Stroke Flashcards
- A 72-year-old male presents to the emergency department with sudden-onset right-sided weakness and slurred speech. His last known normal time was 2 hours ago. Non-contrast CT shows no hemorrhage. What is the next best step?
A) Administer aspirin immediately
B) Initiate IV labetalol to reduce blood pressure below 120/80
C) Administer alteplase (tPA)
D) Proceed directly to endovascular thrombectomy
Answer: C) Administer alteplase (tPA)
Rationale: The patient is within the 4.5-hour window for IV thrombolysis with alteplase (tPA). Blood pressure management is only necessary if above 185/110 mmHg before tPA administration.
- A patient presents with “the worst headache of their life” and loss of consciousness. Which of the following is the most likely diagnosis?
A) Ischemic stroke
B) Subarachnoid hemorrhage
C) Transient ischemic attack
D) Myasthenia gravis crisis
Answer: B) Subarachnoid hemorrhage
Rationale: Aneurysmal subarachnoid hemorrhage classically presents with a sudden, severe headache and possible loss of consciousness.
- A 60-year-old woman presents with a 30-minute episode of left-sided weakness and facial droop that completely resolved. She has a history of hypertension and atrial fibrillation. What is the best next step in management?
A) Reassurance and discharge
B) Initiate aspirin and discharge with primary care follow-up
C) Start aspirin and perform a stroke workup including carotid ultrasound and echocardiogram
D) Administer tPA
Answer: C) Start aspirin and perform a stroke workup including carotid ultrasound and echocardiogram
Rationale: A TIA is a warning sign for stroke. Workup should include identifying the source of embolism (e.g., AFib, carotid stenosis), and secondary prevention should be initiated
- A 55-year-old man with atrial fibrillation, not on anticoagulation, develops sudden left-sided weakness and facial droop. His blood pressure is 170/100 mmHg, and he was last seen normal 6 hours ago. What is the best next step in management?
A) Administer tPA
B) Perform CT angiography to assess for large vessel occlusion
C) Give aspirin and admit for observation
D) Start IV labetalol to lower BP immediately
.
Answer: B) Perform CT angiography to assess for large vessel occlusion
Rationale: The patient is outside the 4.5-hour tPA window, but endovascular thrombectomy is an option if large vessel occlusion is confirmed. Aspirin can be given later if thrombectomy is not performed
- A 68-year-old woman presents with sudden-onset left-sided weakness and slurred speech. A CT scan shows no hemorrhage. What is the most appropriate first-line treatment if symptoms started 2 hours ago?
A) Aspirin
B) IV alteplase (tPA)
C) IV heparin
D) Endovascular thrombectomy
Answer: B) IV alteplase (tPA)
Rationale: The patient is within the 4.5-hour window for thrombolysis.
- A 75-year-old man presents with a history of uncontrolled hypertension
What is the treatment of choice?
Answer: B) Initiate IV labetalol to control BP
Rationale: In hemorrhagic stroke, BP control is key to prevent further bleeding.
- Which of the following is a contraindication to IV thrombolysis in ischemic stroke?
A) Blood pressure of 170/95 mmHg
B) Symptom onset 3 hours ago
C) History of peptic ulcer disease
D) Recent major surgery within 2 weeks
Answer: D) Recent major surgery within 2 weeks
Rationale: Bleeding risk makes tPA contraindicated.
- A patient has a stroke affecting the left middle cerebral artery. What is the expected neurological finding?
A) Right-sided hemiparesis and aphasia
B) Left-sided hemiparesis and neglect
C) Bilateral hemianopia
D) Loss of proprioception
Answer: A) Right-sided hemiparesis and aphasia
Rationale: Left MCA stroke affects motor function on the right and causes language deficits in dominant hemisphere (usually left).
- A 64-year-old man presents with transient left-sided weakness and slurred speech that resolved in 30 minutes. Which diagnostic test is most important in assessing stroke risk?
A) D-dimer
B) Carotid ultrasound
C) EEG
D) MRI of the brain
Answer: B) Carotid ultrasound
Rationale: Carotid stenosis is a major cause of TIA and stroke
- Which medication is the first-line treatment for stroke prevention in TIA?
A) Warfarin
B) Clopidogrel or aspirin
C) IV alteplase
D) Heparin
Answer: B) Clopidogrel or aspirin
Rationale: Antiplatelet therapy is recommended for stroke prevention in non-cardioembolic TIA.
- A 72-year-old male presents with acute right-sided weakness and expressive aphasia. What artery is most likely involved?
A) Left middle cerebral artery
B) Right posterior cerebral artery
C) Left anterior cerebral artery
D) Right vertebral artery
Answer: A) Left middle cerebral artery
Rationale: Left MCA stroke affects the right side and causes language deficits in most individuals.
- A patient arrives with stroke symptoms that began 6 hours ago. What is the best treatment option?
A) Administer IV tPA
B) Start dual antiplatelet therapy
C) Perform endovascular thrombectomy
D) Give IV heparin
Answer: C) Perform endovascular thrombectomy
Rationale: Endovascular thrombectomy is an option within 24 hours if large vessel occlusion is confirmed.
- A patient presents with right-sided weakness and neglect. What artery is most likely affected?
A) Left middle cerebral artery
B) Right anterior cerebral artery
C) Left posterior cerebral artery
D) Right vertebral artery
Answer: A) Left middle cerebral artery
Rationale: MCA stroke on the left side affects the right body and can cause neglect.
- Which of the following is the most common complication after a stroke?
A) Seizures
B) Depression
C) Pulmonary embolism
D) Aneurysm formation
Answer: B) Depression
Rationale: Post-stroke depression is common and leads to poorer rehabilitation outcomes.
- A patient with atrial fibrillation is being evaluated for stroke prevention. Which of the following is the best medication choice?
A) Aspirin 325 mg daily
B) Warfarin with INR goal 2-3
C) Clopidogrel 75 mg daily
D) Heparin infusion
Answer: B) Warfarin with INR goal 2-3
Rationale: Anticoagulation (warfarin or DOACs) is recommended for AFib-related stroke prevention.
A 68-year-old man presents to the ED with left-sided weakness and aphasia. His symptoms started 5 hours ago. A non-contrast CT head shows no hemorrhage. What is the most appropriate next step?
A) Administer IV alteplase
B) Perform a CT angiogram and consider thrombectomy
C) Start dual antiplatelet therapy
D) Observe for spontaneous improvement
Answer: B) Perform a CT angiogram and consider thrombectomy
A 55-year-old patient presents with right-sided weakness and gaze deviation toward the left. Which cerebral hemisphere is likely affected?
A) Left
B) Right
C) Brainstem
D) Occipital lobe
Answer: A) Left
A patient with atrial fibrillation suddenly develops unilateral weakness and facial droop. What is the most likely underlying cause?
A) Thrombotic stroke
B) Embolic stroke
C) Intracerebral hemorrhage
D) Subarachnoid hemorrhage
Answer: B) Embolic stroke
Which of the following is NOT a major risk factor for ischemic stroke?
A) Hypertension
B) Atrial fibrillation
C) Hyperlipidemia
D) Multiple sclerosis
Answer: D) Multiple sclerosis
A 72-year-old woman experiences a transient episode of unilateral weakness that resolves within 30 minutes. What is the best long-term management?
A) No intervention needed
B) Start aspirin and lifestyle modifications
C) Start thrombolytic therapy
D) Admit to ICU for continuous monitoring
Answer: B) Start aspirin and lifestyle modifications
A 40-year-old male presents with sudden onset of the “worst headache of his life.” What is the initial diagnostic test of choice?
A) MRI brain
B) Lumbar puncture
C) Non-contrast CT head
D) EEG
Answer: C) Non-contrast CT head
Which of the following is the MOST important modifiable risk factor for intracerebral hemorrhage?
A) Diabetes
B) Hypertension
C) Smoking
D) Hyperlipidemia
Answer: B) Hypertension
A patient is recovering from a subarachnoid hemorrhage. Seven days after the initial event, they develop confusion and neurological decline. What is the most likely cause?
A) Re-bleeding
B) Vasospasm
C) Meningitis
D) Hydrocephalus
Answer: B) Vasospasm
A patient presents with stroke symptoms, and a non-contrast CT head is normal. What is the next best step?
A) MRI brain
B) Lumbar puncture
C) Cerebral angiogram
D) Administer aspirin
Answer: A) MRI brain
Which medication is commonly used to prevent vasospasm after subarachnoid hemorrhage?
A) Labetalol
B) Nimodipine
C) Phenytoin
D) Alteplase
Answer: B) Nimodipine
A 65-year-old male arrives at the emergency department with sudden-onset right-sided weakness and slurred speech. His last known well time was 3 hours ago. A CT scan shows no hemorrhage, and his symptoms suggest an acute ischemic stroke.
Treatment:
* The patient weighs 80 kg.
* Tenecteplase dose = 0.25 mg/kg × 80 kg = 20 mg.
* Since the maximum dose is 25 mg, 20 mg is safe to administer.
* The medication is reconstituted and given as a single bolus over 5 seconds.
Outcome:
* The patient is transferred for potential mechanical thrombectomy (if a large vessel occlusion is suspected).
* Neurological symptoms start improving within an hour.
A 72-year-old female is brought in by her daughter, who found her unresponsive at 8 AM. The last time she was seen normal was 10 PM the night before. Since it has been 10 hours, she is outside the 4.5-hour window for tenecteplase.
Treatment:
* The patient weighs 70 kg.
* Alteplase dose = 0.9 mg/kg × 70 kg = 63 mg.
* Administration:
o 10% (6.3 mg) is given as an IV bolus over 1 minute.
o Remaining 90% (56.7 mg) is infused over 1 hour.
Outcome:
* Due to the extended time window, the patient may also undergo advanced imaging (e.g., CT perfusion) to assess salvageable brain tissue.
* Neurologic monitoring continues to watch for complications like intracerebral hemorrhage.
Drug Used and Dosage Administration
Tenecteplase 0.25 mg/kg (max 25 mg) IV bolus over 5 sec
Acute Ischemic Stroke (< 4.5 hours) ≤ 4.5 hours
Acute Ischemic Stroke (> 4.5 hours) > 4.5 hours
Alteplase 0.9 mg/kg (max 90 mg) 10% bolus in 1 min, rest over 1 hr
A 75-year-old male presents to the ED with left-sided weakness and slurred speech. His symptoms started 2 hours ago. His BP is 180/90 mmHg. What is the next best step?
A) Administer alteplase (tPA)
B) Give IV labetalol to lower BP below 140/90
C) Order a CT scan to rule out hemorrhage
D) Start dual antiplatelet therapy
Answer: C) Order a CT scan to rule out hemorrhage
A patient with an ischemic stroke is eligible for tPA. What is the contraindication for thrombolysis?
A) BP of 175/95 mmHg
B) NIH Stroke Scale (NIHSS) score of 6
C) History of ischemic stroke 2 years ago
D) Recent gastrointestinal bleeding
Answer: D) Recent gastrointestinal bleeding
A 68-year-old with an NIHSS score of 15 presents within 5 hours of symptom onset. Non-contrast CT is negative for hemorrhage. What is the best treatment option?
A) IV alteplase only
B) Endovascular thrombectomy
C) IV alteplase followed by aspirin
D) Heparin infusion
Answer: B) Endovascular thrombectomy
A patient with SAH from a ruptured aneurysm is at risk for which complication within 4–14 days?
A) Hydrocephalus
B) Vasospasm
C) Seizures
D) Hyponatremia
Answer: B) Vasospasm
A 70-year-old with a history of atrial fibrillation presents with sudden loss of consciousness and a non-contrast CT showing intracerebral hemorrhage. He is on warfarin. What is the best next step?
A) Give fresh frozen plasma (FFP)
B) Administer vitamin K and prothrombin complex concentrate (PCC)
C) Start IV heparin
D) Monitor without intervention
Answer: B) Administer vitamin K and prothrombin complex concentrate (PCC)
Which intervention is most effective in reducing the risk of stroke after a TIA?
A) IV alteplase
B) Smoking cessation
C) Daily ibuprofen
D) IV fluids
Answer: B) Smoking cessation
A 65-year-old male has a TIA, and carotid ultrasound shows 80% stenosis of the internal carotid artery. What is the best treatment?
A) Dual antiplatelet therapy
B) Endarterectomy
C) Warfarin therapy
D) Lifestyle modifications only
Answer: B) Endarterectomy
A 70-year-old patient presents with an acute ischemic stroke. What type of cerebral edema is most likely to develop in this patient?
A) Cytotoxic edema
B) Vasogenic edema
C) Interstitial edema
D) Osmotic edema
Answer: A) Cytotoxic edema
A 65-year-old male presents with right-sided hemiparesis and aphasia. Where is the most likely location of the stroke?
A) Right middle cerebral artery (MCA)
B) Left middle cerebral artery (MCA)
C) Right posterior cerebral artery (PCA)
D) Left posterior cerebral artery (PCA)
Answer: B) Left middle cerebral artery (MCA)
A patient with a history of atrial fibrillation is at increased risk for which type of stroke?
A) Embolic stroke
B) Lacunar stroke
C) Hemorrhagic stroke
D) Venous stroke
Answer: A) Embolic stroke
A patient presents with acute stroke symptoms. What is the most important first-line imaging modality?
A) MRI brain
B) Non-contrast CT head
C) CT angiogram
D) Carotid ultrasound
Answer: B) Non-contrast CT head
. A 58-year-old male presents with sudden-onset left-sided weakness and neglect. What additional sign would confirm a right MCA stroke?
A) Left gaze preference
B) Right gaze preference
C) Aphasia
D) Ataxia
Answer: B) Right gaze preference
A 70-year-old female with polycythemia vera is at risk for stroke due to:
A) Hypotension-induced cerebral hypoperfusion
B) Hyperviscosity leading to thrombosis
C) Hemorrhagic conversion
D) Vasospasm
Answer: B) Hyperviscosity leading to thrombosis
A 68-year-old male presents with an ischemic stroke 3.5 hours after symptom onset. What is the next step?
A) Administer IV TPA
B) Give aspirin 325 mg immediately
C) Start anticoagulation with heparin
D) Obtain a repeat CT scan in 24 hours
Answer: A) Administer IV TPA
What is the maximum dose of IV TPA for ischemic stroke?
A) 0.5 mg/kg up to 45 mg
B) 0.9 mg/kg up to 90 mg
C) 1.2 mg/kg up to 100 mg
D) 1.5 mg/kg up to 120 mg
Answer: B) 0.9 mg/kg up to 90 mg
. After TPA administration, how long should antiplatelet therapy be delayed?
A) 12 hours
B) 24 hours
C) 48 hours
D) 72 hours
Answer: B) 24 hours
A patient with a prior stroke and atrial fibrillation should be started on which long-term therapy?
A) Aspirin 81 mg daily
B) Clopidogrel 75 mg daily
C) Warfarin or a direct oral anticoagulant (DOAC)
D) Heparin infusion
Answer: C) Warfarin or a direct oral anticoagulant (DOAC)
. Which of the following is a modifiable risk factor for ischemic stroke?
A) Age
B) Family history
C) Hypertension
D) Patent foramen ovale
Answer: C) Hypertension
A 72-year-old patient with hypertension presents with sudden-onset headache, vomiting, and altered mental status. What is the most likely diagnosis?
A) Ischemic stroke
B) Subdural hematoma
C) Intracerebral hemorrhage (ICH)
D) Transient ischemic attack (TIA)
Answer: C) Intracerebral hemorrhage (ICH)
A patient is found to have a patent foramen ovale (PFO) after a cryptogenic stroke. What is the best next step?
A) Start long-term warfarin therapy
B) Perform PFO closure in high-risk patients
C) Start daily aspirin therapy
D) No intervention is needed
Answer: B) Perform PFO closure in high-risk patients
What is the most common cause of spontaneous intracerebral hemorrhage?
A) Aneurysm rupture
B) Hypertension
C) Amyloid angiopathy
D) Anticoagulant therapy
Answer: B) Hypertension
A patient with suspected subarachnoid hemorrhage (SAH) has a negative non-contrast CT. What is the next step?
A) MRI brain
B) Lumbar puncture
C) CT angiogram
D) Transcranial Doppler
Answer: B) Lumbar puncture
What is the first-line treatment for vasospasm prevention in subarachnoid hemorrhage (SAH)?
A) Aspirin
B) Nimodipine
C) Mannitol
D) Beta-blockers
Answer: B) Nimodipine
What is a key goal of blood pressure management in intracerebral hemorrhage?
A) Maintain systolic BP < 140 mmHg
B) Allow BP to increase for cerebral perfusion
C) Start anticoagulation to prevent secondary ischemia
D) Maintain SBP > 180 mmHg
Answer: A) Maintain systolic BP < 140 mmHg
. Which of the following is a life-threatening complication of subarachnoid hemorrhage?
A) Vasospasm
B) Seizures
C) Rebleeding
D) Hydrocephalus
Answer: C) Rebleeding
A patient presents with sudden-onset headache, photophobia, and neck stiffness. What is the most appropriate next step?
A) Administer IV TPA
B) Order a non-contrast CT head
C) Start broad-spectrum antibiotics
D) Perform an immediate lumbar puncture
Answer: B) Order a non-contrast CT head
A patient with a TIA is at highest risk of stroke within:
A) 24 hours
B) 7 days
C) 30 days
D) 90 days
Answer: D) 90 days
A patient with an ischemic stroke presents 6 hours after symptom onset. What is the most appropriate next step?
A) Administer IV TPA
B) Perform mechanical thrombectomy if large vessel occlusion is present
C) Start aspirin 325 mg immediately
D) Initiate full-dose anticoagulation
Answer: B) Perform mechanical thrombectomy if large vessel occlusion is present
A patient with a history of ischemic stroke 5 months ago presents with recurrent stroke symptoms. What is the most likely modifiable risk factor contributing to recurrence?
A) Age
B) Male sex
C) Hypertension
D) Family history of stroke
Answer: C) Hypertension
A patient is diagnosed with a right MCA stroke and is found to have atrial fibrillation. When should anticoagulation be initiated to prevent a recurrent stroke?
A) Within 24 hours
B) Within 48 hours
C) After 4-14 days, depending on infarct size
D) Never, because anticoagulation increases hemorrhage risk
Answer: C) After 4-14 days, depending on infarct size
A patient with a TIA is started on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. What is the recommended duration of DAPT for stroke prevention?
A) 7 days
B) 21-30 days
C) 3 months
D) 1 year
Answer: B) 21-30 days
A 72-year-old patient presents with a spontaneous intracerebral hemorrhage (ICH) and SBP of 200 mmHg. What is the target blood pressure?
A) SBP < 120 mmHg
B) SBP < 140 mmHg
C) SBP < 180 mmHg
D) SBP < 220 mmHg
Answer: B) SBP < 140 mmHg
A patient presents with sudden-onset headache, nausea, and altered consciousness. A CT scan shows subarachnoid hemorrhage (SAH). What is the most likely cause?
A) Cerebral amyloid angiopathy
B) Hypertensive vasculopathy
C) Ruptured intracranial aneurysm
D) Arteriovenous malformation (AVM)
Answer: C) Ruptured intracranial aneurysm
A 55-year-old patient with subarachnoid hemorrhage is at risk for vasospasm. What is the first-line prophylactic treatment?
A) Nicardipine
B) Nimodipine
C) Heparin
D) Warfarin
Answer: B) Nimodipine
2 (Scenario-Based)
A patient has a sudden onset of left-sided weakness and difficulty speaking. A CT scan reveals no hemorrhage but shows a small region of low attenuation in the right middle cerebral artery (MCA) territory. This is consistent with:
A. Ischemic stroke
B. Subarachnoid hemorrhage
C. Transient ischemic attack
D. Intracerebral hemorrhage
- A – Ischemic stroke in the MCA territory
Which factor most commonly leads to intracerebral hemorrhage?
A. Chronic, uncontrolled hypertension
B. Hypothyroidism
C. Use of statin therapy
D. Migraine with aura
- A – Chronic hypertension commonly causes ICH
A subarachnoid hemorrhage frequently arises from:
A. Small penetrating a
B. Saccular (berry) aneurysm rupture
A 58-year-old with poorly controlled hypertension suddenly develops severe headache, vomiting, and confusion. Noncontrast CT shows blood within the brain parenchyma, creating a mass effect. This presentation is most consistent with:
A. Ischemic stroke
B. Intracerebral hemorrhage
C. Subarachnoid hemorrhage
D. TIA
- B – Intracerebral hemorrhage (parenchymal bleed)
In evaluating a suspected stroke, noncontrast head CT is crucial as the first imaging step primarily to:
A. Detect ischemic changes within 2 hours
B. Differentiate hemorrhagic from ischemic stroke
C. Assess bone integrity rather than brain tissue
D. Measure cerebral perfusion directly
B. Differentiate hemorrhagic from ischemic stroke
A 70-year-old presents with acute right arm weakness and slurred speech. His glucose is normal. The most critical initial diagnostic test to confirm or exclude hemorrhage is:
A. MRI of the brain with DWI
B. Noncontrast head CT
C. Carotid duplex ultrasound
D. Lumbar puncture
- B – Noncontrast head CT is the critical first imaging test
A patient has a thunderclap headache described as “the worst headache of my life.” A noncontrast head CT is negative, but suspicion for subarachnoid hemorrhage remains high. The next best diagnostic step is:
A. Repeat noncontrast CT in 24 hours
B. Cerebral angiography
C. Lumbar puncture to look for xanthochromia
D. Electroencephalogram (EEG)
- C – Lumbar puncture to detect xanthochromia if CT is negative
Diffusion-weighted imaging (DWI) on MRI is particularly useful in ischemic stroke because it:
A. Distinguishes vasogenic from cytotoxic edema
B. Detects early infarction within minutes to hours
C. Removes the need for CT scanning
D. Only identifies chronic infarcts
- B – DWI is sensitive to early infarction
When evaluating stroke mimics, which condition often presents similarly to an acute stroke but is ruled out by checking blood glucose levels?
A. Hypoglycemia
B. Atrial fibrillation
C. Meningitis
D. Brain tumor
A. Hypoglycemia
A 65-year-old with an acute ischemic stroke arrives 2 hours after symptom onset. Noncontrast CT shows no hemorrhage. Blood pressure is 180/100 mmHg, and labs are within normal limits. The best next management step is:
A. Administer IV alteplase (tPA) if no contraindications
B. Start warfarin therapy immediately
C. Begin nimodipine
D. Wait 24 hours before initiating any therapy
- A – tPA (alteplase) if within 4.5 hours and no contraindications
Which statement is true regarding TIA management?
A. No need for any secondary prevention measures
B. Long-term antiplatelet therapy (aspirin ± clopidogrel) helps prevent stroke
C. Thrombolytics are always indicated
D. Anticoagulation is mandatory for every TIA
- B – Antiplatelet therapy is key for secondary prevention after TIA
Mechanical thrombectomy for an ischemic stroke is indicated for:
A. Large vessel occlusion in the anterior circulation within an extended time window (up to 24 hours)
B. All lacunar infarcts
C. Small vessel disease only
D. Hemorrhagic strokes
- A – Mechanical thrombectomy for large vessel occlusions up to 24 hours
A 72-year-old male presents with acute right-sided weakness and expressive aphasia. What artery is most likely involved?**
A) Left middle cerebral artery
B) Right posterior cerebral artery
C) Left anterior cerebral artery
D) Right vertebral artery
Answer: A) Left middle cerebral artery
Rationale: MCA stroke on the left side affects the right body and can cause language deficits.
A patient arrives with stroke symptoms that began 6 hours ago. What is the best treatment option?**
A) Administer IV tPA
B) Start dual antiplatelet therapy
C) Perform endovascular thrombectomy
D) Give IV heparin
Answer:** C) Perform endovascular thrombectomy
*Rationale: Endovascular thrombectomy is an option within 24 hours if large vessel occlusion is confirmed.
A 68-year-old man presents to the ED with left-sided weakness and aphasia. His symptoms started 5 hours ago. A non-contrast CT head shows no hemorrhage. What is the most appropriate next step?
A) Administer IV alteplase
B) Perform a CT angiogram and consider thrombectomy
C) Start dual antiplatelet therapy
D) Observe for spontaneous improvement
Answer: B) Perform a CT angiogram and consider thrombectomy
Stroke Symptoms and Location
A 55-year-old patient presents with right-sided weakness and gaze deviation toward the left. Which cerebral hemisphere is likely affected?
A) Left
B) Right
C) Brainstem
D) Occipital lobe
Answer: A) Left
Ischemic vs. Hemorrhagic Stroke
A patient with atrial fibrillation suddenly develops unilateral weakness and facial droop. What is the most likely underlying cause?
A) Thrombotic stroke
B) Embolic stroke
C) Intracerebral hemorrhage
D) Subarachnoid hemorrhage
Answer: B) Embolic stroke
Subarachnoid Hemorrhage
A 40-year-old male presents with sudden onset of the “worst headache of his life.” What is the initial diagnostic test of choice?
A) MRI brain
B) Lumbar puncture
C) Non-contrast CT head
D) EEG
Answer: C) Non-contrast CT head
Hemorrhagic Stroke Risk Factors
Which of the following is the MOST important modifiable risk factor for intracerebral hemorrhage?
A) Diabetes
B) Hypertension
C) Smoking
D) Hyperlipidemia
Answer: B) Hypertension
Subarachnoid Hemorrhage Complication
A patient is recovering from a subarachnoid hemorrhage. Seven days after the initial event, they develop confusion and neurological decline. What is the most likely cause?
A) Re-bleeding
B) Vasospasm
C) Meningitis
D) Hydrocephalus
Answer: B) Vasospasm
Stroke Imaging
A patient presents with stroke symptoms, and a non-contrast CT head is normal. What is the next best step?
A) MRI brain
B) Lumbar puncture
C) Cerebral angiogram
D) Administer aspirin
Answer: A) MRI brain
Hemorrhagic Stroke Management
Which medication is commonly used to prevent vasospasm after subarachnoid hemorrhage?
A) Labetalol
B) Nimodipine
C) Phenytoin
D) Alteplase
Answer: B) Nimodipine
Stroke Patient Management
A 75-year-old male presents to the ED with left-sided weakness and slurred speech. His symptoms started 2 hours ago. His BP is 180/90 mmHg. What is the next best step?
A) Administer alteplase (tPA)
B) Give IV labetalol to lower BP below 140/90
C) Order a CT scan to rule out hemorrhage
D) Start dual antiplatelet therapy
Answer: C) Order a CT scan to rule out hemorrhage
Stroke Treatment
A patient with an ischemic stroke is eligible for tPA. What is the contraindication for thrombolysis?
A) BP of 175/95 mmHg
B) NIH Stroke Scale (NIHSS) score of 6
C) History of ischemic stroke 2 years ago
D) Recent gastrointestinal bleeding
Answer: D) Recent gastrointestinal bleeding
Large Vessel Occlusion Treatment
A 68-year-old with an NIHSS score of 15 presents within 5 hours of symptom onset. Non-contrast CT is negative for hemorrhage. What is the best treatment option?
A) IV alteplase only
B) Endovascular thrombectomy
C) IV alteplase followed by aspirin
D) Heparin infusion
Answer: B) Endovascular thrombectomy
Subarachnoid Hemorrhage (SAH)
A patient with SAH from a ruptured aneurysm is at risk for which complication within 4–14 days?
A) Hydrocephalus
B) Vasospasm
C) Seizures
D) Hyponatremia
Answer: B) Vasospasm
Hemorrhagic Stroke Management
A 70-year-old with a history of atrial fibrillation presents with sudden loss of consciousness and a non-contrast CT showing intracerebral hemorrhage. He is on warfarin. What is the best next step?
A) Give fresh frozen plasma (FFP)
B) Administer vitamin K and prothrombin complex concentrate (PCC)
C) Start IV heparin
D) Monitor without intervention
Answer: B) Administer vitamin K and prothrombin complex
Transient Ischemic Attack (TIA)
. TIA Risk Reduction
Which intervention is most effective in reducing the risk of stroke after a TIA?
A) IV alteplase
B) Smoking cessation
C) Daily ibuprofen
D) IV fluids
Answer: B) Smoking cessation
Ischemic Stroke
Pathophysiology
. A 65-year-old male presents with right-sided hemiparesis and aphasia. Where is the most likely location of the stroke?
A) Right middle cerebral artery (MCA)
B) Left middle cerebral artery (MCA)
C) Right posterior cerebral artery (PCA)
D) Left posterior cerebral artery (PCA)
Answer: B) Left middle cerebral artery (MCA)
A patient with a history of atrial fibrillation is at increased risk for which type of stroke?
A) Embolic stroke
B) Lacunar stroke
C) Hemorrhagic stroke
D) Venous stroke
Answer: A) Embolic stroke
stroke Diagnostic Reasoning
. A patient presents with acute stroke symptoms. What is the most important first-line imaging modality?
A) MRI brain
B) Non-contrast CT head
C) CT angiogram
D) Carotid ultrasound
Answer: B) Non-contrast CT head
A 58-year-old male presents with sudden-onset left-sided weakness and neglect. What additional sign would confirm a right MCA stroke?
A) Left gaze preference
B) Right gaze preference
C) Aphasia
D) Ataxia
Answer: B) Right gaze preference
A 68-year-old male presents with an ischemic stroke 3.5 hours after symptom onset. What is the next step?
A) Administer IV TPA
B) Give aspirin 325 mg immediately
C) Start anticoagulation with heparin
D) Obtain a repeat CT scan in 24 hours
Answer: A) Administer IV TPA
What is the maximum dose of IV TPA for ischemic stroke?
A) 0.5 mg/kg up to 45 mg
B) 0.9 mg/kg up to 90 mg
C) 1.2 mg/kg up to 100 mg
D) 1.5 mg/kg up to 120 mg
Answer: B) 0.9 mg/kg up to 90 mg
After TPA administration, how long should antiplatelet therapy be delayed?
A) 12 hours
B) 24 hours
C) 48 hours
D) 72 hours
Answer: B) 24 hours
A patient with a prior stroke and atrial fibrillation should be started on which long-term therapy?
A) Aspirin 81 mg daily
B) Clopidogrel 75 mg daily
C) Warfarin or a direct oral anticoagulant (DOAC)
D) Heparin infusion
Answer: C) Warfarin or a direct oral anticoagulant (DOAC)
Which of the following is a modifiable risk factor for ischemic stroke?
A) Age
B) Family history
C) Hypertension
D) Patent foramen ovale
Answer: C) Hypertension
stroke complications
A patient is found to have a patent foramen ovale (PFO) after a cryptogenic stroke. What is the best next step?
A) Start long-term warfarin therapy
B) Perform PFO closure in high-risk patients
C) Start daily aspirin therapy
D) No intervention is needed
Answer: B) Perform PFO closure in high-risk patients
What is the most common emotional complication after a stroke?
A) Bipolar disorder
B) Depression
C) Psychosis
D) Mania
Answer: B) Depression
Hemorrhagic Stroke Pathophysiology
A 72-year-old patient with hypertension presents with sudden-onset headache, vomiting, and altered mental status. What is the most likely diagnosis?
A) Ischemic stroke
B) Subdural hematoma
C) Intracerebral hemorrhage (ICH)
D) Transient ischemic attack (TIA)
Answer: C) Intracerebral hemorrhage (ICH)
What is the most common cause of spontaneous intracerebral hemorrhage?
A) Aneurysm rupture
B) Hypertension
C) Amyloid angiopathy
D) Anticoagulant therapy
Answer: B) Hypertension
stroke diagnostic reasoning
A patient with suspected subarachnoid hemorrhage (SAH) has a negative non-contrast CT. What is the next step?
A) MRI brain
B) Lumbar puncture
C) CT angiogram
D) Transcranial Doppler
Answer: B) Lumbar puncture
Mangement of Subaracnoid hemorrhage
. What is the first-line treatment for vasospasm prevention in subarachnoid hemorrhage (SAH)?
A) Aspirin
B) Nimodipine
C) Mannitol
D) Beta-blockers
Answer: B) Nimodipine
What is a key goal of blood pressure management in intracerebral hemorrhage?
A) Maintain systolic BP < 140 mmHg
B) Allow BP to increase for cerebral perfusion
C) Start anticoagulation to prevent secondary ischemia
D) Maintain SBP > 180 mmHg
Answer: A) Maintain systolic BP < 140 mmHg
complications of subarachnoid hemorrhage
Which of the following is a life-threatening complication of subarachnoid hemorrhage?
A) Vasospasm
B) Seizures
C) Rebleeding
D) Hydrocephalus
Answer: C) Rebleeding
A patient with SAH develops hyponatremia. What is the most likely cause?
A) SIADH
B) Cerebral salt-wasting syndrome
C) Nephrotic syndrome
D) Adrenal insufficiency
Answer: B) Cerebral salt-wasting syndrome
A patient presents with sudden-onset headache, photophobia, and neck stiffness. What is the most appropriate next step?
A) Administer IV TPA
B) Order a non-contrast CT head
C) Start broad-spectrum antibiotics
D) Perform an immediate lumbar puncture
Answer: B) Order a non-contrast CT head
A patient with a TIA is at highest risk of stroke within:
A) 24 hours
B) 7 days
C) 30 days
D) 90 days
Answer: D) 90 days
Ischemic Stroke
A patient with an ischemic stroke presents 6 hours after symptom onset. What is the most appropriate next step?
A) Administer IV TPA
B) Perform mechanical thrombectomy if large vessel occlusion is present
C) Start aspirin 325 mg immediately
D) Initiate full-dose anticoagulation
Answer: B) Perform mechanical thrombectomy if large vessel occlusion is present
A patient with a history of ischemic stroke 5 months ago presents with recurrent stroke symptoms. What is the most likely modifiable risk factor contributing to recurrence?
A) Age
B) Male sex
C) Hypertension
D) Family history of stroke
Answer: C) Hypertension
A patient is diagnosed with a right MCA stroke and is found to have atrial fibrillation. When should anticoagulation be initiated to prevent a recurrent stroke?
A) Within 24 hours
B) Within 48 hours
C) After 4-14 days, depending on infarct size
D) Never, because anticoagulation increases hemorrhage risk
Answer: C) After 4-14 days, depending on infarct size
A patient presents with an acute ischemic stroke and has sickle cell disease. What additional therapy should be considered beyond standard stroke management?
A) Corticosteroids
B) Exchange transfusion
C) High-dose aspirin
D) Lumbar puncture
Answer: B) Exchange transfusion
A patient with a TIA is started on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. What is the recommended duration of DAPT for stroke prevention?
A) 7 days
B) 21-30 days
C) 3 months
D) 1 year
Answer: B) 21-30 days
Hemorrhagic Stroke
A 72-year-old patient presents with a spontaneous intracerebral hemorrhage (ICH) and SBP of 200 mmHg. What is the target blood pressure?
A) SBP < 120 mmHg
B) SBP < 140 mmHg
C) SBP < 180 mmHg
D) SBP < 220 mmHg
Answer: B) SBP < 140 mmHg
Answer: B) SBP < 140 mmHg
A patient presents with sudden-onset headache, nausea, and altered consciousness. A CT scan shows subarachnoid hemorrhage (SAH). What is the most likely cause?
A) Cerebral amyloid angiopathy
B) Hypertensive vasculopathy
C) Ruptured intracranial aneurysm
D) Arteriovenous malformation (AVM)
Answer: C) Ruptured intracranial aneurysm
A 55-year-old patient with subarachnoid hemorrhage is at risk for vasospasm. What is the first-line prophylactic treatment?
A) Nicardipine
B) Nimodipine
C) Heparin
D) Warfarin
Answer: B) Nimodipine
. A patient with severe subarachnoid hemorrhage is at risk for hydrocephalus. What is the best initial intervention?
A) Administer acetazolamide
B) Perform an emergent lumbar puncture
C) Place an external ventricular drain (EVD)
D) Initiate IV mannitol
Answer: C) Place an external ventricular drain (EVD)
A 67-year-old patient on warfarin presents with a large spontaneous intracranial hemorrhage. What is the best immediate intervention?
A) Administer fresh frozen plasma (FFP)
B) Give prothrombin complex concentrate (PCC) and IV vitamin K
C) Start heparin bridge therapy
D) Initiate thrombolysis
Answer: B) Give prothrombin complex concentrate (PCC) and IV vitamin K
stroke Pathophysiology & Basic Concepts
Which of the following best describes a transient ischemic attack (TIA)?
A. Neurological deficit lasting >24 hours due to permanent infarction
B. Reversible episode of focal neurologic dysfunction without acute infarction
C. Hemorrhage that typically produces severe headache
D. Permanent damage to motor tracts with no chance of recovery
B. Reversible episode of focal neurologic dysfunction without acute infarction
A patient has a sudden onset of left-sided weakness and difficulty speaking. A CT scan reveals no hemorrhage but shows a small region of low attenuation in the right middle cerebral artery (MCA) territory. This is consistent with:
A. Ischemic stroke
B. Subarachnoid hemorrhage
C. Transient ischemic attack
D. Intracerebral hemorrhage
A – Ischemic stroke in the MCA territory
Which factor most commonly leads to intracerebral hemorrhage?
A. Chronic, uncontrolled hypertension
B. Hypothyroidism
C. Use of statin therapy
D. Migraine with aura
- A – Chronic hypertension commonly causes ICH
A subarachnoid hemorrhage frequently arises from:
A. Small penetrating artery disease
B. Saccular (berry) aneurysm rupture
C. Carotid artery dissection
D. Cerebral venous sinus thrombosis
- B – Berry aneurysm rupture → subarachnoid hemorrhage
A 58-year-old with poorly controlled hypertension suddenly develops severe headache, vomiting, and confusion. Noncontrast CT shows blood within the brain parenchyma, creating a mass effect. This presentation is most consistent with:
A. Ischemic stroke
B. Intracerebral hemorrhage
C. Subarachnoid hemorrhage
D. TIA
B – Intracerebral hemorrhage (parenchymal bleed)
In evaluating a suspected stroke, noncontrast head CT is crucial as the first imaging step primarily to:
A. Detect ischemic changes within 2 hours
B. Differentiate hemorrhagic from ischemic stroke
C. Assess bone integrity rather than brain tissue
D. Measure cerebral perfusion directly
- B – Noncontrast CT quickly differentiates hemorrhage vs. ischemia
A 70-year-old presents with acute right arm weakness and slurred speech. His glucose is normal. The most critical initial diagnostic test to confirm or exclude hemorrhage is:
A. MRI of the brain with DWI
B. Noncontrast head CT
C. Carotid duplex ultrasound
D. Lumbar puncture
B – Noncontrast head CT is the critical first imaging test
A patient has a thunderclap headache described as “the worst headache of my life.” A noncontrast head CT is negative, but suspicion for subarachnoid hemorrhage remains high. The next best diagnostic step is:
A. Repeat noncontrast CT in 24 hours
B. Cerebral angiography
C. Lumbar puncture to look for xanthochromia
D. Electroencephalogram (EEG)
C – Lumbar puncture to detect xanthochromia if CT is negative
Diffusion-weighted imaging (DWI) on MRI is particularly useful in ischemic stroke because it:
A. Distinguishes vasogenic from cytotoxic edema
B. Detects early infarction within minutes to hours
C. Removes the need for CT scanning
D. Only identifies chronic infarcts
- B – DWI is sensitive to early infarction
When evaluating stroke mimics, which condition often presents similarly to an acute stroke but is ruled out by checking blood glucose levels?
A. Hypoglycemia
B. Atrial fibrillation
C. Meningitis
D. Brain tumor
- A – Hypoglycemia can mimic stroke
Ischemic Stroke & TIA
A 65-year-old with an acute ischemic stroke arrives 2 hours after symptom onset. Noncontrast CT shows no hemorrhage. Blood pressure is 180/100 mmHg, and labs are within normal limits. The best next management step is:
A. Administer IV alteplase (tPA) if no contraindications
B. Start warfarin therapy immediately
C. Begin nimodipine
D. Wait 24 hours before initiating any therapy
- A – tPA (alteplase) if within 4.5 hours and no contraindications
Which statement is true regarding TIA management?
A. No need for any secondary prevention measures
B. Long-term antiplatelet therapy (aspirin ± clopidogrel) helps prevent stroke
C. Thrombolytics are always indicated
D. Anticoagulation is mandatory for every TIA
- B – Antiplatelet therapy is key for secondary prevention after TIA
Mechanical thrombectomy for an ischemic stroke is indicated for:
A. Large vessel occlusion in the anterior circulation within an extended time window (up to 24 hours)
B. All lacunar infarcts
C. Small vessel disease only
D. Hemorrhagic strokes
- A – Mechanical thrombectomy for large vessel occlusions up to 24 hours
For intracerebral hemorrhage (ICH) with high systolic blood pressure (SBP), the recommended target SBP range to reduce further bleeding while maintaining perfusion is often:
A. <120 mmHg
B. 180–200 mmHg
C. 140–160 mmHg
D. No BP management is necessary
- C – SBP ~140–160 mmHg for ICH
A 52-year-old with an acute intracerebral hemorrhage has a significantly elevated BP of 220/110 mmHg. Which medication might be used to carefully lower BP in this scenario?
A. Subcutaneous heparin
B. IV labetalol or nicardipine infusion
C. Oral β-blocker once daily
D. Thrombolytics
- B – IV labetalol or nicardipine to carefully lower BP
In subarachnoid hemorrhage from a ruptured aneurysm, which medication helps prevent cerebral vasospasm?
A. tPA (alteplase)
B. Warfarin
C. Nimodipine
D. Phenytoin
- C – Nimodipine prevents vasospasm in SAH
A patient with a large intracerebral hemorrhage develops Cushing’s triad (hypertension, bradycardia, irregular respirations). This signifies:
A. Improved intracranial compliance
B. Imminent brain herniation and possible death
C. High glucose levels
D. Recovery of motor function
- B – Cushing’s triad indicates rising ICP and possible herniation
A 70-year-old post-ischemic stroke patient remains bedridden. He develops fever, productive cough, and infiltrates on chest X-ray. Which common complication is likely?
A. Pneumonia
B. UTI
C. Seizure
D. Intracerebral hemorrhage
- A – Pneumonia is a common complication in bedridden stroke patients
Post-stroke depression is very common. Which approach is typically recommended?
A. No screening is needed because it resolves spontaneously
B. Early screening and treatment with psychotherapy and/or antidepressants
C. Anticoagulation alone
D. Strict bedrest
- B – Post-stroke depression warrants early screening and possible antidepressants
A patient who survived a subarachnoid hemorrhage is at risk for:
A. Vasospasm leading to delayed cerebral ischemia
B. Immediate complete recovery
C. Zero chance of re-bleeding
D. Inability to develop hydrocephalus
A – Vasospasm is a well-known risk in SAH survivors
Which of the following best characterizes an ischemic stroke?
A. Bleeding into brain tissue causing increased intracranial pressure
B. Acute occlusion of a cerebral artery leading to tissue ischemia and infarction
C. Rupture of a saccular aneurysm in the subarachnoid space
D. Gradual accumulation of cerebrospinal fluid in the ventricles
- B – Occlusion of a cerebral artery leads to ischemia and infarction
A 67-year-old patient with atrial fibrillation suddenly develops right-sided weakness and difficulty speaking. This presentation most likely suggests which type of stroke etiology?
A. Thrombotic stroke due to atherosclerosis
B. Embolic stroke from a cardiac source
C. Venous sinus thrombosis
D. Hemorrhagic stroke due to hypertension
- B – Embolic stroke from an atrial fibrillation source
Thrombotic ischemic stroke typically results from:
A. Bacterial infection in the sinuses
B. Rupture of a saccular aneurysm
C. Atherosclerosis leading to plaque rupture and in situ clot formation
D. Direct trauma to the scalp
- C – Atherosclerosis with plaque rupture → thrombosis in situ
In an ischemic stroke, brain tissue death can begin within:
A. Seconds of arterial occlusion
B. 4–10 minutes of lost perfusion
C. 4–10 hours of occlusion
D. Only after 24 hours
- B – Brain tissue can begin to die within 4–10 minutes
Which common cause of intracerebral hemorrhage leads to bleeding into the brain tissue?
A. Uncontrolled hypertension causing vessel rupture
B. Venous thromboembolism
C. Rupture of the external carotid artery
D. Sudden drop in intracranial pressure
- A – Hypertension leading to rupture of small vessels
A 58-year-old patient with long-standing poorly controlled hypertension arrives with severe headache and confusion. A CT scan confirms bleeding within the parenchyma of the left hemisphere. This presentation aligns with:
A. Ischemic stroke
B. Subarachnoid hemorrhage
C. Intracerebral hemorrhage
D. Transient ischemic attack
- C – Intracerebral hemorrhage in the parenchyma
In an intracerebral hemorrhage, the mass effect described in the study guide refers to:
A. Complete resolution of swelling
B. Air replacing tissue in the skull
C. Compression of surrounding brain tissue leading to increased intracranial pressure
D. Benign tumor formation at the bleed site
- C – Mass effect = compression of surrounding tissue → ↑ICP
A patient complains of a sudden, excruciating headache often described as the “worst headache of my life.” CT findings show blood in the subarachnoid space around the circle of Willis. Which pathophysiologic event most likely caused this bleed?
A. Embolic clot lodging in a small artery
B. Rupture of a berry (saccular) aneurysm
C. Gradual atherosclerotic plaque formation
D. Hypertensive lacunar stroke
- B – Rupture of a berry aneurysm in the subarachnoid space
In subarachnoid hemorrhage, increased intracranial pressure primarily results from:
A. Arterial dissection in the carotid artery
B. Diffuse vasospasm in the spinal cord
C. Blood entering the CSF-filled space, irritating meninges, and blocking CSF reabsorption
D. Complete closure of the ventricles
- C – Blood in CSF space → meningeal irritation, blocked CSF reabsorption, ↑ICP
A key difference between ischemic and hemorrhagic strokes is that hemorrhagic strokes:
A. Always have a longer onset period
B. Cause tissue ischemia solely through plaque rupture
C. Involve bleeding into or around brain tissue, increasing ICP
D. Can never cause mass effect or sudden neurologic decline
- C – Hemorrhagic strokes involve bleeding, often raising ICP
Stroke clinical presentation
A 70-year-old patient presents with sudden onset of left-sided weakness and numbness. On examination, he is unable to understand simple commands and struggles to speak coherently. This clinical picture most likely suggests a stroke involving:
A. Right hemisphere
B. Left hemisphere
C. Cerebellum
D. Brainstem
- B – Left hemisphere stroke → right-sided weakness + language deficits
Which of the following symptoms is most characteristic of a right-sided stroke?
A. Aphasia (speech/language deficit)
B. Right gaze preference
C. Neglect of the left side
D. Right visual field deficit
- C – Neglect of the left side is typical of a right-sided (right hemisphere) stroke
A patient complains of sudden severe headache and vomiting, followed by confusion and neck stiffness. These symptoms may indicate:
A. Ischemic stroke due to carotid atherosclerosis
B. Migraine with aura
C. Subarachnoid hemorrhage causing increased intracranial pressure
D. Transient ischemic attack (TIA)
- C – Sudden severe headache + vomiting → SAH with ↑ICP suspicion
A 60-year-old experiences unilateral visual loss (“curtain coming down”) that resolves within minutes. This brief monocular blindness, often called amaurosis fugax, is considered a form of:
A. Hemorrhagic stroke
B. Stroke mimic, likely migraine
C. TIA affecting retinal circulation
D. Vertigo from cerebellar dysfunction
- C – TIA in the retinal circulation (amaurosis fugax)
A patient presents with acute confusion, difficulty speaking, and right hemiparesis. Which additional clinical feature would strongly suggest a left hemisphere stroke?
A. Left-sided neglect
B. Aphasia
C. Left visual field deficit
D. Right gaze preference
- B – Aphasia is strongly associated with left hemisphere strokes (in most right-handed individuals)
Stroke imaging
Which initial imaging study is most critical to differentiate hemorrhagic vs. ischemic stroke in the acute setting?
A. MRI with diffusion-weighted imaging (DWI)
B. Noncontrast head CT scan
C. CT angiography (CTA)
D. Ultrasound of the carotid artery
- B – Noncontrast head CT quickly rules out hemorrhage vs. ischemia
In a patient with a suspected acute ischemic stroke, CT angiography (CTA) is primarily used to:
A. Assess vessel occlusion and detect aneurysms
B. Show the earliest signs of infarction
C. Rule out hemorrhage
D. Identify perfusion deficits in real time
- A – CTA checks for vessel occlusion/aneurysms
labs for stroke
Why is a blood glucose check essential in evaluating sudden-onset neurologic deficits that mimic a stroke?
A. Hypoglycemia can produce similar focal neurologic symptoms
B. Hyperglycemia rules out TIA
C. Elevated glucose always indicates hemorrhage
D. Blood glucose has no relevance to stroke diagnosis
- A – Hypoglycemia can mimic stroke, so checking glucose is critical
A 62-year-old with new-onset left hemiparesis undergoes MRI with diffusion-weighted imaging (DWI). The MRI shows a bright signal in the right MCA territory. What does this typically indicate?
A. Chronic infarction of uncertain age
B. Early acute ischemia
C. A normal variant
D. Subarachnoid hemorrhage
- B – DWI “bright signal” indicates acute ischemia
labs for stroke
A patient suspected of having a stroke undergoes blood tests for CBC, electrolytes, renal function, and lipid profile. These labs are primarily done to:
A. Diagnose chronic infections
B. Confirm hemorrhage
C. Identify modifiable risk factors (e.g., hyperlipidemia) and coexisting conditions
D. Rule out migraines
- C – Labs identify risk factors, coexisting issues (lipids, renal function, etc.)
A 75-year-old presenting with acute right-sided weakness has labs showing an INR of 3.5, aPTT above normal, and low platelets. Before administering any thrombolytic, the team must:
A. Administer it immediately
B. Correct coagulopathy or confirm the patient’s eligibility, as abnormal coagulation increases bleeding risk
C. Immediately place a ventriculostomy
D. Ignore the INR level for stroke management
- B – Correct coagulopathy or confirm eligibility before thrombolysis
A seizure can mimic an acute stroke. Which postictal phenomenon might closely resemble stroke symptoms?
A. Todd’s paralysis (transient focal weakness after a seizure)
B. Continuous myoclonic jerking
C. Sudden improvement of neurologic deficits
D. Tonic-clonic activity
- A – Todd’s paralysis can mimic stroke post-seizure
A 50-year-old arrives with left-sided weakness, but imaging and labs are normal. The nurse notes the patient becomes incoherent under stress but recovers quickly when distracted. This raises suspicion for:
A. Cerebellar infarct
B. Conversion disorder (functional neurologic symptom)
C. Small lacunar stroke
D. Hemorrhagic lesion in the right basal ganglia
- B – Conversion disorder may mimic stroke but normal imaging/labs and variable symptoms
A 68-year-old with sudden speech difficulty and right facial droop arrives in the ED. Noncontrast head CT is negative for hemorrhage, and an MRI DWI confirms an acute infarction. Labs show normal glucose and INR. CT angiography indicates possible right MCA occlusion. Which of the following is the most appropriate next step in the diagnostic process?
A. Perform a lumbar puncture
B. Obtain a carotid duplex ultrasound
C. Assess for large vessel occlusion amenable to mechanical thrombectomy
D. Wait 6 hours to see if symptoms resolve spontaneously
- C – After confirming ischemic stroke, evaluate for large vessel occlusion → possible mechanical thrombectomy
*Clinical signs of stroke important to
Distinguish left vs. right hemisphere involvement (aphasia vs. neglect).
Which of the following can also mimic a stroke and must be ruled out during initial assessment?
A. Hypertensive encephalopathy
B. Meningitis
C. Common cold
D. Sinusitis
- A – Hypertensive encephalopathy can present with focal neuro deficits or confusion
Stroke imaging
- Imaging Noncontrast CT to rule out hemorrhage, then MRI DWI for early ischemia, CTA for vessel occlusion.
Stroke Labs
- Labs: Check glucose and coagulation to exclude mimics or contraindications to thrombolysis.
Seizures (Todd’s paralysis), hypoglycemia, hypertensive encephalopathy, conversion disorders.
Mimic strokes
Acute of stroke-stabilizing (A B C )
A 68-year-old with decreased consciousness from a large left MCA stroke has shallow respirations and oxygen saturation at 88%. According to acute stroke guidelines, which intervention is most crucial first?
A. Administer high-dose corticosteroids
B. Secure the airway via intubation if needed to protect airway/oxygenation
C. Immediate suboccipital decompression
D. Give IV mannitol
- B – Secure the airway if consciousness is decreased or oxygenation compromised
For a patient with an ischemic stroke who qualifies for thrombolysis, the systolic blood pressure (SBP) should be maintained at or below:
A. 185 mmHg
B. 200 mmHg
C. 160 mmHg
D. 140 mmHg
- A – SBP <185 mmHg before thrombolysis in ischemic stroke
According to the study guide, alteplase (tPA) for acute ischemic stroke is generally administered if the patient presents within:
A. 24 hours of symptom onset
B. 4.5 hours of symptom onset
C. 2 hours of symptom onset
D. 10 hours of symptom onset
- B – Alteplase window is up to 4.5 hours for eligible patients
Tenecteplase, used off-label for acute ischemic stroke, has which typical dosing schedule?
A. 0.25 mg/kg IV push over 5 seconds (max 25 mg)
B. 0.9 mg/kg over 1 hour (max 90 mg)
C. 1 mg/kg IV infusion over 2 hours
D. 0.1 mg/kg subcutaneous bolus
- A – Tenecteplase dose is 0.25 mg/kg IV push over ~5 seconds (max 25 mg)
A 70-year-old with a confirmed ischemic stroke arrives 3 hours after onset of symptoms. CT scan shows no hemorrhage. Which step best aligns with recommended management?
A. Administer alteplase (tPA) if no contraindications
B. Plan for surgical clipping of an aneurysm
C. Administer subcutaneous heparin immediately
D. Wait 6 hours to see if symptoms improve spontaneously
- A – Give IV alteplase if within 4.5 hours and no contraindications
A 65-year-old with a large vessel occlusion in the left MCA is identified via CT angiography. She presented 10 hours after symptom onset. Based on guidelines, the best next management step is:
A. No intervention is possible after 6 hours
B. Mechanical thrombectomy can be considered up to 24 hours in selected patients
C. Administer alteplase
D. Give mannitol for suspected increased ICP
- B – Mechanical thrombectomy can be done up to 24 hours for select large vessel occlusions
Which antiplatelet therapy is commonly initiated within 48 hours of an acute ischemic stroke to prevent recurrence?
A. Warfarin
B. Aspirin (± clopidogrel or dipyridamole)
C. Nimodipine
D. IV heparin
- B – Aspirin ± clopidogrel or dipyridamole within 48 hours for secondary prevention
Supportive care for ischemic stroke includes maintaining glucose below what approximate threshold to reduce complications?
A. < 250 mg/dL
B. < 180 mg/dL
C. < 80 mg/dL
D. < 300 mg/dL
- B – Goal glucose <180 mg/dL
A patient with an acute ischemic stroke is found to have atrial fibrillation (AF). After the acute phase and appropriate timing, which class of medication is indicated to reduce the risk of embolic stroke?
A. Antiplatelets only
B. Anticoagulants (e.g., warfarin or DOACs)
C. IV Mannitol
D. No therapy is needed if AF is paroxysmal
- B – Anticoagulation (e.g., warfarin, DOAC) is indicated for AF after ischemic stroke
A 70-year-old with an acute ischemic stroke is relatively immobile. To prevent complications like DVT and pressure ulcers, which measure is most appropriate?
A. Complete bedrest without turning
B. Early mobilization, mechanical compression devices, and low-molecular-weight heparin
C. High-dose IV heparin
D. Avoid repositioning to prevent pain
- B – Early mobilization, mechanical prophylaxis, LMWH to prevent DVT/pressure ulcers
In intracerebral hemorrhage, the recommended systolic blood pressure goal is approximately:
A. 120–130 mmHg
B. 200–220 mmHg
C. 140–160 mmHg
D. No need to control BP
- C – Target SBP ~140–160 mmHg in ICH
A 60-year-old with a spontaneous intracerebral hemorrhage has an elevated BP of 210/110 mmHg. Which IV medication might be used per protocol to carefully reduce BP?
A. IV nicardipine or labetalol infusion
B. Subcutaneous heparin
C. Alteplase
D. No need to lower blood pressure in hemorrhagic stroke
- A – IV nicardipine or labetalol to lower BP carefully in ICH
Management of intracranial pressure (ICP) in intracerebral hemorrhage can include:
A. Elevating the head of the bed and possibly using an external ventricular drain (EVD)
B. High-dose steroids in all hemorrhagic cases
C. Routine sedation with propofol for 7 days
D. Immediate mannitol infusion in every hemorrhagic stroke
- A – ICP management includes HOB elevation, possible EVD
A 55-year-old with a ruptured berry aneurysm is diagnosed with subarachnoid hemorrhage (SAH). To secure the aneurysm, two common approaches include:
A. Mechanical thrombectomy or intravenous tPA
B. Clipping via open surgery or endovascular coiling
C. Lumbar puncture or suboccipital craniotomy
D. Beta-blockers or radiofrequency ablation
- B – Clipping or coiling are standard aneurysm-securing procedures in SAH
In subarachnoid hemorrhage, nimodipine is used to:
A. Treat seizures
B. Lower intracranial pressure
C. Prevent cerebral vasospasm
D. Reverse coagulopathy
- C – Nimodipine prevents vasospasm in subarachnoid hemorrhage
A B C of stroke managment
A 65-year-old with a severe left MCA stroke becomes increasingly drowsy, and his gag reflex is diminished. Which life-threatening complication is most likely if no intervention is done?
A. Post-stroke depression
B. Loss of airway protection and subsequent aspiration
C. Recurrent TIA
D. Mild headache only
- B – Loss of airway protection leads to aspiration/airway compromise
A patient with a brainstem stroke is at highest risk for:
A. Hemorrhagic conversion
B. Massive muscle spasms
C. Respiratory failure due to compromised respiratory centers
D. Foot drop with minimal arm involvement
- C – Brainstem strokes can compromise respiratory centers → respiratory failure
Massive hemorrhage following an acute intracerebral bleed often leads to:
A. Slow recovery over several months
B. Rapid neurologic decline and potential death
C. Immediate relief of pressure in the skull
D. Minimal impact on mental status
- B – Massive hemorrhage → rapid decline, potential death
A 70-year-old who received alteplase for ischemic stroke develops a sudden drop in consciousness, with CT showing a large intraparenchymal bleed. This describes:
A. Post-stroke depression
B. Hemorrhagic conversion
C. Seizure activity
D. Benign transformation
- B – Hemorrhagic conversion after thrombolysis
Cerebral edema after a significant ischemic stroke can cause:
A. Decreased intracranial pressure
B. Enhanced venous return
C. Increased intracranial pressure leading to herniation
D. Protection from further infarction
- C – Cerebral edema → ↑ICP, possible herniation
Common therapies to control cerebral edema include:
A. Hypertonic saline or mannitol
B. Long-term steroid infusions
C. Routine vasopressors
D. Prolonged hyperventilation for several days
- A – Hyperosmolar therapy (mannitol, hypertonic saline) for edema
A patient’s neurological deficits suddenly worsen 24 hours post-ischemic stroke. Imaging suggests expanding infarct. Which factor likely contributed to this secondary brain injury?
A. Immediate revascularization
B. Delayed or inadequate reperfusion
C. Use of prophylactic antibiotics
D. Excess sedation
- B – Delayed or insufficient reperfusion can worsen infarct expansion
Which infection is particularly common in hospitalized stroke patients due to immobility and potential swallowing deficits?
A. Skin abscesses
B. Hepatitis
C. Pneumonia
D. Meningitis
- C – Pneumonia due to aspiration risk, immobility
Urinary tract infections (UTIs) often arise in stroke patients because of:
A. Excess fluid intake
B. Frequent sedation
C. Indwelling catheters or incomplete bladder emptying
D. All stroke patients have kidney dysfunction
- C – UTIs often from catheters or incomplete emptying
A 58-year-old with a large hemorrhagic stroke develops tonic-clonic movements involving the right side of the body. Post-event, he remains confused. This scenario most likely indicates:
A. Autonomic dysreflexia
B. Partial meningeal irritation
C. Seizure in the setting of cortical or hemorrhagic involvement
D. Post-stroke depression
- C – Seizures more common in hemorrhagic/cortical strokes
Post-stroke depression is considered “really common.” The best approach to this complication is:
A. Ignore symptoms unless severe
B. Early screening and possible treatment with antidepressants/therapy
C. Restrict all social interactions
D. Assume it will not affect recovery
- B – Early screening and treatment for post-stroke depression
Hemiparesis, aphasia, and neglect are examples of:
A. Transient deficits that always resolve spontaneously
B. Permanent deficits that never change
C. Common post-stroke motor/sensory deficits based on lesion location
D. Symptoms exclusive to hemorrhagic stroke
- C – Common post-stroke deficits based on lesion location
A patient with a right MCA stroke exhibits left-sided weakness, neglect of the left visual field, and emotional lability. Over time, these motor/sensory deficits can persist. Which statement is correct about these deficits?
A. They always fully resolve within one week
B. They may improve with rehabilitation but can remain partially for life
C. They represent hemorrhagic conversion
D. They do not affect daily functioning
- B – They may partially improve but can persist
A major concern post-stroke is recurrent stroke. To reduce this risk, it’s essential to address:
A. Hypertension, diabetes, and anticoagulation needs (if indicated)
B. Only dietary fiber intake
C. Refusing all physical therapy
D. Never using any medications
- A – Control HTN, DM, and use anticoagulation if indicated
Question 15
Which airway issue arises when a stroke patient loses the swallow or gag reflex?
A. Improved airway clearance
B. Aspiration pneumonia risk
C. Lower risk of infection
D. Better speech production
- B – Aspiration pneumonia risk due to swallowing/gag reflex loss
A 59-year-old with a history of a large ischemic stroke is admitted for pneumonia. On assessment, you find he has dysphagia and has had multiple episodes of choking. This repeated pattern of aspiration risk best falls under which complication category?
A. Secondary brain injury
B. Infections (pneumonia) from airway compromise
C. Post-stroke depression
D. Motor deficit only
- B – Pneumonia from repeated aspiration = infection risk
When discussing what will kill a stroke patient, which scenario is least likely?
A. Uncontrolled intracranial pressure (ICP) leading to herniation
B. Massive hemorrhage or hemorrhagic conversion
C. Mild, stable hemiparesis
D. Respiratory failure due to brainstem involvement
- C – Mild hemiparesis is less likely to be fatal than hemorrhage/ICP/respiratory failure
Which of the following harms the patient by extending or aggravating neurologic injury?
A. Early reperfusion
B. Delayed thrombectomy
C. Antibiotic therapy for pneumonia
D. Seizure prophylaxis
- B – Delayed thrombectomy extends neurologic injury
Regarding “what is really common,” which statement is true?
A. Post-stroke depression occurs in a small minority of patients
B. Motor deficits are typically short-lived and never require rehab
C. Recurrent strokes are common if risk factors are not addressed
D. Few stroke patients have any sensory deficits
- C – Recurrent strokes are common if risk factors not addressed
A 72-year-old discharged after an acute ischemic stroke returns with another stroke within 6 months. He admits to not taking his antihypertensive or anticoagulant medications as prescribed. Which factor most likely contributed to his recurrent stroke?
A. Inadequate control of modifiable risk factors
B. Post-stroke depression
C. Complete motor recovery
D. Seizure activity
- A – Poor compliance with risk factor management leads to recurrent stroke
Massive hemorrhage, high ICP, respiratory failure
What kills the stroke patient
Secondary injury (edema, lack of reperfusion), infections, seizures
What harms the stroke patient?
Depression, ongoing deficits, recurrent stroke
What’s common in stroke paient
in stroke What will kill your patient
(ABCs—airway, breathing, circulation, massive hemorrhage)
In stroke What will harm your patient?
(secondary injury, complications such as infection, seizures)
in stroke 3. What is really common?
(post-stroke depression, motor deficits, recurrent stroke)
Which of the following best describes a transient ischemic attack (TIA)?
A. Neurological deficit lasting >24 hours due to permanent infarction
B. Reversible episode of focal neurologic dysfunction without acute infarction
C. Hemorrhage that typically produces severe headache
D. Permanent damage to motor tracts with no chance of recovery
- B – TIA = reversible focal deficits without infarction
A patient has a sudden onset of left-sided weakness and difficulty speaking. A CT scan reveals no hemorrhage but shows a small region of low attenuation in the right middle cerebral artery (MCA) territory. This is consistent with:
A. Ischemic stroke
B. Subarachnoid hemorrhage
C. Transient ischemic attack
D. Intracerebral hemorrhage
- A – Ischemic stroke in the MCA territory
Which factor most commonly leads to intracerebral hemorrhage?
A. Chronic, uncontrolled hypertension
B. Hypothyroidism
C. Use of statin therapy
D. Migraine with aura
- A – Chronic hypertension commonly causes ICH
A subarachnoid hemorrhage frequently arises from:
A. Small penetrating artery disease
B. Saccular (berry) aneurysm rupture
C. Carotid artery dissection
D. Cerebral venous sinus thrombosis
- B – Berry aneurysm rupture → subarachnoid hemorrhage
1.
A 58-year-old with poorly controlled hypertension suddenly develops severe headache, vomiting, and confusion. Noncontrast CT shows blood within the brain parenchyma, creating a mass effect. This presentation is most consistent with:
A. Ischemic stroke
B. Intracerebral hemorrhage
C. Subarachnoid hemorrhage
D. TIA
- B – Intracerebral hemorrhage (parenchymal bleed)
In evaluating a suspected stroke, noncontrast head CT is crucial as the first imaging step primarily to:
A. Detect ischemic changes within 2 hours
B. Differentiate hemorrhagic from ischemic stroke
C. Assess bone integrity rather than brain tissue
D. Measure cerebral perfusion directly
- B – Noncontrast CT quickly differentiates hemorrhage vs. ischemia
A 70-year-old presents with acute right arm weakness and slurred speech. His glucose is normal. The most critical initial diagnostic test to confirm or exclude hemorrhage is:
A. MRI of the brain with DWI
B. Noncontrast head CT
C. Carotid duplex ultrasound
D. Lumbar puncture
- B – Noncontrast head CT is the critical first imaging test
A patient has a thunderclap headache described as “the worst headache of my life.” A noncontrast head CT is negative, but suspicion for subarachnoid hemorrhage remains high. The next best diagnostic step is:
A. Repeat noncontrast CT in 24 hours
B. Cerebral angiography
C. Lumbar puncture to look for xanthochromia
D. Electroencephalogram (EEG)
- C – Lumbar puncture to detect xanthochromia if CT is negative
Diffusion-weighted imaging (DWI) on MRI is particularly useful in ischemic stroke because it:
A. Distinguishes vasogenic from cytotoxic edema
B. Detects early infarction within minutes to hours
C. Removes the need for CT scanning
D. Only identifies chronic infarcts
- B – DWI is sensitive to early infarction
A 65-year-old with an acute ischemic stroke arrives 2 hours after symptom onset. Noncontrast CT shows no hemorrhage. Blood pressure is 180/100 mmHg, and labs are within normal limits. The best next management step is:
A. Administer IV alteplase (tPA) if no contraindications
B. Start warfarin therapy immediately
C. Begin nimodipine
D. Wait 24 hours before initiating any therapy
- A – tPA (alteplase) if within 4.5 hours and no contraindications
When evaluating stroke mimics, which condition often presents similarly to an acute stroke but is ruled out by checking blood glucose levels?
A. Hypoglycemia
B. Atrial fibrillation
C. Meningitis
D. Brain tumor
- A – Hypoglycemia can mimic stroke
Which statement is true regarding TIA management?
A. No need for any secondary prevention measures
B. Long-term antiplatelet therapy (aspirin ± clopidogrel) helps prevent stroke
C. Thrombolytics are always indicated
D. Anticoagulation is mandatory for every TIA
- B – Antiplatelet therapy (aspirin ± clopidogrel) is key for secondary prevention after TIA
Mechanical thrombectomy for an ischemic stroke is indicated for:
A. Large vessel occlusion in the anterior circulation within an extended time window (up to 24 hours)
B. All lacunar infarcts
C. Small vessel disease only
D. Hemorrhagic strokes
- A – Mechanical thrombectomy for large vessel occlusions up to 24 hours
For intracerebral hemorrhage (ICH) with high systolic blood pressure (SBP), the recommended target SBP range to reduce further bleeding while maintaining perfusion is often:
A. <120 mmHg
B. 180–200 mmHg
C. 140–160 mmHg
D. No BP management is necessary
- C – SBP ~140–160 mmHg for ICH
A 52-year-old with an acute intracerebral hemorrhage has a significantly elevated BP of 220/110 mmHg. Which medication might be used to carefully lower BP in this scenario?
A. Subcutaneous heparin
B. IV labetalol or nicardipine infusion
C. Oral β-blocker once daily
D. Thrombolytics
- B – IV labetalol or nicardipine to carefully lower BP
In subarachnoid hemorrhage from a ruptured aneurysm, which medication helps prevent cerebral vasospasm?
A. tPA (alteplase)
B. Warfarin
C. Nimodipine
D. Phenytoin
- C – Nimodipine prevents vasospasm in SAH
Question 17
A patient with a large intracerebral hemorrhage develops Cushing’s triad (hypertension, bradycardia, irregular respirations). This signifies:
A. Improved intracranial compliance
B. Imminent brain herniation and possible death
C. High glucose levels
D. Recovery of motor function
- B – Cushing’s triad indicates rising ICP and possible herniation
A 70-year-old post-ischemic stroke patient remains bedridden. He develops fever, productive cough, and infiltrates on chest X-ray. Which common complication is likely?
A. Pneumonia
B. UTI
C. Seizure
D. Intracerebral hemorrhage
Pneumonia is a common complication in bedridden stroke patients
Post-stroke depression is very common. Which approach is typically recommended?
A. No screening is needed because it resolves spontaneously
B. Early screening and treatment with psychotherapy and/or antidepressants
C. Anticoagulation alone
D. Strict bedrest
B. Post-stroke depression warrants early screening and possible antidepressants
A patient who survived a subarachnoid hemorrhage is at risk for:
A. Vasospasm leading to delayed cerebral ischemia
B. Immediate complete recovery
C. Zero chance of re-bleeding
D. Inability to develop hydrocephalus
- A – Vasospasm is a well-known risk in SAH survivors
stroke management
tPA timing, BP control, thrombectomy, SAH vasospasm prophylaxis
Management of stroke key concern
Complications of stroke include
Cushing’s triad (herniation), pneumonia, post-stroke depression, vasospasm
A 67-year-old patient with atrial fibrillation suddenly develops right-sided weakness and difficulty speaking. This presentation most likely suggests which type of stroke etiology?
A. Thrombotic stroke due to atherosclerosis
B. Embolic stroke from a cardiac source
C. Venous sinus thrombosis
D. Hemorrhagic stroke due to hypertension
- B – Embolic stroke from an atrial fibrillation source
Thrombotic ischemic stroke typically results from:
A. Bacterial infection in the sinuses
B. Rupture of a saccular aneurysm
C. Atherosclerosis leading to plaque rupture and in situ clot formation
D. Direct trauma to the scalp
- C – Atherosclerosis with plaque rupture → thrombosis in situ
Which of the following best characterizes an ischemic stroke?
A. Bleeding into brain tissue causing increased intracranial pressure
B. Acute occlusion of a cerebral artery leading to tissue ischemia and infarction
C. Rupture of a saccular aneurysm in the subarachnoid space
D. Gradual accumulation of cerebrospinal fluid in the ventricles
- B – Occlusion of a cerebral artery leads to ischemia and infarction
In an ischemic stroke, brain tissue death can begin within:
A. Seconds of arterial occlusion
B. 4–10 minutes of lost perfusion
C. 4–10 hours of occlusion
D. Only after 24 hours
- B – Brain tissue can begin to die within 4–10 minutes
Which common cause of intracerebral hemorrhage leads to bleeding into the brain tissue?
A. Uncontrolled hypertension causing vessel rupture
B. Venous thromboembolism
C. Rupture of the external carotid artery
D. Sudden drop in intracranial pressure
- A – Hypertension leading to rupture of small vessels
A 58-year-old patient with long-standing poorly controlled hypertension arrives with severe headache and confusion. A CT scan confirms bleeding within the parenchyma of the left hemisphere. This presentation aligns with:
A. Ischemic stroke
B. Subarachnoid hemorrhage
C. Intracerebral hemorrhage
D. Transient ischemic attack
- C – Intracerebral hemorrhage in the parenchyma
In an intracerebral hemorrhage, the mass effect described in the study guide refers to:
A. Complete resolution of swelling
B. Air replacing tissue in the skull
C. Compression of surrounding brain tissue leading to increased intracranial pressure
D. Benign tumor formation at the bleed site
- C – Mass effect = compression of surrounding tissue → ↑ICP
A patient complains of a sudden, excruciating headache often described as the “worst headache of my life.” CT findings show blood in the subarachnoid space around the circle of Willis. Which pathophysiologic event most likely caused this bleed?
A. Embolic clot lodging in a small artery
B. Rupture of a berry (saccular) aneurysm
C. Gradual atherosclerotic plaque formation
D. Hypertensive lacunar stroke
- B – Rupture of a berry aneurysm in the subarachnoid space
In subarachnoid hemorrhage, increased intracranial pressure primarily results from:
A. Arterial dissection in the carotid artery
B. Diffuse vasospasm in the spinal cord
C. Blood entering the CSF-filled space, irritating meninges, and blocking CSF reabsorption
D. Complete closure of the ventricles
- C – Blood in CSF space → meningeal irritation, blocked CSF reabsorption, ↑ICP
A key difference between ischemic and hemorrhagic strokes is that hemorrhagic strokes:
A. Always have a longer onset period
B. Cause tissue ischemia solely through plaque rupture
C. Involve bleeding into or around brain tissue, increasing ICP
D. Can never cause mass effect or sudden neurologic decline
- C – Hemorrhagic strokes involve bleeding, often raising ICP
A 70-year-old patient presents with sudden onset of left-sided weakness and numbness. On examination, he is unable to understand simple commands and struggles to speak coherently. This clinical picture most likely suggests a stroke involving:
A. Right hemisphere
B. Left hemisphere
C. Cerebellum
D. Brainstem
- B – Left hemisphere stroke → right-sided weakness + language deficits
A patient complains of sudden severe headache and vomiting, followed by confusion and neck stiffness. These symptoms may indicate:
A. Ischemic stroke due to carotid atherosclerosis
B. Migraine with aura
C. Subarachnoid hemorrhage causing increased intracranial pressure
D. Transient ischemic attack (TIA)
C. Subarachnoid hemorrhage causing increased intracranial pressure
Rationale: – Sudden severe headache + vomiting → SAH with ↑ICP suspicion
Which of the following symptoms is most characteristic of a right-sided stroke?
A. Aphasia (speech/language deficit)
B. Right gaze preference
C. Neglect of the left side
D. Right visual field deficit
- C – Neglect of the left side is typical of a right-sided (right hemisphere) stroke
A 60-year-old experiences unilateral visual loss (“curtain coming down”) that resolves within minutes. This brief monocular blindness, often called amaurosis fugax, is considered a form of:
A. Hemorrhagic stroke
B. Stroke mimic, likely migraine
C. TIA affecting retinal circulation
D. Vertigo from cerebellar dysfunction
- C – TIA in the retinal circulation (amaurosis fugax)
A patient presents with acute confusion, difficulty speaking, and right hemiparesis. Which additional clinical feature would strongly suggest a left hemisphere stroke?
A. Left-sided neglect
B. Aphasia
C. Left visual field deficit
D. Right gaze preference
- B – Aphasia is strongly associated with left hemisphere strokes (in most right-handed individuals)
Which initial imaging study is most critical to differentiate hemorrhagic vs. ischemic stroke in the acute setting?
A. MRI with diffusion-weighted imaging (DWI)
B. Noncontrast head CT scan
C. CT angiography (CTA)
D. Ultrasound of the carotid artery
- B – Noncontrast head CT quickly rules out hemorrhage vs. ischemia
- In a patient with a suspected acute ischemic stroke, CT angiography (CTA) is primarily used to:
A. Assess vessel occlusion and detect aneurysms
B. Show the earliest signs of infarction
C. Rule out hemorrhage
D. Identify perfusion deficits in real time
- A – CTA checks for vessel occlusion/aneurysms
- Why is a blood glucose check essential in evaluating sudden-onset neurologic deficits that mimic a stroke?
A. Hypoglycemia can produce similar focal neurologic symptoms
B. Hyperglycemia rules out TIA
C. Elevated glucose always indicates hemorrhage
D. Blood glucose has no relevance to stroke diagnosis
- A – Hypoglycemia can mimic stroke, so checking glucose is critical
- A 75-year-old presenting with acute right-sided weakness has labs showing an INR of 3.5, aPTT above normal, and low platelets. Before administering any thrombolytic, the team must:
A. Administer it immediately
B. Correct coagulopathy or confirm the patient’s eligibility, as abnormal coagulation increases bleeding risk
C. Immediately place a ventriculostomy
D. Ignore the INR level for stroke management
- B – Correct coagulopathy or confirm eligibility before thrombolysis
- A patient suspected of having a stroke undergoes blood tests for CBC, electrolytes, renal function, and lipid profile. These labs are primarily done to:
A. Diagnose chronic infections
B. Confirm hemorrhage
C. Identify modifiable risk factors (e.g., hyperlipidemia) and coexisting conditions
D. Rule out migraines
- C – Labs identify risk factors, coexisting issues (lipids, renal function, etc.)
A 62-year-old with new-onset left hemiparesis undergoes MRI with diffusion-weighted imaging (DWI). The MRI shows a bright signal in the right MCA territory. What does this typically indicate?
A. Chronic infarction of uncertain age
B. Early acute ischemia
C. A normal variant
D. Subarachnoid hemorrhage
- B – DWI “bright signal” indicates acute ischemia
