Stroke unit care principles US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Stroke unit care principles. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Stroke unit care principles US Medical PG Question 1: A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?
- A. Discharge without activity restrictions
- B. Discharge and refrain from all physical activity for one week
- C. Observe for 6 hours in the ED and refrain from contact sports for one week (Correct Answer)
- D. Administer prophylactic levetiracetam and observe for 24 hours
- E. Administer prophylactic phenytoin and observe for 24 hours
Stroke unit care principles Explanation: ***Observe for 6 hours in the ED and refrain from contact sports for one week***
- This patient experienced a brief period of **confusion, headache, dizziness**, and **nausea** immediately after a head injury, which are symptoms consistent with a **mild traumatic brain injury (mTBI)** or **concussion**.
- Although his symptoms have resolved at presentation, observation in the ED for a few hours is prudent to ensure no delayed onset of more severe symptoms, and he should **refrain from contact sports** for at least one week as part of concussion management.
*Discharge without activity restrictions*
- Discharging without activity restrictions is unsafe given the initial symptoms of **confusion** and the potential for delayed symptom presentation or complications from a concussion.
- Concussion management requires a period of **physical and cognitive rest** to allow the brain to heal and prevent **second impact syndrome**.
*Discharge and refrain from all physical activity for one week*
- While refraining from all physical activity for one week is part of concussion management, discharging immediately without any observation period after initial neurological symptoms could be risky.
- An observation period allows for monitoring of any **worsening neurological signs** or symptoms that might indicate a more serious injury.
*Administer prophylactic levetiracetam and observe for 24 hours*
- **Prophylactic anticonvulsants** like levetiracetam are typically not recommended for routine management of **mild traumatic brain injury** or concussion.
- Their use is generally reserved for patients with more severe injuries, evolving conditions, or those who have had **seizures post-trauma**.
*Administer prophylactic phenytoin and observe for 24 hours*
- Similar to levetiracetam, **phenytoin** is an anticonvulsant and its prophylactic use is not indicated for **mild head injuries** or concussions.
- Anticonvulsant prophylaxis is associated with potential side effects and is reserved for specific high-risk scenarios, such as **severe TBI** or **penetrating head trauma**.
Stroke unit care principles US Medical PG Question 2: A recent study examined trends in incidence and fatality of ischemic stroke in a representative sample of Scandinavian towns. The annual incidence of ischemic stroke was calculated to be 60 per 2,000 people. The 1-year case fatality rate for ischemic stroke was found to be 20%. The health department of a town in southern Sweden with a population of 20,000 is interested in knowing the 1-year mortality conferred by ischemic stroke. Based on the study's findings, which of the following estimates the annual mortality rate for ischemic stroke per 20,000?
- A. 600 people
- B. 400 people
- C. 120 people (Correct Answer)
- D. 60 people
- E. 12 people
Stroke unit care principles Explanation: ***120 people***
- The annual incidence of ischemic stroke is 60 per 2,000 people. For a population of 20,000, the annual number of new stroke cases would be (60/2,000) * 20,000 = **600 cases**.
- With a 1-year case fatality rate of 20%, the annual mortality from ischemic stroke is 20% of these 600 cases, which is 0.20 * 600 = **120 people**.
*600 people*
- This number represents the estimated **annual incidence of ischemic stroke** in a town of 20,000 people, not the mortality rate.
- It is calculated as (60/2,000) * 20,000 = 600, before applying the case fatality rate.
*400 people*
- This number is not directly derived from the provided incidence and fatality rates for a population of 20,000.
- It might represent a miscalculation of either incidence or mortality.
*60 people*
- This is the **incidence of ischemic stroke** per 2,000 people, not the mortality rate for a larger population of 20,000.
- It does not account for the total population size or the case fatality rate.
*12 people*
- This would be the mortality if the incidence was extremely low or the case fatality rate was significantly lower than 20% for a population of 20,000.
- It is a significant underestimate based on the given data.
Stroke unit care principles US Medical PG Question 3: 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
Stroke unit care principles 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.
Stroke unit care principles US Medical PG Question 4: A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?
- A. Alteplase
- B. MRI brain
- C. CT head (Correct Answer)
- D. Aspirin
- E. CTA head
Stroke unit care principles Explanation: ***CT head***
- A **non-contrast CT head** is the immediate priority to differentiate between ischemic and hemorrhagic stroke, which is critical for guiding subsequent treatment decisions.
- Given the patient's acute neurological deficits (slurred speech, facial asymmetry, weakness) and vascular risk factors (hypertension, diabetes), **stroke is highly suspected**, and identifying intracerebral hemorrhage is crucial before considering thrombolytic therapy.
*Alteplase*
- **Alteplase** (tPA) is a thrombolytic agent used for acute ischemic stroke, but its administration is **contraindicated in hemorrhagic stroke**.
- Initiating alteplase without first ruling out hemorrhage with a CT scan could lead to catastrophic bleeding.
*MRI brain*
- While an **MRI brain** can provide more detailed imaging of stroke, it is typically **not the initial imaging modality** in the emergency setting due to longer acquisition times and limited availability, especially when emergent differentiation between ischemic and hemorrhagic stroke is needed.
- Its use is usually reserved for cases where the CT is inconclusive or for later evaluation.
*Aspirin*
- **Aspirin** is an antiplatelet agent used in the management of ischemic stroke, but it should **not be given until a hemorrhagic stroke has been ruled out** via CT head.
- Administering aspirin in the context of an intracerebral hemorrhage could worsen bleeding.
*CTA head*
- A **CT angiography (CTA) head** is used to visualize the cerebral vasculature and identify large vessel occlusions, which can guide thrombectomy decisions in ischemic stroke.
- However, performing a **non-contrast CT head is a prerequisite** to rule out hemorrhage before proceeding with CTA or any other advanced imaging or therapeutic interventions.
Stroke unit care principles US Medical PG Question 5: A 57-year-old man was brought into the emergency department unconscious 2 days ago. His friends who were with him at that time say he collapsed on the street. Upon arrival to the ED, he had a generalized tonic seizure. At that time, he was intubated and is being treated with diazepam and phenytoin. A noncontrast head CT revealed hemorrhages within the pons and cerebellum with a mass effect and tonsillar herniation. Today, his blood pressure is 110/65 mm Hg, heart rate is 65/min, respiratory rate is 12/min (intubated, ventilator settings: tidal volume (TV) 600 ml, positive end-expiratory pressure (PEEP) 5 cm H2O, and FiO2 40%), and temperature is 37.0°C (98.6°F). On physical examination, the patient is in a comatose state. Pupils are 4 mm bilaterally and unresponsive to light. Cornea reflexes are absent. Gag reflex and cough reflex are also absent. Which of the following is the next best step in the management of this patient?
- A. Second opinion from a neurologist
- B. Withdraw ventilation support and mark time of death
- C. Electroencephalogram
- D. Repeat examination in several hours
- E. Apnea test (Correct Answer)
Stroke unit care principles Explanation: ***Apnea test***
- The patient exhibits classic signs of **brain death**, including a **coma**, fixed and dilated pupils, and absent brainstem reflexes (corneal, gag, cough). The next step is to perform an apnea test to confirm the absence of spontaneous respiratory drive.
- An apnea test confirms brain death by demonstrating the **absence of respiratory effort** despite a rising pCO2, provided that spinal cord reflexes are not mistaken for respiratory efforts.
*Second opinion from a neurologist*
- While consulting a neurologist is often helpful in complex neurological cases, the current clinical picture presents such clear signs of brain death that **further confirmatory testing** for brain death (like the apnea test) is more immediately indicated before seeking additional opinions on diagnosis.
- A second opinion would typically be sought to confirm the diagnosis or guide management, but establishing brain death requires a specific protocol which is incomplete without the apnea test.
*Withdraw ventilation support and mark time of death*
- It is **premature to withdraw ventilation** before brain death is unequivocally confirmed by all necessary clinical and confirmatory tests, including the apnea test.
- Withdrawing support without full confirmation could lead to ethical and legal issues, as the patient might still have residual brainstem function, however minimal.
*Electroencephalogram*
- An **EEG** can show absent electrical activity, supporting brain death, but it is **not a mandatory part of the core brain death criteria** in many protocols, especially when clinical signs are clear and an apnea test can be performed.
- The primary diagnostic criteria for brain death usually prioritize clinical examination and the apnea test for proving irreversible cessation of all brain functions.
*Repeat examination in several hours*
- Repeating the examination in several hours is typically done if there are **confounding factors** (e.g., severe hypothermia, drug intoxication) that might mimic brain death, or if the initial assessment is incomplete.
- In this case, there are no mentioned confounding factors, and the immediate priority is to complete the brain death protocol with an apnea test, given the current clear clinical picture.
Stroke unit care principles US Medical PG Question 6: A 5-year-old boy is brought to the emergency department by his mother because of a 2-hour history of word-finding difficulty, speech slurring, and weakness and sensory loss of his right arm and leg. He has not had fever, nausea, headache, or diarrhea. His mother reports an episode of severe pain and soft tissue swelling of the dorsum of his hands and feet when he was 12 months old, which self-resolved after 2 weeks. His temperature is 37.7°C (99.8°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. He follows commands but has nonfluent aphasia. Examination shows marked weakness and decreased sensation of the right upper and lower extremities. Deep tendon reflexes are 2+ bilaterally. Babinski sign is present on the right. An MRI scan of the brain shows signs of an evolving cerebral infarction on the patient's left side. Which of the following is the most appropriate initial step in management?
- A. Hydroxyurea therapy
- B. Exchange transfusion therapy (Correct Answer)
- C. Heparin therapy
- D. Intravenous tissue plasminogen activator therapy
- E. Aspirin therapy
Stroke unit care principles Explanation: ***Exchange transfusion therapy***
- The patient's presentation with **acute neurological deficits** (word-finding difficulty, speech slurring, right-sided weakness/sensory loss) and imaging showing an **evolving cerebral infarction** in a 5-year-old child with a history concerning for **sickle cell disease** (dactylitis at 12 months) indicates an acute ischemic stroke.
- **Exchange transfusion therapy** is the **most appropriate initial management** for an acute ischemic stroke in a patient with sickle cell disease as it rapidly reduces the percentage of sickled cells and increases oxygen-carrying capacity, improving cerebral perfusion and preventing further infarction.
*Hydroxyurea therapy*
- **Hydroxyurea** is a long-term preventative therapy for sickle cell disease, increasing fetal hemoglobin (HbF) and reducing the frequency of vaso-occlusive crises and acute chest syndrome.
- It is **not an acute treatment** for an evolving stroke, which requires immediate intervention to reduce sickled cells and improve blood flow.
*Heparin therapy*
- **Heparin therapy** (anticoagulation) is typically used for specific types of stroke (e.g., cardioembolic stroke, cerebral venous sinus thrombosis) but is generally **not indicated for acute ischemic stroke** in sickle cell disease.
- The primary pathophysiology of stroke in sickle cell disease involves sickled cells causing vaso-occlusion, rather than a thrombotic event usually responsive to heparin.
*Intravenous tissue plasminogen activator therapy*
- **Intravenous tissue plasminogen activator (tPA)** is a fibrinolytic agent used to break down clots in acute ischemic stroke, but its use is **contraindicated in pediatric patients** and in patients with known sickle cell disease due to an increased risk of hemorrhage and lack of demonstrated benefit.
- The underlying mechanism of stroke in sickle cell disease (vaso-occlusion by sickled cells) is not directly addressed by tPA.
*Aspirin therapy*
- **Aspirin therapy** (antiplatelet agent) is used for secondary stroke prevention in some cases of ischemic stroke but is **not the primary acute treatment** for an evolving stroke in sickle cell disease.
- It does not rapidly reduce the burden of sickled cells or improve oxygen delivery, which are critical for acute management in this patient population.
Stroke unit care principles US Medical PG Question 7: 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
Stroke unit care principles 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.
Stroke unit care principles 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
Stroke unit care principles 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.
Stroke unit care principles 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
Stroke unit care principles 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**.
Stroke unit care principles 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
Stroke unit care principles 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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