolly, et al. (2017), ILAE classification of

the epilepsies: Position paper of the ILAE Commission for Classification and Terminology.

Epilepsia, 58: 512-521. doi:10.1111/epi.13709

9. A 25 years old auto-rickshaw driver presented with multiple events in the last 1-year. He had continued to have these events in spite of regularly taking 3 prescribed anti-epileptic drugs. Three types of events were described: in one, the patient was unable to see for a variable time lasting from seconds to hours. In the second, he described abrupt onset ‘loss of consciousness’ with a fall. There had however never been any injury during these falls. In the third, there was thrashing movement of all 4 limbs lasting for 20-30 minutes. There was no history of urinary incontinence or tongue bite during these events. Which of the following is the most likely diagnosis?

a) Drug resistant epilepsy

b) PNES

c) Absence epilepsy

d) Temporal lobe epilepsy

REFERENCE: W. Curt LaFrance Jr., Gus A. Baker, Rod Duncan, Laura H. Goldstein, Markus Reuber.

Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged

approach. A report from the International League Against Epilepsy Nonepileptic Seizures Task

Force. Epilepsia. Volume54, Issue11 November 2013 2005-2018. doi.org/10.1111/epi.12356

10. A patient was newly started on carbamazepine monotherapy after 2 focal seizures in 9 months. He has had no seizures for 12 months since. Which of the following best describes him?

a) He has drug responsive epilepsy

b) He has drug resistant epilepsy

c) His status is undefined

d) His epilepsy has resolved

EXPLANATION: Drug resistant epilepsy may be defined as failure of adequate trials of two

tolerated and appropriately chosen and used AED schedules (whether as monotherapies or in

combination) to achieve sustained seizure freedom.

A person’s epilepsy can be classified as “drug responsive” if he/she has been seizure‐free for a

minimum of three times the longest pretreatment interseizure interval, or 12 months,

whichever is longer.”1

“Epilepsy is considered to be resolved for individuals who either had an age-dependent epilepsy

syndrome but are now past the applicable age or who have remained seizure-free for the last 10

years and off antiseizure medicines for at least the last 5 years.”2

REFERENCES:

1 Kwan, P., Arzimanoglou, A., Berg, A.T., Brodie, M.J., Allen Hauser, W., Mathern, G.,

Moshé, S.L., Perucca, E., Wiebe, S. and French, J. (2010), Definition of drug resistant epilepsy:

Consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies.

Epilepsia, 51: 1069-1077. doi:10.1111/j.1528-1167.2009.02397.x

2 Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical

definition of epilepsy. Epilepsia. 2014;55(4):475-482. doi:10.1111/epi.12550

11. When is a patient with epilepsy said to be in remission?

a) No seizure for 3 years on AED’s.

b) No seizure for 5 years on AED’s

c) No seizure for 10 years with last 5 years off AED’s

d) No seizure for 5 years with last 2 years off AED’s

EXPLANATION: “Epilepsy is considered to be resolved for individuals who either had an age-

dependent epilepsy syndrome but are now past the applicable age or who have remained

seizure-free for the last 10 years and off antiseizure medicines for at least the last 5 years.”

REFERENCE: Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical

definition of epilepsy. Epilepsia. 2014;55(4):475-482. doi:10.1111/epi.12550

12. In which of the following categories of patients do you think a routine 40-minute interictal EEG may provide the most useful information with a bearing on management?

a) PNES

b) Juvenile myoclonic epilepsy

c) Focal epilepsy due to a frontal calcified lesion in a patient who has become seizure-free on one AED

d) Focal drug-resistant temporal lobe epilepsy

REFERENCE: Grünewald RA, Panayiotopoulos CP. Juvenile Myoclonic Epilepsy: A Review. Arch

Neurol. 1993;50(6):594–598. doi:10.1001/archneur.1993.00540060034013

13. In an OPD patient, when would you advise serum level of anti-epileptic drugs to be done?

a) When seizures are adequately controlled

b) When seizures remain poorly controlled despite patients reporting adequate compliance

c) Should be routinely done once every 3 months in patients on polytherapy

d) All of the above

EXPLANATION: Indications for monitoring of AED blood levels are:

• detection of non-adherence to the prescribed medication

• suspected toxicity

• adjustment of phenytoin dose

• management of pharmacokinetic interactions (for example, changes in bioavailability, changes in elimination, and co-medication with interacting drugs)

• specific clinical conditions, for example, status epilepticus, organ failure and certain situations in pregnancy.

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published date:

January 2012 Last updated: October 2019. (https://www.nice.org.uk/guidance/cg137/chapter/1-

Guidance)

14. An epilepsy patient weighing 50 kgs is taking Sodium valproate 1500 mg/d for the past 3 years without any seizure. He presents to the OPD with 2 recent seizures in one day. What would be your next step of management?

a) Order an MRI brain

b) Enquire about recent history preceding the seizure

c) Escalate dose of Sodium valproate to 2 g/d as previous dose is sub-optimal

d) Add a second anti-epileptic drug

15. A 7 years old boy came to the clinic with his parents. He was a healthy child doing well at school with normal birth and development. The parents had previously visited a doctor occasionally for bouts of inflamed tonsils. Two days before presentation, the boy went to sleep as usual. He had spent most of the day playing video games or watching movies as his school had been closed. The parents were woken up at about 2 am by sounds coming from his room. They rushed to find him drooling, making strange gurgling sounds and having some twitching movements around his lips. He seemed to be wide-awake and conscious but was not able to speak. This went on for a few minutes after which he went back to sleep. What is the likely diagnosis in this patient?

a) Photosensitive epilepsy

b) Night terror

c) Benign epilepsy with centrotemporal spikes

d) Generalized epilepsy

EXPLANATION: Rolandic epilepsy or benign epilepsy with centrotemporal spikes (BECTS) is one of the most common childhood epilepsy syndromes, occurring in 15–25% of pediatric epilepsy patients. Characteristically the seizures begin in middle childhood, between 4 and 10 years of age, and resolve by puberty. The seizures predictably occur during sleep, often in the early morning hours. However, daytime seizure occasionally may take place. BECTS is a genetic disorder with autosomal dominant transmission, although only 18–25% of persons with the trait will express seizures. The diagnosis of BECTS can be strongly suspected by the distinctive seizure semiology in addition to the age of onset and nocturnal predominance. The seizures have a focal onset involving arm and oral facial tonic or clonic contractions associated with guttural sounds and drooling. If the seizure occurs in the dominant hemisphere, speech arrest is evident, although the child remains fully cognizant.

REFERENCE: Donald Shields, W. and Carter Snead III, O. (2009), Benign epilepsy with

centrotemporal spikes. Epilepsia, 50: 10-15. doi:10.1111/j.1528-1167.2009.02229.x

PHARMACOLOGICAL TREATMENT

1. A 25 years old labourer is seen in a rural primary health centre clinic. He describes stereotyped convulsive events that have been occurring about once every 6-12 months over the last 5-years. These events have never happened in sleep and most have occurred about 1-2 hours after waking up in the morning. He has never consulted a doctor or taken any treatment. From the description of the events they seem likely to be epileptic seizures. The nearest hospital where an EEG and imaging are available is about 1000 kms from the patient’s home. What may be the best option for this patient at this point?

a) Start Carbamazepine

b) Start Levetiracetam

c) Start Sodium Valproate

d) Get a CT Head and EEG and then start treatment

EXPLANATION: In this patient, the history reveals that the patient most likely has generalized tonic clonic seizures with a frequency of 1-2 episodes in one year. Here the feasibility and financial implications of travelling 1000 kms and then getting access to EEG and imaging are huge, so it is best to start the patient on AED treatment straightaway. Sodium valproate is one of the first line broad spectrum antiepileptic drugs used in generalized tonic clonic seizures and is appropriate in this setting.

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published date:

January 2012 Last updated: October 2019.(https://www.nice.org.uk/guidance/cg137/chapter/1-

Guidance)

2. Which of the following drugs is the safest to use especially in elderly because of its least drug-drug interactions?

a) Phenytoin

b) Phenobarbitone

c) Carbamazepine

d) Levetiracetam

REFERENCE: Bradley’s neurology in clinical practice. Seventh edition.

3. Which of the following drugs can cause SJS/TEN?

a) Carbamazepine

b) Lamotrigine

c) Phenytoin

d) All of the above

REFERENCE: Mockenhaupt M, Messenheimer J, Tennis P, Schlingmann J. Risk of Stevens-Johnson syndrome and toxic epidermal necrolysis in new users of antiepileptics. Neurology. 2005;64(7):1134-1138. doi:10.1212/01.WNL.0000156354.20227.F0

4. Which of the following commonly used antiepileptic drugs can cause disabling cerebellar dysfunction on chronic use?

a) Carbamazepine

b) valproate

c) Phenytoin

d) Levetiracetam

REFERENCE: Bradley’s neurology in clinical practice. Seventh edition.

5. Which of the following categories of drugs can precipitate seizures?

a) Anti depressants and Anti psychotics

b) Anti hypertensives

c) Anti diabetics

d) Anti microbials

REFERENCE: Muhammad Bhatti, Parshaw Dorriz, Prachi Mehndiratta. Impact of Psychotropic drugs on Seizure threshold (P6.311). Neurology Apr 2017, 88 (16 Supplement)

6. Unless contraindicated due to some reason, which of the following do you rate as the first line therapy for focal epilepsy?

a) Valproate

b) Phenytoin

c) Levetiracetam

d) Carbamazepine

REFERENCE: Epilepsies: diagnosis and management. Clinical guideline [CG137]Published date: 11 January 2012 https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#pharmacological-treatment

7. What is the mechanism of action of Levetiracetam?

a) Na channel blocker

b) increases GABA

c) binds to synaptic vesical protein SV2A

d) Glutamate receptor antagonist

REFERENCE: Bradley’s neurology in clinical practice. Seventh edition.

8. When AED blood levels are not available, it is reasonable to increase the AED dose after the first trimester for women with epilepsy when they are on AEDs that are prone to marked changes in clearance. Therefore an increase in the dose may be recommended in the second trimester for all of the following AEDs except:

a) Oxcarbazepine

b) Carbamazepine

c) Levetiracetam

d) Lamotrigine

REFERENCE: Johnson EL, Stowe ZN, Ritchie JC, et al. Carbamazepine clearance and seizure stability during pregnancy. Epilepsy Behav. 2014;33:49-53. doi:10.1016/j.yebeh.2014.02.011

9. Most marked increase in bone turnover markers and reduction in bone mineral density is associated with which of the following antiepileptic drugs?

a) Phenytoin

b) Levetiracetam

c) Valproic Acid

d) Lamotrigine

REFERENCE: Feldkamp J, Becker A, Witte OW, Scharff D, Scherbaum WA. Long-term

anticonvulsant therapy leads to low bone mineral density--evidence for direct drug effects of

phenytoin and carbamazepine on human osteoblast-like cells. Exp Clin Endocrinol Diabetes.

2000;108(1):37-43. doi:10.1055/s-0032-1329213

10. Carbamazepine is an effective and relatively inexpensive antiepileptic drug used to treat patients with focal epilepsy. Which of the following regarding carbamazepine is a correct statement?

a) Carbamazepine works by primarily blocking slow calcium channels

b) A dreaded complication of the drug is memory loss

c) It is an enzyme-inducing drug

d) Carbamazepine can be effectively used in OD doses

REFERENCE: Brodie, M.J., Mintzer, S., Pack, A.M., Gidal, B.E., Vecht, C.J. and Schmidt, D. (2013), Enzyme induction with antiepileptic drugs: Cause for concern?. Epilepsia, 54: 11-27. doi:10.1111/j.1528-1167.2012.03671.x

11. Which adverse drug effect is observed more often with oxcarbazepine as compared to carbamazepine?

a) Hyponatremia

b) Thyroid disease

c) Rash

d) Sexual dysfunction

REFERENCE: Berghuis, B., van der Palen, J., de Haan, G.‐J., Lindhout, D., Koeleman, B.P.C.,

Sander, J.W. and (2017), Carbamazepine‐ and oxcarbazepine‐induced hyponatremia in

people with epilepsy. Epilepsia, 58: 1227-1233. doi:10.1111/epi.13777

12. Juvenile Myoclonic epilepsy is a common genetically determined epilepsy syndrome. What is the first line antiepileptic drug for Juvenile Myoclonic epilepsy?

a) Sodium Valproate

b) Phenytoin

c) Carbamazepine

d) Levetiracetam

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published date:

January 2012 Last updated: October 2019.(https://www.nice.org.uk/guidance/cg137/chapter/1-

Guidance)

13. Broad spectrum antiepileptic drugs are effective against both focal and generalized onset seizures. Narrow spectrum drugs are primarily used to treat focal onset seizures. Which of the following is a narrow spectrum drug with a potential of worsening some generalized seizures?

a) Clobazam

b) Phenytoin

c) Valproate

d) Carbamezapine

REFERENCE: Lige Liu, Thomas Zheng, Margaret J. Morris, Charlott Wallengren, et al.

The Mechanism of Carbamazepine Aggravation of Absence Seizures. Journal of Pharmacology and Experimental Therapeutics November 1, 2006, 319 (2) 790-798; DOI: https://doi.org/10.1124/jpet.106.104968

14. Auto-induction is a phenomenon that results in decreased serum concentrations of the antiepileptic drug with chronic use. This phenomenon is likely to occur with use of:

a) Valproate

b) Phenytoin

c) Levetiracetam

d) Carbamazepine

REFERENCE: Tolou-Ghamari Z, Zare M, Habibabadi JM, Najafi MR. A quick review of

carbamazepine pharmacokinetics in epilepsy from 1953 to 2012. J Res Med Sci.

2013;18(Suppl 1):S81-S85.

15. Combined oral contraceptive pills may reduce the serum levels of antiepileptic drug by >60% leading to loss of seizure control. Which antiepileptic drug is susceptible to such an interaction?

a) Levetiracetam

b) Lamotrigine

c) Carbamazepine

d) Sodium Valproate

REFERENCE: Reddy DS. Clinical pharmacokinetic interactions between antiepileptic drugs

and hormonal contraceptives. Expert Rev Clin Pharmacol. 2010;3(2):183-192.

doi:10.1586/ecp.10.3

16. Benign epilepsy with centrotemporal spikes is a genetically determined childhood epilepsy. The drug of choice to treat this syndrome is?

a) Sodium valproate

b) Lamotrigine

c) Carbamazepine

d) Phenytoin

REFERENCE: Epilepsies: diagnosis and management. Clinical guideline [CG137]Published date: 11 January 2012 https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance#pharmacological-treatment

COUNSELLING

1. What percentage of people with epilepsy could become seizure free with appropriate usage of cost effective basic anti-seizure medications?

a) 30%

b) 50%

c) 70%

d) 99%

REFERENCE: Global Report – Epilepsy: a public health imperative. Published 2019.

https://www.who.int/mental_health/neurology/epilepsy/report_2019/en/

2. A 26 year old married female with epilepsy who is seizure free on carbamezapine for the past 2 years is planning to start using oral contraception. Which of the following advice would you give to the patient?

a) Oral contraceptives can be started and continued without any concern

b) Consider switching from carbamezapine to phenytoin

c) Consider using additional contraception such as barrier methods

d) Stop carbamezapine as the patient is seizure free

REFERENCE: Epilepsies: diagnosis and management. Clinical guideline [CG137]Published

date: 11 January 2012 https://www.nice.org.uk/guidance/cg137/chapter/1-

Guidance#women-and-girls-with-epilepsy

3. What information would you give a 25 years old lady whose seizures are controlled on Sodium valproate 500 mg BD and is planning to start a family?

a) Start Folic acid and continue Sodium valproate

b) Recommend switching over to another AED atleast 3 months before conception

c) Continue Sodium valproate as seizures are well controlled

d) No change required as dose being used is safe

REFERENCE: Epilepsies: diagnosis and management. Clinical guideline [CG137]Published

date: 11 January 2012 https://www.nice.org.uk/guidance/cg137/chapter/1- Guidance#women-and-girls-with-epilepsy

4. Women with epilepsy were once counseled to avoid pregnancy, but epilepsy is no longer considered a contraindication to pregnancy because ----------- of women with epilepsy will have good outcomes:

a) More than 75%

b) More than 80%

c) More than 85%

d) More than 90%

REFERENCE: Practice parameter: management issues for women with epilepsy (summary

statement). Report of the Quality Standards Subcommittee of the American Academy of

Neurology. Neurology. 1998;51(4):944.

5. Epilepsy patients who are started on antiepileptic drugs often want to know the duration of their treatment. What would you tell a patient who enquires about how long the treatment is going to last?

a) This may vary from patient to patient and there is no fixed duration of treatment

b) 2 years seizure free

c) 3 years seizure free

d) Treatment can never be stopped

REFERENCE: Epilepsies: diagnosis and management. Clinical guideline [CG137]Published

date: 11 January 2012 https://www.nice.org.uk/guidance/cg137/chapter/1Guidance#

pharmacological-treatment

6. Middle and low-income countries struggle with large epilepsy treatment gaps. One important fact that is often forgotten is that some epilepsy is also preventable and effective individual and community measures may help to reduce epilepsy burden. Approximately what percentage of epilepsy can be prevented?

a) 10

b) 15

c) 20

d) 25

REFERENCE: Global Report – Epilepsy: a public health imperative. Published 2019.

https://www.who.int/mental_health/neurology/epilepsy/report_2019/en/

7. There is evidence that the malformation rates for some antiepileptic drug monotherapies vary with the dose of the drug at conception. This has not been demonstrated for which of the following?

a) Carbamazepine

b) Sodium Valproate

c) Phenytoin

d) Lamotrigine

REFERENCES: Tomson T, Battino D, Bonizzoni E, et al. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry. Lancet Neurol. 2011;10(7):609-617. doi:10.1016/S1474-4422(11)70107-7

8. People with epilepsy have a higher risk of death from various causes compared with the general population. Among deaths attributable to epilepsy or seizures, an important immediate cause includes SUDEP. Patients need to be informed about it. While estimates vary, what is the annual risk of SUDEP per 1000 adults with epilepsy?

a) 1

b) 2

c) 3

d) 4

REFERENCE: Sudden, Unexpected Death in Epilepsy. Orrin Devinsky, M.D. N Engl J Med

2011; 365:1801-1811 DOI: 10.1056/NEJMra1010481

9. Your patient is supposed to take her epilepsy medicine twice a day at 7 am and 7 pm. At 5 pm, she realizes that she has forgotten to take the 7 am dose. What should she do?*

a) Take the 7 pm dose immediately

b) Wait till 7 pm and take then take the medicine

c) Take the missed dose immediately and then take the 7 pm dose as usual

d) Take the missed dose immediately and wait until at least 11 pm to take the second dose

REFERENCE: https://www.epilepsysociety.org.uk/strategies-and-tools-taking-medication

EMERGENCIES

1. Generalized convulsive status epilepticus in adults and children > 5 years of age, is operationally defined as?

a) Any prolonged seizure which doesn’t respond to therapy

b) 3 or more seizures within 24 hours

c) 2 or more seizures between which there is incomplete recovery of consciousness

d) Generalized tonic-clonic seizure lasting for > 60 minutes

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published

date: January 2012 Last updated: October 2019. www.nice.org.uk/guidance/cg137/chapter/

Appendix-F-Protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-

adults-published-in-2004-and-children-published-in-2011

2. In adults, the most common etiology of status epilepticus is:

a) Antiseizure drug non-adherence or discontinuation in patients with epilepsy

b) Acute symptomatic

c) Chronic structural lesions

d) Use of, or overdose with, drugs that lower the seizure threshold

REFERENCE: Rui-Juan Lv, Qun Wang, Tao Cui, Fei Zhu, Xiao-Qiu Shao. Status epilepticus-related etiology, incidence and mortality: A meta-analysis. Epilepsy Research. Volume 136, 2017, Pages 12-17. https://doi.org/10.1016/j.eplepsyres.2017.07.006

3. What is the first line pharmacological treatment of a convulsive status epilepticus in children and adults?

a) I/v Lorazepam

b) I/v Propofol

c) I/v Phenytoin

d) I/v Valproate

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published

date: January 2012 Last updated: October 2019. www.nice.org.uk/guidance/cg137/chapter/

Appendix-F-Protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-

adults-published-in-2004-and-children-published-in-2011

4. Intravenous access may sometimes be difficult to establish in a patient presenting with convulsive status. The most studied, safe and effective initial pharmacological treatment in such a situation would be:

a) Oral Levetiracetam

b) Intramuscular midazolam

c) Intranasal midazolam

d) Oral phenytoin

REFERENCE: Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of

Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of

the American Epilepsy Society. Epilepsy Currents. 2016;16(1):48-61. doi:10.5698/1535-7597-

16.1.48

5. When do you classify an established convulsive status epilepticus as refractory?

a) When status epilepticus is not controlled in the first 10 minutes

b) When 1st line therapy fails to control status epilepticus usually around 20 minutes after initial therapy

c) When 1st and 2nd line therapy including a benzodiazepine fails to control status epilepticus usually around 60 minutes after initial therapy

d) When status epilepticus continues or recurs 24 hours or more after initial therapy

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published

date: January 2012 Last updated: October 2019. www.nice.org.uk/guidance/cg137/chapter/

Appendix-F-Protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-

adults-published-in-2004-and-children-published-in-2011

6. When do you classify an established convulsive status epilepticus as super-refractory?

a) When status epilepticus is not controlled in the first 10 minutes

b) When 1st line therapy fails to control status epilepticus usually around 20 minutes after initial therapy

c) When 1st and 2nd line therapy including a benzodiazepine fails to control status epilepticus usually around 60 minutes after initial therapy

d) When status epilepticus continues or recurs 24 hours or more after initiation of treatment with anesthetic AED’s

REFERENCE: Epilepsies: diagnosis and management Clinical guideline [CG137] Published

date: January 2012 Last updated: October 2019. www.nice.org.uk/guidance/cg137/chapter/

Appendix-F-Protocols-for-treating-convulsive-status-epilepticus-in-adults-and-children-

adults-published-in-2004-and-children-published-in-2011

COMORBIDITIES

1. What is the most common comorbidity in people with epilepsy?

a. Psychiatric comorbidities

b. Neurodegenerative comorbidities

c. Migraine

d. Stroke

REFERENCE: Global Report – Epilepsy: a public health imperative. Published 2019.

https://www.who.int/mental_health/neurology/epilepsy/report_2019/en/

2. People with epilepsy have higher rates of psychiatric disorders compared to the general population. Such comorbidities place patients with epilepsy at higher risk of poor QOL, poor adherence to medication, and increased risk of suicide. Up to what percentage of epilepsy patients have these comorbidities?

a) 10%

b) 20%

c) 30%

d) 50%

REFERENCE: Global Report – Epilepsy: a public health imperative. Published 2019.

https://www.who.int/mental_health/neurology/epilepsy/report_2019/en/

3. Some anti-epileptic drugs have mood stabilizing properties. If such drugs are being prescribed to a person with epilepsy, one needs to be watchful about occurrence of depression upon their discontinuation. Discontinuation of which of the following drugs may lead to depression?

a) Levetiracetam

b) Carbamezapine

c) Phenobarbital

d) Benzodiazepines

REFERENCE: Ettinger AB, Argoff CE. Use of antiepileptic drugs for nonepileptic conditions: psychiatric disorders and chronic pain. Neurotherapeutics. 2007;4(1):75-83. doi:10.1016/j.nurt.2006.10.003

EPILEPSY SURGERY

1. Which of the following would be the epilepsy surgery of choice in a patient with generalized (>2 EZ) drug-resistant epilepsy?

a) Selective amygdalo-hippocampectomy

b) Laser interstitial thermal therapy

c) Corpus callosotomy

d) Cortical resection

REFERENCE: A Modern Epilepsy Surgery Treatment Algorithm: Incorporating Traditional and Emerging Technologies. Dario J. Englot. Epilepsy Behav. 2018 March ; 80: 68–74. doi:10.1016/j.yebeh.2017.12.041.

2. The most common surgical procedure for mesial temporal lobe epilepsy is temporal lobe resection. This is an effective and relatively safe procedure. Which of the following about this surgery is not true?

a) Visual field defects due to the surgery are usually limited to a superior quadrant and the risk is higher for left-sided resections

b) Patients with higher pre-surgical abilities are at greater risk for memory decline following temporal lobectomy

c) Approximately one-fourth to one-third of patients develop some degree of memory loss

d) Most adults who have recurrent seizures after discontinuation of AEDs following surgery do not regain control with reinstitution of previous AEDs

REFERENCE: Schmidt, D., Baumgartner, C. and Löscher, W. (2004), Seizure Recurrence after

Planned Discontinuation of Antiepileptic Drugs in Seizure‐free Patients after Epilepsy

Surgery: A Review of Current Clinical Experience. Epilepsia, 45: 179-186.

doi:10.1111/j.0013-9580.2004.37803.x

3. Which of the following is the most common post-operative complication in patients who undergo anterior temporal lobectomy for drug-resistant temporal lobe epilepsy?

a) Language disturbances

b) Hemiparesis

c) Psychiatric disturbances

d) Cognitive impairment

EXPLANATION: In a meta-analysis conducted to estimate the postoperative mortality and

morbidity and the most frequent complications their relatve frequency associated with

Anterior temporal lobectomy for medically intractable temporal lobe epilepsy, Psychiatric

disorders were found to be the most common postoperative complication, followed by

visual field defects (VFDs) and cognitive disorders. Psychiatric disorders were the most

common postoperative complication group, with an estimated frequency as high as 0.07

(95% CI: 0.04, 0.10), followed by visual field defects (0.06; 0.03, 0.11), and cognitive

disorders (0.05; 0.02, 0.10). Less frequent complications included hemiparesis/hemiplegia

and language disorders (0.03; 0.01, 0.06), infections (0.03; 0.02, 0.04), hemorrhage (0.02;

0.01, 0.05), cranial nerve deficits (especially trochlear nerve) (0.03; 0.02, 0.05),

hydrocephalus and cerebrospinal fluid (CSF)-related disorders (0.02; 0.01, 0.04), extra- axial

fluid collections (0.02; 0.01, 0.03), and medical complications (0.02, 0.01, 0.03).

REFERENCE: Brotis AG, Giannis T, Kapsalaki E, Dardiotis E, Fountas KN. Complications after

Anterior Temporal Lobectomy for Medically Intractable Epilepsy: A Systematic Review and

Meta-Analysis. Stereotact Funct Neurosurg. 2019;97(2):69-82. doi:10.1159/000500136

4. Which of the following is not true regarding presurgical evaluation for drug refractory epilepsy surgery?

a) Presurgical evaluation for drug refractory epilepsy must be multidisciplinary

b) Video EEG monitoring and MRI are the standard requisites for forming a surgical plan

c) Neuropsychological assessment should be done in every surgical candidate

d) Intracranial EEG recordings are more accurate than scalp EEG and should be done in every surgical candidate

REFERENCE: Epilepsy surgery. Rugg-Gunn F. Pract Neurol. 2019 Aug 16. pii: practneurol-2019-

002192. doi: 10.1136/practneurol-2019-002192

BIOLOGY OF EPILEPSY

1. Which of the following zones has not been described in the estimation of the epileptogenic zone?

a) Ictal onset zone

b) Irritative zone

c) Propagative zone

d) Functional deficit zone

REFERENCE: Hans O Lüders, Imad Najm, Dileep Nair, Peter Widdess-Walsh, William

Bingman . The epileptogenic zone: general principles. Epileptic Disorders. 2006;8(2):1-9.