Long answer:

Q1: Most patients with epilepsy fall into one of the following treatment categories:
– New Seizures
– Recurrent Seizures
– Multiple Seizures/Status epilepticus
• Determining serum levels of drugs
Blood levels of the anticonvulsant drugs should be measured in samples taken just prior to a
scheduled dose
• For a single seizure no acute change in medication is mandated
• Even if there has been no interruption of drug therapy and anticonvulsant drug levels are in
the therapeutic rangeà Slight increase in prescribed dose
• If the history or serum drug levels suggest that treatment has been interruptedàThe
prescribed drug should be started again as for new seizures
•
• 2. Changing to a second drug—seizures continue to occur after maximum therapeutic
benefit has been achieved with the initial drugànot only that blood levels of the drug are in the
therapeutic range but also that drug toxicity precludes further dosage increments
• An anticonvulsant that has failed to alter seizure frequency should be discontinued gradually
once therapeutic levels of the second drug have been achieved
• If the first drug has produced partial control of the seizure disorder, it is often continued
along with the second drug
• The newer anticonvulsants may be helpful adjunctive medications for patients who respond
suboptimally to conventional anticonvulsant drugs
• CONVENTIONAL anticonvulsants: Phenobarbital, Phenytoin, Carbamazepine,Valproic acid
Benzodiazepine,Ethosuximide, Primidone àNEWER anticonvulsants: Gabapentin, amotrigine
Topiramate, Vigabatrin Oxcarbazepine Levetiracetam, Zonisamide Tiagabine
· 3. Treating refractory seizures—disabling seizures persist despite trials of all major
anticonvulsants, alone and in combination—and at the highest doses the patient can tolerate. no
treatable cause can be found
· seizures are not due to a progressive
neurodegenerative disease
Q1 (continued)....
- medical treatment has been unsuccessful for at least 2 years
· evaluation for possible surgical therapy

• Presurgical evaluation begins with a detailed history and neurologic examination to explore
the cause of seizures and their site of origin within the brain and to document the adequacy of
prior attempts at medical treatment
• MRI and electrophysiologic studies are performed to identify the epileptogenic zone within
the brain
Several electrophysiologic techniques can be used
– EEG
– Stereotactic depth electrode EEG
– Electrocorticography
Several electrophysiologic techniques can be used
• EEG, in which cerebral electrical activity is recorded noninvasively from the scalp
• Stereotactic depth electrode EEG , in which activity is recorded from electrodes inserted
(depth electrodes) into the brain or placed over the brain surface (subdural electrodes)
• Electrocorticography, which involves intraoperative recording from the surface of the brain

When an epileptogenic zone can be identified in this manner and its removal is not expected to
produce undue neurologic impairment, surgical excision may be indicated.
• Patients with complex partial seizures arising from a single temporal lobe are the most
frequent surgical candidates
• seizures freeà50%
• frequency of the seizures reducedà25%

Hemispherectomy and corpus callosum section are also sometimes used to treat intractable
epilepsy

• Vagal nerve stimulation

implantation of a device that stimulates the vagus nerve with electrical impulses
− reduce seizure frequency by as much as 50% in adults and children with refractory epilepsy
Short answer 4. Coma: Reduced alertness and responsiveness in severest form , a deep sleeplike
state from which the patient cannot be aroused.
Part2. Q3 Wallenbergs syndrome: Lateral medullary syndrome is a neurological disorder causing a
range of symptoms due to ischemia in the lateral part of the medulla oblongata in the brainstem.
The ischemia is a result of a blockage in the posterior inferior cerebellar artery or one of its
branches. Lateral medullary syndrome is also called Wallenberg syndrome, posterior inferior
cerebellar artery syndrome, PICA syndrome, Vertebral artery syndrome, and Wallenberg's
syndrome.
short ans 2. Brown – Sequard’s syndrome: It is a loss of sensation and motor function that is
caused by the lateral hemisection of the spinal cord. It is characterized by loss of motor function,
loss of vibration sense and fine touch, loss of proprioception, loss of 2-point discrimination, and
signs of weakness on the ipsilateral side of the spinal injury. On the contralateral of the lesion,
there will be a loss of pain and temperature sensation.
Long answer Q3:
Long answer Q3:
Criteria:
1. Understand the mechanism or illness that led up to brain death
2. Exclude conditions which may influence examination (Hypothermia, Sedating
Medications/Toxins, Paralytic Agents, Severe Peripheral Nervous System Disease)
-The cause of coma must be known
-Sedative drug intoxication, hypothermia, neuromuscular blockade and shock must be ruled out
- Deep coma- The patient must be unresponsive to sensory input, including pain and speech.
- No spontaneous breath
- Absent brainstem reflexes- Pupillary, corneal, and oropharyngeal responses are absent
- Isoelectric EEG(flat)
- No cerebral blood flow(Transcranial Doppler)
-Silent short –latency somatosensory evoked potential(SLSEP)
- Last at least 12 hours

• Eye response:
There are four grades starting with the most severe:
1. No eye opening
2. Eye opening in response to pain stimulus. (a peripheral pain stimulus, such as squeezing the
lunula area of the patient's fingernail is more effective than a central stimulus such as a trapezius
squeeze, due to a grimacing effect).
3. Eye opening to speech.
4. Eyes opening spontaneously

• Verbal response
1. No verbal response
2. Incomprehensible sounds.
3. Inappropriate words.
4. Confused.
5. Oriented.

• Motor response
1. No motor response
2. Decerebrate posturing accentuated by pain (extensor response)
3. Decorticate posturing accentuated by pain (flexor response)
4. Withdrawal from pain (Absence of abnormal posturing)
5. Localizes to pain (Purposeful movements towards painful stimuli)
6. Obeys commands

• Generally, brain injury is classified as:

-Severe, with GCS < 8–9
-Moderate, GCS 8 or 9–12 (controversial)[4]
-Minor, GCS ≥ 13.
• The GCS has limited applicability to children, especially below the age of 36 months 、
Dementia 、 aphasia and mental patient
Short answer 1. Lhermitte's sign : was described by Marie and Chatelin and named after Jean
Lhermitte. This sign is mostly described as an electric shock like condition by some patients of
multiple sclerosis. This sensation occurs when the neck is moved in a wrong way or rather flexed.
It can also travel down to the spine, arms, and legs, and sometimes the trunk. Demyelination and
hyperexcitability are the main pathophysiological reasons depicted for the Lhermitte's sign. Other
causes for Lhermitte's sign include transverse myelitis, behçet's disease, trauma, etc.
Case Study
1)Meniere’s Disease

2)-Repeated episodes of dizziness

-Episodes of dizziness increasing from few minutes to many hours
-Nausea and vomiting
-Abnormal sounds such as ringing, buzzing and paper-rolling
-Has sensorineural hearing loss in one ear (left ear)

3)Acoustic Neuroma- Acoustic Neuroma should be ruled out in any unilateral sensorineural
hearing and therefore in patients with Meniere’s Disease.

Vestibular Migraine- Though both Vestibular Migraine and Meniere’s Disease patients have
overlapping symptoms; Vestibular Migraines can be ruled out. This is because patients with
Vestibular Migraine are more likely to have visual auras (compared to Meniere’s Disease patients
who report aural fullness in the ear). Also, in Vestibular Migraine hearing loss is usually very mild
as compared to Meniere’s Disease.