The document discusses various aspects of epilepsy, including: 1) Enflurane can precipitate seizures in epileptics and is contraindicated in a patient with a history of epilepsy. 2) Temporal lobe epilepsy is the most likely diagnosis for a patient presenting with short episodes of agitation and dream-like states with limb movements they do not recall. 3) Gustatory hallucinations are most commonly associated with temporal lobe epilepsy.

1. 22-year-old Suma, with a history of epilepsy is undergoing the pre-anaesthetic review. The
use of which inhalational agent is contraindicated in this patient?
A: Halothane
B:
Enfluran
e
C: Sevoflurane
D: Isoflurane
Correct Ans:B
Explanation
Enflurane can precipitate generalized tonic clonic seizure in epileptics. It is however safer than
halothane, causes less myocardiac depression and less hypotension.
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A patient presented with short lasting episodic behavioural changes which include agitation
and dream like state with thrashing movements of his limbs. He does not recall these
episodes and has no apparent precipitating factor. Which of the following is the most likely
diagnosis?
A: Panic episodes
B:
Schizophreni
a
C: Temporal lobe epilepsy
D: Dissociative disorder
Correct Ans:C
Explanation
The patient in the question has most likely suffered an attack of temporal lobe epilepsy. The
loss of consciousness need not always be present but it is associated with loss of memory
for the episode. In temporal lobe seizure, the patient usually experiences auras or warning
signs, epigastric discomfort, olfactory hallucination, sensation of deja vu. A dream like state
is often a feature of TLE. There may be loss of consciousness abnormal movement of mouth,
and rarely abnormal movement of body. Frontal lobe epilepsy is also associated with
episodes of agitation known as ‘intermittent explosive disorder’.

2. Ref: Clinical Neuroanatomy By Stephen G. Waxman, 26th Edition, Chapter 19
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Gustatory hallucinations are most commonly associated with:
A: Temporal lobe epilepsy
B:
Grand mal
epilepsy
C: Anxiety disorders
D: Tobacco dependence
Correct Ans:A
Explanation
Gustatory hallucinations are most commonly associated with temporal lobe lesions,
especially uncinate gyrus seizures. Patients report experiencing bitter, sweet, salty,
tobacco-like, metallic or indescribable strange tastes. They are found in 4% of seizure
patients with temporal lobe foci.
Ref: Clinical neuropsychology 4th Ed By Kenneth M.Heilman, Page 488.
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A 27 year old man with epilepsy presents with complaints of persistent lethargy and
occasional feelings of intoxication, although he does not consume alcohol. The patient is
currently taking phenobarbital for the long-term management of tonic-clonic seizures. In
addition, he was recently started on a medication for the treatment of gastroesophageal
reflux disease. Which of the following agents was he most likely prescribed?
A:
Cimetidin
e
B: Famotidine
C: Lansoprazole
D: Ranitidine
Correct Ans:A
Explanation

3. Cimetidine is an H2-receptor antagonist indicated for the short-term and maintenance
treatment of duodenal and gastric ulceration, as well as gastroesophageal reflux disease.
One of the primary disadvantages of using this agent, with respect to other H2-receptor
antagonists famotidine and ranitidine, is that it is a relatively potent hepatic enzyme
inhibitor. Therefore, this medication is likely to decrease the metabolism of other
hepatically metabolized medications, such as phenobarbital. When the metabolism of a
medication is decreased, the blood levels will increase, leading to an extension of the
therapeutic effect and/or toxicity. Phenobarbital is a barbiturate indicated for the
treatment of tonic-clonic seizures and status epilepticus. When the blood concentration of
this medication increases, lethargy and feelings of intoxication may occur.
Lansoprazole is a gastric acid proton-pump inhibitor indicated for the short-term and
maintenance treatment of duodenal and gastric ulceration, as well as gastroesophageal
reflux disease. This agent does not affect hepatic enzymes.
Ref: McQuaid K.R. (2012). Chapter 62. Drugs Used in the Treatment of Gastrointestinal
Diseases. In B.G. Katzung, S.B. Masters, A.J. Trevor (Eds),Basic & Clinical Pharmacology,
12e.
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At autopsy, a body is found to have copious fine leathery froth in mouth and
nostrils which increased on pressure over chest. Which of the following was the
most likely cause of death?
A: Epilepsy
B:
Hangin
g
C: Drowning
D: Opium poisoning
Correct Ans:C
Explanation
Presence of fine, white, leathery froth seen at the mouth and nostrils is one of the
most characteristic external signs of drowning. It is white or rarely blood stained,
lather-like, abundant and increase in amount with compression of chest. Even
after wiping it gradually reappears, especially if pressure is applied to the chest.
Froth is also seen in strangulation, acute pulmonary edema, electric shock,
during epileptic fit, in opium poisoning and putrefaction. But in all these cases
the quantity of froth is not as large as in drowning, and the bubbles are also
much smaller.

4. Ref: Parikh’s Textbook of Medical Jurisprudence, Forensic Medicine and
Toxicology, 6th Edition, Pages 3.66-3.67 ; Essentials of Forensic Medicine and
Toxicology By Dr K S Narayan Reddy, 27th Edition, Pages 325-6
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Corpus callosotomy is useful in treatment of:
A: Epilepsy
B:
Strok
e
C: Alzheimer’s disease
D: none of the above
Correct Ans:A
Explanation
Patients with generalized seizures, atonic seizures associated with drop attacks, or absence
seizures, who are found to have bilaterally coordinated pathologic cortical discharges on
EEG and who fail AED therapy, may be candidates for corpus callosotomy. The corpus
callosum is a large white matter tract that connects the cerebral hemispheres.
Loss of consciousness requires simultaneous seizure activity in both hemispheres. Focal or
partial seizures may spread via the corpus callosum to the contralateral hemisphere,
causing generalization and loss of consciousness. Division of the corpus callosum can
interrupt this spread.
Ref: Schwartz’s principle of surgery 9th edition, chapter 42.
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Which of the following methods of contraception should be avoided in women with
epilepsy?
A: Oral contraceptive pills
B: IUCD
C: Condoms
D: Diaphragm

5. Correct Ans:A
Explanation
All the antileptics (except for sodium valproate and clonazepam) have the property to
induce the enzyme complex which metabolizes the oral contraceptives. Hence it is better
avoided in patients with a history of epilepsy on medications. The other three methods of
contraception mentioned in the question have no such contraindication.
Ref: Dutta textbook of Obstetrics, 6th Edition, Page 545; Textbook of Gynaecology By Rao,
Page 183-184
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Which of the following drugs is not used in Juvenile Myoclonic Epilepsy (JME)?
A:
Topiramat
e
B: Zonisamide
C: Carbamezapine
D: Valproate
Correct Ans:C
Explanation
Carbamezipine, Phenytoin, Oxcarbazepine are few drugs which are capable of aggravating
Juvenile Myoclonic Epilepsy.
Ref: Epileptic Syndromes in Infancy, Childhood and Adolescence By Joseph Roger, Michelle
Bureau, Charlotte Dravet, Pierre Genton, Page 382
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6. All of the following factors are associated with a substantially greater risk of developing
epilepsy after febrile seizures, except:
A: Complex Febrile seizures
B:
Early age of
onset
C: Developmental abnormalities
D: Positive family History of Epilepsy
Correct Ans:B
Explanation
Factors increasing risk of epilepsy after febrile seizures include family history of epilepsy, a
typical seizures/complex nature of seizures and presence of a neurodevelopmental
abnormality.
Early age on onset increases the risk of recurrence of febrile convulsions.
Ref: Febrile Seizures By Tallie Z. Baram, Shlomo Shinnar, Page 63; Essential of Pediatrics By
O P Ghai, 6th Edition, Page 509
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An adolescent is brought to the emergency department following an episode of myoclonic
jerks at morning after waking up. His consciousness was not impaired. His EEG shows
generalized 3-4 Hz spike and slow wave complexes. Most probable diagnosis is?
A: Generalized tonic clonic seizure
B: Absent seizure
C: Temporal lobe epilepsy
D: Juvenile myoclonic epilepsy
Correct Ans:D
Explanation
Juvenile myoclonic epilepsy is a subtype of idiopathic generalized epilepsy with onset
usually between 8 and 20 years of age. Myoclonic jerks, especially in the morning, are of
variable intensity ranging from simple twitching (“flying saucer syndrome”) to
falls; consciousness is not impaired in it. It is precipitated by alcohol and sleep deprivation.
Patients will have normal intelligence. The typical interictal EEG abnormality consists of a
generalized 4- to 6-Hz spike or polyspike and slow-wave discharges lasting 1-20 seconds.
Usually, 1-3 spikes precede each slow wave.
Also know:

7.  In Generalized tonic clonic seizure EEG shows a normal background with
generalized epileptiform discharges such as spike or polyspike wave
complexes at 2.5 to 4 Hz.
 During absence seizures there is an abrupt onset of bilaterally
synchronous and symmetrical 3 Hz spike-wave discharge, irrespective of
whether typical absences are simple or complex.
 Ictal recordings from patients with typical temporal lobe epilepsy usually
exhibit 5-7 Hz, rhythmic, sharp theta activity, maximal in the sphenoidal
and the basal temporal electrodes on the side of seizure origin.
Ref: A-Z of Neurological Practice: A Guide to Clinical Neurology By Andrew J. Larner,
Alasdair J Coles, Neil J. Scolding, Roger A Barker, 2011, Page 368 ; Clinical
Electroencephalography by Misra,2005, Page 188
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Which one of the following is the characteristic feature of juvenile myoclonic epilepsy?
A: Myoclonic seizures frequently occur in morning
B:
Complete remission is
common
C: Response to anticonvulsants is poor
D: Associated absence seizures are present in majority of patients
Correct Ans:A
Explanation
Juvenile myoclonic epilepsy (JME) is a generalized seizure disorder of unknown cause that
appears in early adolescence and is usually characterized by bilateral myoclonic jerks that
may be single or repetitive. The myoclonic seizures are most frequent in the morning after
awakening and can be provoked by sleep deprivation. Consciousness is preserved unless
the myoclonus is especially severe. Many patients also experience generalized tonic-clonic
seizures, and up to one-third have absence seizures.
Although complete remission is relatively uncommon, the seizures respond well to
appropriate anticonvulsant medication. There is often a family history of epilepsy, and
genetic linkage studies suggest a polygenic cause.

8. Ref: Lowenstein D.H. (2012). Chapter 369. Seizures and Epilepsy. In D.L. Longo, A.S. Fauci,
D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo (Eds), Harrison's Principles of Internal
Medicine, 18e.
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Which of the following statements is incorrect in relation to pregnant women with epilepsy?
A: The rate of congenital malformation is increased in the offspring of women with epilepsy
B:
Seizure frequency increases in approximately 70% of
women
C: Breast feeding is safe with most anticonvulsants
D: Folic acid supplementation may reduce the risk of neural tube defect
Correct Ans:B
Explanation
Frequency of convulsions is unchanged in majority.
Ref:Textbook of Gynecology By D C Dutta, 6th Edition, Page 298; Harrison’s Principles of Internal
Medicine, 16th Edition, Page 2371
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Vitamin deficient is most commonly seen in a pregnant mother who is on phenytoin therapy
for epilepsy?
A: Vitamin B6
B: Vitamin B12
C: Vitamin A
D:
Folic
acid
Correct Ans:D
Explanation

9. Phenytoin interferes with metabolism of folate and patients taking phenytoin may become
deficient in folic acid. Phenytoin decreases absorption of folic acid and increases its
excretion.
Ref: Advanced Therapy in Epilepsy By Wheless, James W. Wheless, James Willmore, Roger
A. Brumback, 2009, Page 259.
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Triad of Tuberous Sclerosis includes all, except:
A: Epilepsy
B: Low intelligence
C: Hydrocephalus
D: Adenoma sebaceum
Correct Ans:C
Explanation
Diagnostic triad of Tuberous sclerosis includes epilepsy, mental retardation and adenoma
sebaceum (facial angiofibroma).
Tuberous sclerosis (TS) is an autosomal dominant disorder which result from mutations in
either the TSC1 gene encoding hamartin or the TSC2 gene encoding tuberin. Hamartin and
tubulin form a complex which negatively regulate cell growth and proliferation through
inhibition of mTOR.
Ref: Harrison’s Internal Medicine, 18th Edition, Chapter 284; The 5-Minute Neurology
Consult By D. Joanne Lynn, Page 430; Tuberous Sclerosis Complex: Genes, Clinical Features
and Therapeutics By David J. Kwiatkowsk, Page 221
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In pediatric patients, the risk of developing post-traumatic epilepsy is significantly
increased by:

10. A: Brief loss of consciousness
B: Acute intracranial hemorrhage
C: Retrograde amnesia
D: Post-traumatic vomiting
Correct Ans:B
Explanation
Late post-traumatic epilepsy is diagnosed when a seizure occurs for the first time more
than one week after a head injury. Factors that correlate with an increased risk of
developing post-traumatic epilepsy include presence of a depressed skull fracture, acute
intracranial hemorrhage, cerebral contusion, or unconsciousness lasting more than 24
hours. Because the risk of a subsequent seizure is approximately 75%, acute and chronic
treatment with anticonvulsants is indicated.
Loss of consciousness, retrograde amnesia, and vomiting are relatively common immediate
consequences of head trauma. They are usually transient and are not highly correlated with
a risk of subsequent post-traumatic seizures.
Ref: Smith W.S., English J.D., Johnston S.C. (2012). Chapter 370. Cerebrovascular Diseases.
In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo
(Eds),Harrison's Principles of Internal Medicine, 18e.
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