Stroke SAEs Flashcards
Which clinical examination finding increases the likelihood that a stroke patient has had an ischemic stroke and NOT a hemorrhagic stroke?
(a) Neck stiffness
(b) Cervical bruit
(c) Diastolic blood pressure greater than 110 mm Hg (d) Headache
There are two fundamental types of stroke and differentiating the two types of
stroke has become more important as the use of thrombolytics in the acute management of stroke
has become more important. Runchey and McGee in a review of 19 prospective articles with
data from 6438 patients found that the following clinical findings increased the probability of
hemorrhagic stroke: coma, neck stiffness, seizures, diastolic blood pressure greater than 110 mm
Hg, vomiting and headache. While other findings (cervical bruit and prior transient ischemic
attack) decreased the probability of hemorrhagic stroke and made ischemic stroke more probable.
However, no specific finding or combination of findings was definitively diagnostic.
Which is the most significant risk factor for a stroke?
(a) Smoking
(b) Hypertension
(c) Age
(d) Diabetes
Answer: (c)
Commentary: Age is the single most important risk factor for stroke, worldwide. The incidence
of stroke for both males and females doubles for each decade after age 55. Stroke is more
prevalent in men than women, except for the age cohort of 35-44 (a finding considered to be due
to the use of oral contraceptives and pregnancy) and among persons over age 85. Hypertension is
the most important modifiable risk factor for both ischemic and hemorrhagic stroke regardless of
age. A family history of stroke increases the risk of stroke by about 30%. Cigarette smoking is
an important risk factor and doubles one’s risk of ischemic stroke and triples the risk of
subarachnoid hemorrhage. Other well-documented risk factors include diabetes, dyslipidemia,
and atrial fibrillation.
Which modifiable risk factor MOST increases the relative risk of stroke?
(a) Smoking
(b) Hypertension
(c) Hypercholesterolemia
(d) Diabetes mellitus
Answer: (b)
Commentary: Hypertension, defined as a systolic pressure greater than 165mmHg, or a diastolic
pressure greater than 95mmHg, increases the relative risk of stroke by a factor of 6. The
Framingham study has confirmed that smoking is independently associated with stroke. The
relative risk for heavy smokers (more than 40 cigarettes a day) is twice that of light smokers
(fewer than 10 cigarettes a day). Cessation of smoking reverses the risk to that of nonsmokers
within 5 years of quitting. Hypercholesterolemia has not been epidemiologically linked to
increased stroke incidence, but its strong influence on atherosclerosis makes it an indirect risk
factor. Diabetes mellitus increases the relative risk of stroke by 3 to 6 times the general
population.
Neuromuscular electrical stimulation to treat shoulder subluxation after stroke should be applied
to which muscles?
(a) Deltoid and supraspinatus
(b) Supraspinatus and infraspinatus
(c) Deltoid and trapezius
(d) Subscapularis and infraspinatus
Answer: (a)
Commentary: Neuromuscular electrical stimulation (NMES) to the deltoid (mainly posterior) and
the supraspinatus can decrease subluxation and reduce shoulder pain. It is required for several
hours daily over several weeks to achieve clinical benefits.
Which statement best describes the effects of repetitive task training after stroke?
(a) Lower limb functional recovery is greater than upper limb functional recovery.
(b) Improvement in activities of daily living is a major benefit of the training.
(c) Training effects are more significant in early stroke therapy.
(d) Improvement in functional benefit is sustained for more than a year.
Answer: (a)
Commentary: This review of 14 studies with 659 participants looked at whether repeated practice
of tasks similar to those commonly performed in daily life could improve functional abilities. In
comparison with usual care or placebo groups, people who practiced functional tasks showed
modest improvements in walking speed, walking distance and the ability to stand from sitting, but
improvements in leg function were not maintained 6 months later. Repetitive task practice had no
effect on arm or hand function. There was a small amount of improvement in ability to manage
activities of daily living. Training effects were no different for people whether the training was
given early or late after stroke
What is the most common medical complication during postacute stroke rehabilitation?
(a) Venous thromboembolism
(b) Falls
(c) Depression
(d) Pulmonary aspiration, pneumonia
Answer: D
Commentary: Of the complications listed, aspiration/pneumonia is seen in about 40%, while venous thromboembolism is seen in 6%; falls occur in 16%, musculoskeletal complications in 5%, and reflex sympathetic dystrophy (RSD) in 30 %. Depression affects 30%. Urinary tract infection is just as frequent at 40%, but is not listed.
A 60-year-old woman had a stroke 1 week ago. On examination you find loss of pain-and-temperature sensation on the right side of her face as well as on the left side of her body. You also note some nystagmus, with right eye ptosis and miosis. What is the most likely location of the lesion?
(a) Lateral pons
(b) Frontoparietal lobe
(c) Lateral medulla
(d) Medial basal midbrain
Answer: C
Commentary: A lesion in the lateral medulla causes Wallenberg syndrome and is associated with ipsilateral loss of facial pain- and temperature-sensation and contralateral loss of body pain-and-temperature sensation. Ipsilateral Horner syndrome (ptosis, miosis and anhidrosis) is found, as well as nystagmus, dysphagia and dysphonia.
The Western Aphasia Battery provides
(a) an aphasia quotient as a measure of the severity of aphasia.
(b) a classification of the aphasic features observed in a particular patient.
(c) a statistical summary of language impairments and an outcome prediction.
(d) an overall rating of functional communication
Answer: A
Commentary: The Western Aphasia Battery measures various parameters of language and provides the aphasia quotient as a measure of aphasic severity. The Boston Diagnostic Aphasia examination produces a classification of the features of a particular patient and a score of severity and is similar to the Western Aphasia battery, but not the aphasia quotient. The Porch Index of Communication Ability (PICA) is different and evaluates verbal, gestural and graphic responses. The Functional Communication profile provides an overall rating of functional communication.
What is the main principle underlying the Bobath neurofacilitation techniques for rehabilitation?
(a) Work from proximal to distal muscle groups.
(b) Promote diagonal movement patterns.
(c) Focus on multiple joint movements.
(d) Establish synergistic patterns.
Answer: A
Commentary: The Bobath technique of therapy focuses on good posture and works on proximal muscle groups first before proceeding to distal muscle groups. Brunnstrom method uses synergistic patterns and focuses on general movement patterns before moving to more isolated movements. Proprioceptive neuromuscular facilitation (PNF) focuses on multijoint movement patterns in a “diagonal” pattern. The Rood approach focuses on specific muscles selected according to the recovery stage of the stroke.
Which Brunnstrom stage of motor recovery in a stroke patient with a hemiplegic arm is
characterized by activating muscles selectively outside the flexor and extensor synergies?
(a) Stage 2
(b) Stage 3
(c) Stage 4
(d) Stage 5
(c)
The Brunnstrom stages of motor recovery can be used to describe motor recovery following stroke. Brunnstrom classification stage 4 is when the patient begins to activate muscles selectively outside of flexor and extensor synergy.
For a patient with hemiplegia who prefers to use his legs and push his wheelchair backwards, the wheelchair should be configured with
(a) the back edge of the seat lower than the front edge.
(b) a single arm drive mechanism on the non-hemiplegic side.
(c) the large wheel axle plate moved to a more anterior position.
large wheels in the front and casters in the back.
(d)
The casters should lead the rear wheels for the most common direction of travel. This will help reduce the possibility of the user flipping over when hitting an obstacle and will make the chair more directionally stable.
A patient presents with right hemiparesis and dysarthria but language and sensation are intact. The lesion is most likely in the
(a) posterior limb of the internal capsule.
(b) left frontoparietal lobe.
(c) lateral pons.
(d) thalamus.
(a)
A pure motor stroke (hemiplegia and dysarthria without sensory deficits) is caused by a lesion in the posterior limb of the internal capsule.
The largest change in bone mineral density in a hemiplegic patient 1 year after a stroke occurs in the
(a) humerus on the paretic side.
(b) proximal femur on the paretic side.
(c) distal radius on the paretic side.
lumbar spine.
(a) In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density (BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine.
You are seeing a 56-year-old male patient in consultation 3 days after a severe stroke. He is medically stable and has flaccid hemiplegia with poor sitting balance. He is sitting up in a chair for 2 hours twice daily and has just started bedside physical therapy (PT) and occupational therapy (OT). You recommend
(a) continued bedside therapy with OT and PT, focusing on sitting balance, followed by transfer to your inpatient rehabilitation unit when he can sit and stand with minimum assistance.
(b) transfer to your inpatient rehabilitation unit to start aggressive PT and OT.
(c) transfer to a subacute rehabilitation center to allow the patient time to improve with less intensive therapy.
that his OT start functional electrical stimulation to the flaccid arm to enhance neurologic recovery.
(b) Early and aggressive therapy addressing the higher level skills of gait, higher order functional skills, and problem solving were associated with better outcomes in a multi-center observational study.
It is recommended that a patient with a first ischemic stroke who is positive for an antiphospholipid antibody be treated with:
(a) aspirin, 325mg orally daily.
(b) warfarin, with an INR goal of 3.0–3.5.
(c) clopidogrel (Plavix), 75mg orally daily.
ticlopidine (Ticlid), 250mg orally twice daily.
(a) Patients with a first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325mg/day) or moderate-intensity warfarin (INR 1.4–2.8).
Which statement is TRUE regarding post-stroke central pain?
(a) Damage to the thalamus plays a central role in the pathogenesis of central pain.
(b) Amitriptyline is the drug of first choice to treat central pain.
(c) 80% of stroke patients with central pain develop the pain within a month of their stroke.
(d) The pain usually resolves spontaneously and does not require medication.
(b) The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to 60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief for some patients who do not respond to amitriptyline.
A patient with a recent stroke and hemiplegia presents to your clinic and is noted to have a genu recurvatum gait pattern. An aggressive stretching program has improved ankle range-of-motion, but not her spasticity and gait. The most appropriate treatment is
(a) an ankle foot orthosis with 5º of plantarflexion.
(b) Achilles tendon lengthening.
(c) phenol motor point injection to the hamstrings.
(d) botulinum toxin injection to the gastrocsoleus muscle group.
(d) Genu recurvatum is a common atypical gait pattern in patients with upper motor neuron pathology. It may be caused by ankle plantarflexor spasticity, heel cord contracture, quadriceps weakness, or spasticity and a combination of the above impairments. In this case an ankle foot orthosis with 5º of plantarflexion would worsen the gait. A tendon lengthening would be aggressive and more conservative management should be attempted first. A phenol motor point injection to the hamstrings would make knee control more problematic. Botulinim toxin can be very helpful for focal spasticity and can decrease ankle plantarflexor spasticity and decrease the backward force at the knee.
After an acute stroke, a 60-year-old woman presents for stroke rehabilitation with an indwelling
catheter for bladder management. What action should you order regarding the catheter?
(a) Maintain it until the patient is able to transfer to the toilet with minimal assistance.
(b) Remove it because reflex voiding returns very quickly after a stroke and risk of urine retention
is minimal.
(c) Remove it and start intermittent catheterization because reflex voiding return is often delayed
and the risk of urine retention is high.
(d) Maintain it to decrease the risk of urinary incontinence and pressure sores.
(b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding
returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke
rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.
After an acute stroke, a 60-year-old woman presents for stroke rehabilitation with an indwelling
catheter for bladder management. What action should you order regarding the catheter?
(a) Maintain it until the patient is able to transfer to the toilet with minimal assistance.
(b) Remove it because reflex voiding returns very quickly after a stroke and risk of urine retention
is minimal.
(c) Remove it and start intermittent catheterization because reflex voiding return is often delayed
and the risk of urine retention is high.
(d) Maintain it to decrease the risk of urinary incontinence and pressure sores.
(b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding
returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke
rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.
Which physical diagnosis finding is associated with poor functional outcome following stroke?
(a) Loss of pinprick sensation
(b) Prolonged flaccid period
(c) Generalized increase in tone
(d) Significant shoulder subluxation
(b) Factors associated with poor functional outcome following stroke include a prolonged flaccid
period, severe proprioceptive deficits, late return of reflexes, and severe proximal spasticity.
A 45-year-old man with left hemiparesis following a stroke complains of left shoulder pain with
ambulation. Which of the following is the most probable cause?
(a) Cervical radiculopathy
(b) Impingement syndrome
(c) Adhesive capsulitis
(d) Shoulder subluxation
(d) Inferior subluxation of the glenohumeral joint occurs frequently following stroke. Pain in the
shoulder is often felt in the upright position, since gravity further aggravates the subluxation.
Which type of stroke typically results in the best overall outcome?
(a) Pontine hemorrhage
(b) Embolic cortical infarction
(c) Anterior cerebral artery aneurysm rupture
(d) Internal capsule lacune
(d) Lacunar strokes are typically small and very localized and, in general, have the best prognosis.
A 67-year-old patient with coronary artery disease suffered a stroke 1 week ago. His resting vital
signs are: blood pressure 140/86, pulse 87 beats per minute, respiration 18 breaths per minute and
oxygen saturation 97%. Which change in vital signs would warrant stopping a therapy session?
(a) Oxygen saturation 92%
(b) Diastolic blood pressure 110mmHg
(c) Systolic blood pressure 130mmHg
(d) Heart rate 105 beats per minute
(b) An increase in the diastolic blood pressure is indicative of an unstable cardiac condition. The other
choices are normal responses to exercise.
Which is the best predictor of discharge from a rehabilitation center to home for a man who has had
a stroke?
(a) Lesion location
(b) Shoulder pain
(c) Ambulatory status
(d) Bladder incontinence
(d) Of the choices presented above, the most consistent predictor of good outcome and discharge home
is bladder continence. Probably the strongest overall predictor of ability is admission functional
ability (which reflects severity of stroke).
Which of the following is an appropriate compensatory technique for managing dysphagia?
(a) Tilting the head to the weaker side
(b) Glossopharyngeal breathing
(c) Chin tuck
(d) Turning the head to the stronger side
(c) Tilting the head to the stronger side and turning the head to the weaker side (but not vice versa) are
appropriate compensatory techniques. Glossopharyngeal breathing is used in pulmonary
rehabilitation and has no value in dysphagia management.
Regarding subarachnoid hemorrhages,
(a) arteriovenous malformations present with hemorrhage after age 40.
(b) the risk of rebleeding after an unoperated aneurysm is low.
(c) their clinical presentation is nonspecific.
(d) aneurysms usually occur in the anterior region of the circle of Willis.
(d) Clinical presentation is not nonspecific. Patients often complain of severe headaches (“worst of
their lives”) and present with loss of consciousness. Atriovenous malformation present with
hemorrhages earlier in life, in the second or third decade. Aneurysms are most commonly found in
the anterior region of the circle of Willis, particularly near branches of the anterior communicating,
internal carotid, and middle cerebral arteries.
A 67-year-old woman who had a left cortical stroke 12 months ago wishes to improve her arm and
hand function. She has good cognition. Sensation is only mildly decreased to light touch. Muscle
strength is shoulder flexion 4-/5, elbow flexion 3/5, elbow extension 3-/5, wrist extension 3-/5,
finger flexion 2/5, and finger extension 2-/5. Which technique is most likely to result in functional
improvement in this patient?
(a) Constraint-induced movement
(b) Proprioceptive neuromuscular facilitation
(c) Electromyographic biofeedback to wrist and arm extensors
(d) Electrical stimulation to finger flexors
(a) Constraint-induced movement is effective in persons more than a year after stroke if they have
preserved wrist extension and finger movement along with good sensation. Proprioceptive
neuromuscular facilitation is typically used during the acute phase of stroke and is not more
effective than other traditional treatments. EMG biofeedback has a mixed record but is probably a
good adjunctive treatment. Functional electrical stimulation appears to be useful in muscle
retraining but would probably not be applied to the finger flexors in this patient. No randomized,
controlled studies have compared these therapies for efficacy.
A 43-year-old man with a history of insulin dependent diabetes mellitus, gastroparesis, hypertension,
and obesity had a right cortical ischemic infarct 7 days ago. The nurses note that he is having
frequent small urinary voids with a weak voiding stream. What bladder mechanism is most
characteristic for this presentation?
(a) Small volume bladder with sphincter flaccidity
(b) Spastic detrusor activity with normal sphincter
(c) Flaccid detrusor with large volume bladder
(d) Hyperactive detrusor with large volume bladder
(c) Although the most common bladder among patients with stroke is normal or hyperreflexic, bladder
hyporeflexia is very common in diabetics (especially in this case with recorded gastroparesis).
These patients will have small frequent voids due to overflow from distended bladders with poor
detrusor contraction.
Findings commonly seen after a right hemispheric stroke include
(a) right hemiplegia.
(b) aphasia.
(c) visual-perceptual deficits.
(d) agraphia.
(c) Strokes on the nondominant hemisphere present with contralateral hemiplegia and hemianesthesia,
aprosody, visual-spatial deficit, and neglect syndrome.
A 60-year-old woman with dysarthria and right arm weakness is admitted to your stroke unit. Her
lower extremity strength is intact. You would expect the infarct to be located in the
(a) posterior frontal lobe.
(b) ventromedial thalamus.
(c) lateral medulla.
anterior limb of the internal capsule.
(d) This is a classic description of the dysarthria-clumsy hand syndrome. The lesion is most commonly
located in the anterior limb of the internal capsule but may also be seen with certain pontine lesions.
What magnetic resonance imaging findings would help to distinguish an acute from a chronic
intracerebral hemorrhage?
(a) T1 decreased, T2 increased
(b) T1 decreased, T2 decreased
(c) T1 increased, T2 increased
T1 increased, T2 decreased
b) The T1 signal in an acute hemorrhagic event would be decreased. Magnetic resonance imaging can
be helpful in distinguishing acute from chronic hemorrhagic events. The pathology and subsequent
neuroimaging results are based on the stage of hemoglobin molecular breakdown. In acute
hemorrhagic states, deoxyhemoglobin predominates and T1/T2 images are both decreased. In
chronic hemorrhagic states (more than 2 weeks) methemoglobin predominates (mainly
extracellular) and T1/T2 signals are decreased.
A 75-year-old man with a recent anterior communicating artery aneurysm, treated by neurosurgical
clipping is admitted to the inpatient rehabilitation unit for poststroke care. Deep vein thrombosis
prophylaxis should include
(a) heparin 5,000 units BID.
(b) warfarin doses based on INR values.
(c) pneumatic compression stocking (ankle or calf).
(d) continuous passive motion devices.
(c) Venous thromboembolic events can occur in as many as 75% of untreated patients with after
stroke. Prophylaxis is typically pharmacologic or manual venous compression. In patients with
documented intracerebral bleeding, anticoagulation is not recommended, and alternating pneumatic
compression derives are best used.
