BinAmir Epilepsy

A 24-year-old college student presents with uncontrolled epilepsy. His seizures consist of an aura of déjà vu followed by oral automatisms and periods of unresponsiveness. The neurological examination is normal. MRI of the brain is performed and shown below. What is the etiology of this patient’s epilepsy?

Which of the following is not a side effect of topiramate?

A 6-year-old girl presents to the clinic with frequent episodes of awakening from sleep in extreme fear. Sometimes she has a brief twitching of the limbs with this. She has these events in clusters on some nights, lasting seconds to minutes. On further questioning, you discover the mother had a similar problem when she was around this age, which slowly got better over time. Both patient and mother are otherwise healthy with no intellectual deficits or symptomatic features. Which of the following gene mutations do they both likely share?

What is the most likely clinical scenario related to the EEG provided below?

A 34-year-old man with medically-refractory epilepsy has an MRI brain completed. The lesion shown (T2 sequence) does not enhance with contrast. If a surgical resection was performed, which of the following would be the most likely seen on pathologic analysis?

A 28-year-old woman of Chinese descent was recently diagnosed with focal/symptomatic epilepsy. Which of the following medications should best be avoided in the management of her epilepsy?

Which of the anti-seizure medications (ASMs) listed operates under zero-order kinetics at high doses?

An 8-year-old boy with no significant past medical history is brought to the clinic due to difficulties in school. His mother states that over the past year, she has received multiple phone calls from his teacher about his lack of concentration in class. On multiple occasions when asked a question, the patient would blankly stare at the wall and ignore the teacher, but then would return to his normal, talkative self immediately after each episode. An EEG is ordered, which shows 3 Hz generalized spike and wave discharges. The patient would most likely benefit from a medication targeting what?

Which of the following medications increase the risk of contraceptive failure in patients taking estrogen-containing oral contraceptive pills (OCPs)?

An 18-year-old male presents to the ED after having his first generalized tonic-clonic seizure. MRI was unremarkable but a routine EEG showed 4-6 Hz polyspike and wave discharges in sleep. Which of the following antiepileptic drugs are most appropriate to start based on the available information?

You are caring for a 1-year-old girl with severe refractory epilepsy with frequent focal seizures. She had normal developmental until 3 months of age when she had seizure onset as well as a loss of milestones. Continuous EEG revealed multiple seizure types, with multiple foci of onset in each hemisphere. The seizures appear to migrate between hemispheres on EEG, and clinically. Which gene is most often associated with this disorder?

A 54-year-old male with hypertension, hyperlipidemia, and atrial fibrillation on warfarin is newly diagnosed with epilepsy. Of the following medications, which is the most appropriate anti-seizure medication to prescribe?

What clinical diagnosis does this EEG tracing suggest?

A full-term (40 weeks gestational age) male had an uncomplicated delivery with good APGAR scores. However, the family has noticed unexplained episodes of tremulousness. Because of these abnormal movements, an EEG was ordered. Which of the following is the most accurate description of the findings shown in the epoch below?

Which of the following is a necessary requirement for electrocerebral inactivity (ECI) testing?

A 67-year-old woman with a past medical history of osteoporosis, hypertension, bipolar disorder, and a remote right MCA stroke is referred to the epilepsy clinic after experiencing her first epileptic seizure. An EEG has shown right temporal epileptiform discharges. Which of the following medications are most appropriate to start as initial therapy?

The electrographic pattern appreciated in the 6th second of this recording likely represents which of the following?

Which direction are the patient’s eyes moving at the points marked by the green circles?

Identify the electrographic pattern appreciated at electrode P3 in the EEG below:

The EEG pattern on this bipolar EEG recording is most consistent with which of the following epilepsy syndromes?

Which of the following EEG artifacts is prominently seen on this EEG?

What seizure type is most commonly seen with the pathology shown in the image below?

The pathology slide below is most consistent with which of the following disorders?

A 68-year-old woman presents to the emergency room with a 3-month history of worsening cognition, ataxia, dysphagia, and periodic episodes of brachial dystonia, and facial grimacing. A continuous EEG was performed but no EEG correlate was seen with the abnormal movements. An autoimmune process is suspected. Which of the following serum autoantibodies is most likely present?

What is the mechanism of action of phenobarbital?

A 6-year-old Amish female presents to the emergency department with a 2-month history of gradual cognitive decline and jerking limb movements. A routine EEG was obtained (see below). Which of the following diseases is consistent with these EEG findings?

A 7-year-old boy with no significant past medical history presents to the clinic after declining school performance and daydreaming. A routine EEG is performed and shown below (bipolar montage). Which of the following medications is the most appropriate first-line therapy?

A 14-year-old male is evaluated in your clinic for seizures. Past medical history is significant for brief staring spells in elementary school. Now the patient is having generalized seizures especially when he is sleep-deprived. Additionally, the patient has recently been experiencing jerky movements of both arms in the morning, resulting in him dropping objects from his hands. An EEG shows generalized 4-6 Hz polyspike and wave discharges. What is the most likely diagnosis?

A 4-year-old girl with multiple seizure types and intellectual disability has an EEG performed that shows 1.5 Hz to 2.5 Hz spike and wave discharges. Which of the following is the most likely diagnosis?

The epileptologist’s EEG report for a patient in the neuro-ICU identifies a “burst suppression” pattern. Which of the following is not a criterion required to diagnose burst suppression?

Which of the following antiepileptic drugs can induce myoclonic seizures?

The EEG shown below is consistent with which of the following?

Hyperammonemia is a side effect seen with which of the following antiepileptic drugs?

Which of the following is the most common cause of focal clonic seizures in full-term neonates?

A 28-year-old woman with a history of intractable epilepsy presents to you for outpatient follow-up. She has been seizure-free on valproic acid and levetiracetam for the last 18 months. She reports a desire to become pregnant and asks if she has an increased risk of in-utero defects with her medications. Which of the following is the most appropriate answer to this question?

Which of the following is most strongly associated with an increased risk of seizure recurrence after a first unprovoked seizure?

What is the state of the patient in the EEG shown below?

A patient with medically-refractory epilepsy has an MRI brain performed as part of their pre-surgical workup. Based on the imaging provided, what type of seizures is this patient most likely experiencing?

What is the electrographic pattern seen best in the right temporal electrodes?

Identify the finding shown in the EEG below:

Which of the following is not a known side effect of chronic phenytoin use?

Which of the following conditions is most likely to have an associated disorder of abnormal motor activity during the following sleep state?

Which of the following EEG patterns is typically seen over the age of 50?

A 21-year-old woman with a past medical history of depression presents with recurrent episodes of out-of-body sensations lasting 30 seconds. This may be followed by 1-2 minutes of staring and unresponsiveness that she does not remember. She often remains confused for 10 minutes after an event. They occur 1-3 times every 2 weeks. An MRI brain is done and shows no pathology. Which test is the most diagnostically valuable next step in her workup?

The following is a sample of gray matter stained with Anti-NeuN and viewed under a low-power microscope lens. The pathology marked by the blue arrow is most consistent with which of the following causes of epilepsy?

A 7-year-old male with a history of multiple febrile seizures has recently presented repeatedly with new recurrent non-febrile clonic seizures. Which of the following gene mutations is associated with this epilepsy syndrome?

A 27-year-old man presents after having an unprovoked generalized tonic-clonic seizure. Which of the following should he be told regarding his clinical situation?

Which of the following is appreciated in the right posterior quadrant in the EEG shown below?

What task is likely being performed during this EEG recording?

A 19-year-old female who was admitted to the epilepsy monitoring unit for medically refractory epilepsy had one of her typical seizures captured during recording (see below). Which of the following symptoms did the patient most likely experience at the time of this recording?

Which way are the patient’s eyes moving at the point of the asterisk marked below?

A 4-day-old full-term baby is brought to the hospital for two episodes of generalized stiffening and apnea for less than 1 minute followed by a return to baseline. The physical exam is unremarkable and CTH is negative. The mother reports having similar episodes shortly after birth. What is the most likely cause of the episodes?

A 6-year-old developmentally normal male presents after experiencing an episode of jerking of the right side of his mouth and inability to speak lasting 2 minutes. The patient is now back to baseline and has an EEG performed. Based on this clinical picture, which of the following abnormalities would you most expect to see on the EEG?

Stevens-Johnson syndrome associated with carbamazepine use is more likely in patients with which of the following HLA alleles?

A patient with a history of focal to bilateral tonic-clonic seizures has an EEG performed to see if they have responded to levetiracetam. Based on the EEG below, from which region of the brain does epileptiform activity arise?

Deep brain stimulation has been FDA approved for the management of medically refractory epilepsy when it targets which of the following structures?

What sensitivity should the EEG be at to qualify for brain death criteria?

A 4-month-old male with no significant past medical history was admitted to the epilepsy monitoring unit with episodes concerning for possible seizures. The family has noticed that events tend to occur when the child is angry. One episode is captured during his stay. The first symptoms appreciated were excessive crying followed by loss of tone and a few myoclonic jerks for 20 seconds. The patient then rapidly returned to baseline thereafter. There were no epileptiform discharges seen during this episode. Based on the most likely diagnosis, what is the most appropriate next step in management?

An 8-year-old patient with new-onset seizures has an MRI performed after seeing you in the clinic. Based on the lesion appreciated in the image, what seizure type does this patient most likely experience?

Which of the following medications is considered a first-line agent for the management of juvenile myoclonic epilepsy?

Estrogen-containing oral contraceptive pills are known to reduce serum levels of which of the following medications?

An 8-year-old girl is noted to have staring spells during class by her teacher. In the office, you are able to provoke an event by having her blow repeatedly into a pinwheel. What is the most likely underlying pathology of her disease?

Identify the pattern seen in the 5th second of this EEG recording.

A focal seizure must involve how much cortex in order to be appreciated with scalp EEG recording?

Which of the following is most consistent with this EEG tracing?

The electrical fields that generate the cortical activity appreciated on electroencephalogram (EEG) are the result of which of the following?

Identify the finding noted with a blue arrow.

A 4-year-old male with no significant past medical history presents to the emergency room after experiencing a first-time seizure. An EEG is obtained and captures a seizure arising from the left hemisphere and polymorphic delta slowing on the same side. Over the next several months the child continues to experience focal-onset seizures despite being on 2 maximally-dosed seizure medications. His brain MRI, below, shows asymmetric left-hemispheric atrophy. His clinic presentation and imaging are most consistent with which of the following diseases?

A 35-year-old female with a history of heroin abuse was found unresponsive and received 35 minutes of CPR before a return of spontaneous circulation (ROSC). She was intubated in the field and was brought urgently to the hospital. While in the ICU, the nursing staff noticed abnormal movements concerning for possible seizure. An EEG was performed and shown below. What is this finding most consistent with?

A 5-month-old female is brought to the emergency room by her parents because of an episode concerning for possible seizure. On arrival, the patient appears back to her clinical baseline neurologically. Several hypomelanotic lesions are appreciated while performing a skin check. The mother notes that her older brother has similar skin findings. An EEG is performed and shown below. A typical event was captured that correlated with an electrodecrement of cortical activity on EEG.

Based on the child’s diagnosis, what is the most appropriate therapy?

A 32-year-old Chinese male is referred to the epilepsy clinic after experiencing two episodes concerning for possible seizures. The first episode was unwitnessed, but the patient states that there was an abrupt loss of consciousness and that he woke up with the side of his tongue bitten and generalized myalgias. The second event was witnessed by his wife who noticed one day that the patient was unresponsive and lip-smacking for 2 minutes before returning back to baseline. MRI brain was performed and showed left-sided mesial temporal sclerosis. Which of the following medications should be avoided for this patient?

Based on the EEG shown below, how old is this patient?

The EEG pattern shown below is most consistent with which of the following?

A 40-year-old male with bilateral mesial sclerosis and medically refractory epilepsy presents to the epilepsy monitoring unit for a presurgical evaluation. His current anti-seizure medication regimen includes levetiracetam, lamotrigine, and clobazam. Over three days and weaned medication, the patient had 7 seizures; four from the left temporal lobe, and three from the right temporal lobe. Which of the following is the most appropriate next step in treatment?

A mother and father bring in their 8-month-old son to your clinic for clinical events described as sudden flexion of the limbs and trunk, seen most often upon awakening or falling asleep. His interictal EEG is demonstrated below. Which of the following is the most likely cause of the patient’s symptoms and EEG findings?

A patient with an unclear history of epilepsy has an EEG performed. Based on the region of her epileptiform activity, what is the most likely semiology of her clinical seizures?

A 26-year-old physics teacher and mother on valproic acid (VPA) for epilepsy presents to your clinic with her husband stating she wishes to try to become pregnant soon. She asks how anti-seizure medications (ASMs) used during pregnancy may impact the intelligence and school performance of her child. Which is the most accurate response?

The combination of lamotrigine and which of the following drugs increases the risk of lamotrigine toxicity?

Sleep spindles can be asynchronous until what age?

A 45-year-old man suffered a cardiac arrest after a heroin overdose. He received 30 minutes of CPR with an eventual return of spontaneous circulation. After being cooled per post-arrest protocol the patient was rewarmed. 48 hours after being warmed the patient remained in a persistent comatose state with minimal brainstem reflexes. To evaluate the degree of hypoxic-ischemic injury an EEG was ordered. Which of the following EEG patterns carries the worst prognosis after a hypoxic-ischemic injury?

A 19-year-old male presents to the ED during finals week of college after he had witnessed generalized convulsive activity on the floor of his dorm room. He has since returned to baseline. He states he has never had shaking like this before, other than when he wakes in the morning he’ll get an occasional twitch or two. An EEG is performed as below. Which is the treatment of choice?

An 18-year-old woman with a history of symptomatic epilepsy presents with medically-refractory seizures. An MRI brain is performed during presurgical evaluation and reveals the non-contrast-enhancing lesion shown below on T2 FLAIR. This lesion is most likely which of the following?

Which of the following anti-seizure medications carries the highest risk of major congenital malformations?

Which of the following is associated with a “delta brush” pattern on EEG?

A 6-year-old male with a history of medically-refractory epilepsy (on three anti-seizure medications), and right-sided-hemiparesis, presents to the emergency room with a three-day history of continuous right facial twitching. Symptoms persist during sleep and have not responded to benzodiazepines. On examination, the patient has retained awareness despite the continuous facial movements. MRI brain was performed and shown below. Of the following, which is the most appropriate therapy to achieve seizure freedom?

A 42-year-old female with a history of epilepsy has an EEG performed while establishing care with a new provider. She admits to knowing very little about what type of epilepsy she has. A 10-second epoch of her study is shown below. Based on the available data, what medication should be avoided in the management of her epilepsy?

A 32-year-old male with a longstanding history of epilepsy secondary to mesial temporal sclerosis returns to your clinic. Despite being on appropriate doses of levetiracetam and valproic acid he continues to have 20 partial seizures and 4 generalized tonic-clonic seizures per month. Which of the following is the next best step in his care?

A 24-year-old male with no known past medical history experienced a first-time generalized tonic-clonic seizure while at work. She is now in the emergency room and back to her neurological baseline. Bloodwork was unremarkable. A routine EEG and MRI of the brain were normal. Which is the most appropriate next step in management?

A 35-year-old male presents to the neurology clinic for the management of seizures. The patient reports having focal to bilateral tonic-clonic seizures (FTBTC) since the age of 15. His seizures are usually preceded by the smell of burning rubber. He will then have left hand automatisms followed by whole-body tonic-clonic activity. Levetiracetam monotherapy was initially effective. However, 1 year ago seizures returned, occurring once every two months. Lacosamide was added 6 months ago but there has been no significant improvement in his seizure frequency. Levels of these two anti-seizure medications (ASMs) are therapeutic and there have been no concerns regarding medication adherence. What is the most appropriate next step in management?

Which of the following seizure characteristics are typically seen in patients with temporal lobe epilepsy?

A 9-year-old boy with no significant past medical history was referred to get an EEG because of declining school performance and concern for staring vs. daydreaming episodes. Hyperventilation was performed and shown below. His EEG was otherwise unremarkable. Based on the available data which is the most appropriate next clinical step?

A 30-year-old woman with well-controlled epilepsy with lamotrigine monotherapy comes to the clinic today stating that she and her husband are planning to start a family. Which of the following statements is most correct regarding her clinical situation?