Management of stroke complications US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Management of stroke complications. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Management of stroke complications US Medical PG Question 1: A 69-year-old male presents to the emergency department for slurred speech and an inability to use his right arm which occurred while he was eating dinner. The patient arrived at the emergency department within one hour. A CT scan was performed of the head and did not reveal any signs of hemorrhage. The patient is given thrombolytics and is then managed on the neurology floor. Three days later, the patient is recovering and is stable. He seems depressed but is doing well with his symptoms gradually improving as compared to his initial presentation. The patient complains of neck pain that has worsened slowly over the past few days for which he is being given ibuprofen. Laboratory values are ordered and return as indicated below:
Serum:
Na+: 130 mEq/L
K+: 3.7 mEq/L
Cl-: 100 mEq/L
HCO3-: 24 mEq/L
Urea nitrogen: 7 mg/dL
Glucose: 70 mg/dL
Creatinine: 0.9 mg/dL
Ca2+: 9.7 mg/dL
Urine:
Appearance: dark
Glucose: negative
WBC: 0/hpf
Bacterial: none
Na+: 320 mEq/L/24 hours
His temperature is 99.5°F (37.5°C), pulse is 95/min, blood pressure is 129/70 mmHg, respirations are 10/min, and oxygen saturation is 98% on room air. Which of the following is the best next step in management?
- A. Demeclocycline
- B. Fluid restriction (Correct Answer)
- C. Oral salt tablets
- D. Continue conservative management
- E. Conivaptan
Management of stroke complications Explanation: ***Fluid restriction***
- The patient presents with **hyponatremia** (Na+ 130 mEq/L) and elevated urine sodium (320 mEq/L/24 hours) in the setting of recent stroke and possible SIADH (**Syndrome of Inappropriate Antidiuretic Hormone secretion**).
- **Fluid restriction** is the initial and most crucial step in managing euvolemic hyponatremia due to SIADH, reducing water intake to allow the kidney to excrete excess water and correct serum sodium.
*Demeclocycline*
- **Demeclocycline** is a tetracycline derivative that inhibits the action of ADH on renal tubules, used in chronic or refractory cases of SIADH.
- It is *not* the first-line treatment for acute, moderate hyponatremia, especially when fluid restriction has not yet been attempted.
*Oral salt tablets*
- **Oral salt tablets** would increase the solute load but would also draw water, potentially worsening hyponatremia if unrestricted fluid intake persists in SIADH.
- This intervention is generally not appropriate for **euvolemic hyponatremia** where the primary issue is excess free water.
*Continue conservative management*
- With a sodium level of 130 mEq/L, this is considered **mild to moderate hyponatremia** and requires active intervention to prevent potential neurological complications.
- Simply continuing conservative management without addressing the underlying **hyponatremia** or its cause would be inadequate and potentially harmful.
*Conivaptan*
- **Conivaptan** is an ADH receptor antagonist that can be used for persistent or significant hyponatremia in SIADH.
- It is typically reserved for more severe or refractory cases of hyponatremia and is usually administered intravenously, making it less suitable as a first-line outpatient management strategy.
Management of stroke complications US Medical PG Question 2: A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?
- A. Obtain transcranial doppler
- B. Start tissue plasminogen activator (tPA)
- C. Consult cardiology
- D. Intubate the patient
- E. Obtain noncontrast CT of the brain (Correct Answer)
Management of stroke complications Explanation: ***Obtain noncontrast CT of the brain***
- An **urgent noncontrast CT of the brain** is the **most crucial initial step** in managing acute neurological deficits suggestive of stroke.
- This imaging is essential to **rule out hemorrhagic stroke** before considering thrombolytic therapy like tPA.
*Obtain transcranial doppler*
- **Transcranial Doppler (TCD)** can be used to assess cerebral blood flow and identify vascular stenosis but is not the immediate first-line diagnostic imaging for an acute stroke presentation.
- TCD is typically performed **after initial imaging** to determine the presence of large vessel occlusion or monitor for vasospasm, not to differentiate between ischemic and hemorrhagic stroke.
*Start tissue plasminogen activator (tPA)*
- While **tPA** is a treatment for acute ischemic stroke, it is **contraindicated in hemorrhagic stroke**.
- Without a **noncontrast CT scan to rule out hemorrhage**, administering tPA can be life-threatening.
*Consult cardiology*
- Consulting cardiology is important for evaluating potential cardiac sources of emboli (e.g., atrial fibrillation) as a cause of stroke but it is **not the immediate next step** in managing acute stroke symptoms.
- The **immediate priority is diagnosing the type of stroke** and determining eligibility for acute interventions.
*Intubate the patient*
- **Intubation** is reserved for patients with compromise of their **airway, breathing, or circulation (ABCs)**, or a significantly decreased level of consciousness (e.g., GCS < 8).
- This patient is described as **awake and alert**, making intubation unnecessary at this stage.
Management of stroke complications US Medical PG Question 3: A 65-year-old man presents to the emergency department for sudden weakness. He was doing mechanical work on his car where he acutely developed right-leg weakness and fell to the ground. He is accompanied by his wife, who said that this has never happened before. He was last seen neurologically normal approximately 2 hours prior to presentation. His past medical history is significant for hypertension and type II diabetes. His temperature is 98.8°F (37.1°C), blood pressure is 177/108 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. Neurological exam reveals that he is having trouble speaking and has profound weakness of his right upper and lower extremity. Which of the following is the best next step in management?
- A. Thrombolytics
- B. Noncontrast head CT (Correct Answer)
- C. CT angiogram
- D. MRI of the head
- E. Aspirin
Management of stroke complications Explanation: ***Noncontrast head CT***
- A **noncontrast head CT** is the most crucial initial step in managing acute stroke symptoms because it can rapidly rule out an **intracranial hemorrhage**.
- Distinguishing between ischemic stroke and hemorrhagic stroke is critical, as the management strategies are vastly different and administering thrombolytics in the presence of hemorrhage can be fatal.
*Thrombolytics*
- **Thrombolytics** can only be administered after an **intracranial hemorrhage** has been excluded via noncontrast head CT.
- Administering thrombolytics without imaging could worsen a hemorrhagic stroke, causing significant harm or death.
*CT angiogram*
- A **CT angiogram** is used to identify large vessel occlusions in ischemic stroke and is typically performed after a noncontrast CT rules out hemorrhage.
- This imaging is crucial for determining eligibility for **endovascular thrombectomy** but is not the very first diagnostic step.
*MRI of the head*
- An **MRI of the head** is more sensitive for detecting acute ischemic changes but takes longer to perform and is often not readily available in the acute emergency setting.
- It is not the initial imaging of choice for ruling out hemorrhage due to its longer acquisition time compared to CT.
*Aspirin*
- **Aspirin** is indicated for acute ischemic stroke but should only be given after an **intracranial hemorrhage** has been ruled out.
- Like thrombolytics, aspirin could exacerbate a hemorrhagic stroke and is thus deferred until initial imaging is complete.
Management of stroke complications US Medical PG Question 4: A 77-year-old man is brought to the emergency department by his wife because of headache, nausea, and vomiting for 24 hours. His wife says that over the past 2 weeks, he has been more irritable and has had trouble remembering to do routine errands. Two weeks ago, he fell during a skiing accident but did not lose consciousness. He has coronary artery disease and hypertension. He has smoked one pack of cigarettes daily for 50 years. He has had 2 glasses of wine daily since his retirement 10 years ago. Current medications include atenolol, enalapril, furosemide, atorvastatin, and aspirin. He appears acutely ill. He is oriented to person but not to place or time. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 16/min, and blood pressure is 160/90 mm Hg. During the examination, he is uncooperative and unable to answer questions. Deep tendon reflexes are 4+ on the left and 2+ on the right. Babinski's sign is present on the left. There is mild weakness of the left iliopsoas and hamstring muscles. A CT scan of the head without contrast shows a high-density, 15-mm crescentic collection across the right hemispheric convexity. Which of the following is the most appropriate next step in the management of this patient?
- A. Recombinant tissue plasminogen activator administration
- B. Obtain an Electroencephalography
- C. Obtain an MRI of the head
- D. Surgical evacuation (Correct Answer)
- E. Observation
Management of stroke complications Explanation: ***Surgical evacuation***
- The CT scan reveals a **high-density, crescentic collection**, strongly indicative of an **acute subdural hematoma**, which is causing significant neurological deficits and mass effect (e.g., increased intracranial pressure symptoms like headache, nausea, vomiting, and altered mental status, and focal neurological signs).
- Given the patient's **acute neurological decline**, significant mass effect from the 15-mm hematoma, and age, prompt **surgical evacuation** is the definitive treatment to relieve pressure and prevent further brain injury.
*Recombinant tissue plasminogen activator administration*
- **tPA** is indicated for **acute ischemic stroke**, not hemorrhagic stroke or subdural hematoma. Administering tPA in this context would be harmful, potentially worsening the hemorrhage.
- The patient's CT scan clearly shows a **hemorrhagic lesion**, not an ischemic event.
*Obtain an Electroencephalography*
- **EEG** is primarily used to evaluate **seizure disorders** or certain types of encephalopathy. While the patient has altered mental status, the primary issue identified on CT is a subdural hematoma requiring immediate intervention.
- EEG would not provide information relevant to the immediate management of an **acute subdural hematoma**.
*Obtain an MRI of the head*
- An **MRI** can provide more detailed imaging, but in the context of an **acute subdural hematoma** with significant neurological compromise, it would delay crucial and time-sensitive surgical intervention.
- The **CT scan** has already provided sufficient diagnostic information to warrant immediate surgical planning.
*Observation*
- **Observation** is not appropriate for a patient with a rapidly expanding **acute subdural hematoma** causing significant neurological deficits and a 15-mm collection, especially given the patient's age and clinical presentation.
- Delaying treatment would likely lead to further neurological deterioration, **herniation**, and potentially death.
Management of stroke complications US Medical PG Question 5: An 8-month-old boy is brought to the emergency department by his mother. She is concerned that her son has had intermittent periods of severe abdominal pain over the past several days that has been associated with emesis and "currant jelly" stool. Of note, the family lives in a rural part of the state, requiring a 2 hour drive to the nearest hospital. He currently appears to be in significant pain and has vomited twice in the past hour. On physical examination, a sausage-shaped mass is noted on palpation of the right upper quadrant of the abdomen. Ultrasound of the abdomen was consistent with a diagnosis of intussusception. An air-contrast barium enema was performed, which confirmed the diagnosis and also successfully reduced the intussusception. Which of the following is the next best step in the management of this patient?
- A. Keep patient NPO and initiate work-up to identify lead-point
- B. Admit to hospital for 24 hour observation for complications and/or recurrence (Correct Answer)
- C. Pursue urgent surgical reduction with resection of necrotic segments of bowel
- D. Repeat barium enema q6 hrs to monitor for recurrence
- E. Discharge to home with follow-up in 3 weeks in an outpatient pediatric gastroenterology clinic
Management of stroke complications Explanation: ***Admit to hospital for 24 hour observation for complications and/or recurrence***
- Following successful non-operative reduction of intussusception, there is a risk of **recurrence** (approximately 5-10%) and potential for **perforation** or other delayed complications, necessitating close hospital observation.
- The patient's presentation with significant pain and vomiting, coupled with the long travel time to the hospital, further supports the need for **hospital admission** to monitor for stability and potential early recurrence.
*Keep patient NPO and initiate work-up to identify lead-point*
- While keeping the patient NPO (nil per os) might be appropriate initially, a work-up for a **lead point** is generally performed if there are multiple recurrences or in older children, as most intussusceptions in infants are idiopathic.
- Doing this immediately without observation can delay identification of recurrence and prompt intervention.
*Pursue urgent surgical reduction with resection of necrotic segments of bowel*
- Surgical reduction is indicated if **non-operative reduction fails**, if there are signs of **perforation**, diffuse peritonitis, or if there is clinical evidence of **bowel necrosis**.
- Since the intussusception was successfully reduced by air-contrast enema and there are no signs of perforation or necrosis currently, urgent surgery is not the immediate next step.
*Repeat barium enema q6 hrs to monitor for recurrence*
- Repeated enemas carry risks such as **radiation exposure** and potential for perforation, and are not a standard monitoring strategy for recurrence.
- Clinical observation and physical examination are generally sufficient for monitoring during the initial 24-hour period.
*Discharge to home with follow-up in 3 weeks in an outpatient pediatric gastroenterology clinic*
- Discharging the patient home so soon after reduction is unsafe due to the significant risk of **early recurrence** (especially within the first 24-48 hours) or development of complications.
- A follow-up in 3 weeks is too delayed for immediate post-reduction concerns.
Management of stroke complications US Medical PG Question 6: A researcher is studying the brains of patients who recently died from stroke-related causes. One specimen has a large thrombus in an area of the brain that is important in relaying many modalities of sensory information from the periphery to the sensory cortex. Which of the following embryologic structures gave rise to the part of the brain in question?
- A. Metencephalon
- B. Diencephalon (Correct Answer)
- C. Mesencephalon
- D. Telencephalon
- E. Myelencephalon
Management of stroke complications Explanation: ***Diencephalon***
- The **thalamus**, a key relay center for sensory information to the cerebral cortex, develops from the diencephalon.
- A thrombus in this area would severely impair the transmission of **sensory modalities** from the periphery.
*Metencephalon*
- The metencephalon gives rise to the **pons** and the **cerebellum**.
- These structures are primarily involved in motor control, coordination, and respiratory regulation, not direct sensory relay to the cortex.
*Mesencephalon*
- The mesencephalon develops into the **midbrain**.
- The midbrain contains structures involved in visual and auditory reflexes, and motor control, but not the primary sensory relay described.
*Myelencephalon*
- The myelencephalon gives rise to the **medulla oblongata**.
- The medulla is crucial for vital autonomic functions (e.g., breathing, heart rate) and connects the brain to the spinal cord.
*Telencephalon*
- The telencephalon develops into the **cerebral hemispheres** (cerebral cortex, basal ganglia, hippocampus).
- While it processes sensory information, it is not the primary relay center from the periphery; that role belongs to the thalamus.
Management of stroke complications US Medical PG Question 7: A female presents with a 1 × 1 cm thyroid swelling. What is the next best step in management?
- A. I-131
- B. TSH (Correct Answer)
- C. TSH & T4
- D. T3 & T4
- E. FNAC
Management of stroke complications Explanation: ***Correct Option: TSH***
- **Thyroid-stimulating hormone (TSH)** is the most sensitive initial test to assess thyroid function when a thyroid nodule is discovered.
- An abnormal TSH level (either high or low) can guide further investigation into whether the nodule is associated with a functional thyroid disorder.
- **TSH should be the first test** according to American Thyroid Association guidelines for thyroid nodule evaluation.
*Incorrect Option: I-131*
- **I-131 (radioactive iodine therapy)** is a treatment modality for hyperthyroidism or thyroid cancer, not a diagnostic step for initial thyroid swelling evaluation.
- Administering I-131 before assessing thyroid function would be inappropriate and could lead to unnecessary or harmful intervention.
*Incorrect Option: TSH & T4*
- While TSH is crucial, adding **T4 (thyroxine)** as an initial step is often not necessary if TSH is normal, as TSH alone effectively screens for primary thyroid dysfunction.
- Measuring both TSH and T4 is typically reserved for situations where TSH is abnormal or when central hypothyroidism is suspected.
*Incorrect Option: T3 & T4*
- Measuring **T3 (triiodothyronine)** along with T4 as an initial screening for a thyroid nodule is generally not recommended.
- T3 levels are primarily used to diagnose **hyperthyroidism** or to evaluate the severity of thyrotoxicosis after an abnormal TSH and T4 have been identified.
*Incorrect Option: FNAC*
- While **Fine Needle Aspiration Cytology (FNAC)** is an essential diagnostic tool for thyroid nodules, it is typically performed after TSH assessment.
- FNAC is indicated for nodules >1 cm with suspicious ultrasound features, but **functional assessment with TSH comes first** to rule out hyperfunctioning nodules.
Management of stroke complications US Medical PG Question 8: A 48-year-old woman presents with acute stroke symptoms 18 hours ago. MRI shows a right MCA M1 occlusion with large penumbra on perfusion imaging (mismatch ratio >1.8) and small infarct core (25 mL). Her NIHSS is 16. She has no significant comorbidities. Her family is concerned about disability but wants to pursue treatment if reasonable chance of benefit exists. Synthesize the evidence and evaluate the treatment approach.
- A. Intravenous alteplase as salvageable tissue is present
- B. Intra-arterial thrombolysis combined with mechanical device
- C. No intervention as she is outside the standard treatment window
- D. Mechanical thrombectomy based on perfusion imaging criteria (Correct Answer)
- E. Medical management with antiplatelet and early rehabilitation
Management of stroke complications Explanation: ***Mechanical thrombectomy based on perfusion imaging criteria***
- For patients with large vessel occlusion (LVO) in the extended 6–24 hour window, **DAWN** and **DEFUSE-3** trials demonstrated significant functional benefit when clinical-core mismatch is present.
- This patient satisfies criteria with an **M1 occlusion**, a **small infarct core (<70 mL)**, and a **large mismatch ratio (>1.8)**, indicating substantial salvageable penumbra.
*Intravenous alteplase as salvageable tissue is present*
- The therapeutic window for **IV alteplase** is strictly limited to within **4.5 hours** of symptom onset; it is not recommended at 18 hours due to high hemorrhage risk.
- While salvageable tissue exists, chemical thrombolysis is less effective than mechanical intervention for **proximal M1 occlusions** and is unsafe in this late window.
*Intra-arterial thrombolysis combined with mechanical device*
- **Intra-arterial thrombolysis** is generally superseded by modern **stent retrievers** and aspiration catheters which provide faster and more complete recanalization.
- Current guidelines prioritize standalone **mechanical thrombectomy** in the late window to minimize procedural risks and intracranial hemorrhage.
*No intervention as she is outside the standard treatment window*
- The "Time is Brain" concept has evolved into "Tissue is Brain," where **perfusion imaging** identifies candidates who benefit regardless of the traditional 6-hour clock.
- Denying treatment based solely on the 18-hour timeframe ignores high-level evidence from the **DAWN** trial showing benefit up to 24 hours.
*Medical management with antiplatelet and early rehabilitation*
- Standard **medical management** (aspirin/heparin) for an M1 occlusion with a high **NIHSS score (16)** usually results in poor functional outcomes and severe disability.
- While rehabilitation is essential, it does not address the underlying **large vessel occlusion** which can be reversed with mechanical intervention to prevent infarct expansion.
Management of stroke complications US Medical PG Question 9: A 55-year-old man undergoes successful thrombectomy for left MCA occlusion. Post-procedure, he develops progressive lethargy and his blood pressure increases to 180/100 mmHg. CT shows hyperdensity in the treated territory without hemorrhage, and his symptoms worsen over 4 hours despite blood pressure control. Evaluate the most likely diagnosis and management priority.
- A. Hemorrhagic transformation; reverse anticoagulation immediately
- B. Cerebral edema from large infarction; emergent decompressive hemicraniectomy
- C. Reperfusion injury; start high-dose corticosteroids and osmotic therapy
- D. Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering (Correct Answer)
- E. Recurrent arterial occlusion; emergent repeat angiography and thrombectomy
Management of stroke complications Explanation: ***Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering***
- Post-thrombectomy **hyperdensity** on CT often represents contrast that leaked through an ischemic **blood-brain barrier**, which can mimic hemorrhage but lacks significant **mass effect**.
- Management is **supportive care** because the contrast is typically reabsorbed within 24–48 hours; avoiding aggressive **blood pressure lowering** prevents secondary ischemia in the penumbra.
*Hemorrhagic transformation; reverse anticoagulation immediately*
- While **hemorrhagic transformation** is a risk, true blood usually demonstrates higher density earlier and is associated with rapid clinical decline and **midline shift**.
- Reversing anticoagulation without confirming blood on a follow-up **dual-energy CT** or MRI may lead to **stent thrombosis** or re-occlusion.
*Cerebral edema from large infarction; emergent decompressive hemicraniectomy*
- **Cerebral edema** typically peaks between 72–96 hours post-stroke; a presentation within 4 hours is too acute for **malignant MCA syndrome**.
- While edema causes lethargy, the hyperdensity on CT more specifically points toward **contrast staining** or blood rather than simple cytotoxic edema.
*Reperfusion injury; start high-dose corticosteroids and osmotic therapy*
- **Corticosteroids** are not indicated for stroke-related edema or reperfusion injury as they do not improve outcomes and may increase **infection risk**.
- **Osmotic therapy** is reserved for patients with clear clinical or radiologic signs of **elevated intracranial pressure**, not isolated hyperdensity on CT.
*Recurrent arterial occlusion; emergent repeat angiography and thrombectomy*
- **Recurrent occlusion** usually presents with a sudden recurrence of the original **focal neurological deficits** (e.g., hemiplegia, aphasia) rather than progressive lethargy.
- The presence of **hyperdensity** in the stroke territory on CT is specifically indicative of material (contrast or blood) being present, which is not a feature of a simple **re-occlusion**.
Management of stroke complications US Medical PG Question 10: An 80-year-old woman with atrial fibrillation presents 2 hours after acute ischemic stroke. NIHSS is 22. Imaging shows large left MCA territory infarction involving >1/3 of MCA territory with basilar artery occlusion. She lives alone but was independent before this event. Her family requests all possible interventions. Evaluate the management approach considering benefits versus risks.
- A. Comfort measures only given poor prognosis and age
- B. Thrombolysis alone as thrombectomy unlikely to benefit with established large infarction
- C. Proceed with thrombolysis and thrombectomy given the therapeutic window
- D. Thrombectomy only for basilar occlusion, avoid thrombolysis due to large infarction (Correct Answer)
- E. Delay intervention and repeat imaging in 6 hours to assess progression
Management of stroke complications Explanation: ***Thrombectomy only for basilar occlusion, avoid thrombolysis due to large infarction***
- Intravenous **thrombolysis (IV alteplase)** is generally contraindicated or highly risky when imaging shows an established infarction involving **>1/3 of the MCA territory** due to the high risk of **hemorrhagic transformation**.
- **Basilar artery occlusion** is a life-threatening emergency with a broader treatment window; mechanical **thrombectomy** can be lifesaving and is indicated even if thrombolysis is withheld.
*Comfort measures only given poor prognosis and age*
- Age is not a primary contraindication for intervention, especially since the patient was **independent** prior to the event (low **pre-stroke mRS**).
- Family requests all possible interventions, and **basilar occlusion** has a catastrophic natural history that may be mitigated by mechanical intervention.
*Thrombolysis alone as thrombectomy unlikely to benefit with established large infarction*
- Thrombolysis is dangerous in this context due to the **large infarct volume** seen on imaging, which increases the likelihood of fatal **intracerebral hemorrhage**.
- Thrombolysis is notably less effective for large vessel occlusions compared to **mechanical thrombectomy**, which is the gold standard for **basilar artery** recanalization.
*Proceed with thrombolysis and thrombectomy given the therapeutic window*
- While the patient is within the 4.5-hour window for thrombolysis, the presence of **established early ischemic changes** (>1/3 MCA territory) is a relative contraindication.
- Attempting both increases the risk of **secondary hemorrhage** in the damaged MCA territory without providing significant additional benefit over thrombectomy alone for the **basilar occlusion**.
*Delay intervention and repeat imaging in 6 hours to assess progression*
- Delaying treatment in the setting of **basilar artery occlusion** is inappropriate, as "time is brain" and outcomes worsen significantly with every minute of **brainstem ischemia**.
- Immediate decision-making is required based on the initial imaging, which already confirmed the **large-vessel occlusion** needing intervention.
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