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?

Observe for 6 hours in the ED and refrain from contact sports for one week

Discharge without activity restrictions

Discharge and refrain from all physical activity for one week

Administer prophylactic levetiracetam and observe for 24 hours

Administer prophylactic phenytoin and observe for 24 hours

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?

Continue conservative management

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?

Second opinion from a neurologist

Withdraw ventilation support and mark time of death

Repeat examination in several hours

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?

Intravenous tissue plasminogen activator therapy

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.

Mechanical thrombectomy based on perfusion imaging criteria

Intravenous alteplase as salvageable tissue is present

Intra-arterial thrombolysis combined with mechanical device

No intervention as she is outside the standard treatment window

Medical management with antiplatelet and early rehabilitation

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.

Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering

Hemorrhagic transformation; reverse anticoagulation immediately

Cerebral edema from large infarction; emergent decompressive hemicraniectomy

Reperfusion injury; start high-dose corticosteroids and osmotic therapy

Recurrent arterial occlusion; emergent repeat angiography and thrombectomy

Stroke unit care principles for USMLE Step 1: High-Yield Management Lessons

Stroke Unit Care - The Stroke Squad Hub

Multidisciplinary Team: Coordinated care from neurologists, nurses, physio/occupational/speech therapists.
Core Principles (📌 SQUAD):
- Swallowing screen (early) to prevent aspiration.
- Quick & early mobilization to reduce complications.
- Unified protocols for vitals & neuro checks.
- Assessment for DVT/PE risk.
- DVT prophylaxis (mechanical ± pharmacological).
Continuous Monitoring: Cardiac rhythm, BP, O₂ saturation.

⭐ Stroke unit care is one of the few interventions proven to reduce mortality, long-term disability, and the need for institutionalization, regardless of patient age, sex, or stroke severity.

Multidisciplinary Stroke Team Roles and Care Principles

Multidisciplinary Team - Avengers Assemble!

Coordinated care in a specialized stroke unit is crucial for recovery. The team collaborates on a patient-centered plan to maximize functional outcomes and prevent recurrence.

Core Members: Neurologists, specialized nurses, physiatrists.
Rehabilitation: Physical & Occupational Therapists (PT/OT), Speech-Language Pathologists (SLP).
Support: Social workers, case managers, dietitians.

⭐ Coordinated stroke unit care is the most critical intervention, proven to reduce mortality and long-term disability by up to 20% compared to general medical ward care.

Key Protocols - The Stroke Playbook

Hemodynamic: Maintain BP <180/105 mmHg post-tPA; otherwise, permissive hypertension (goal <220/120 mmHg) is acceptable.
Metabolic: Target glucose 140-180 mg/dL. Treat fever aggressively to maintain normothermia.
VTE Prophylaxis: Start intermittent pneumatic compression (IPC) on admission. Delay pharmacologic prophylaxis for 24h post-tPA.
Aspiration Risk: Patient remains NPO until a formal swallow screen is passed.
Rehabilitation: Mobilize within 24-48 hours; consult PT, OT, and speech therapy early.

⭐ Coordinated stroke unit care is the single most effective intervention for reducing post-stroke mortality and long-term disability, benefiting a broader patient population than thrombolysis.

Complication Management - Dodging Dangers

VTE Prophylaxis:
- Immediate intermittent pneumatic compression (IPC).
- Start LMWH/heparin after 24-48h if stable; hold for 24h post-tPA.
Aspiration & Pneumonia:
- Strict NPO until passing a bedside swallow screen.
- Keep head of bed elevated >30°.
Cerebral Edema (Malignant Infarct):
- Peaks at 3-5 days.
- Treat with hyperosmolar therapy (mannitol, hypertonic saline).
- Consider decompressive hemicraniectomy.
Other Complications:
- Seizures: Treat if they occur; no prophylaxis.
- UTI: Avoid indwelling catheters.

⭐ Post-stroke depression is common (~33%) and impairs recovery. Routinely screen and treat with SSRIs (Sertraline, Escitalopram).

Rehabilitation & Discharge - The Road to Recovery

Early start: Initiate rehab within 24-48 hours if medically stable to maximize recovery.
Core team: Coordinated effort by Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP).
Primary goals: Improve mobility, restore Activities of Daily Living (ADLs), and prevent complications (e.g., DVT, contractures).
Discharge planning: Begins on admission, evaluating home safety and social support.

⭐ The most significant motor and functional gains are typically seen within the first 3-6 months post-stroke.

High-Yield Points - ⚡ Biggest Takeaways

Stroke unit care is superior to general ward care, utilizing a multidisciplinary team (physicians, nurses, PT, OT, speech therapy).

Early mobilization and DVT prophylaxis are critical to prevent venous thromboembolism and other complications of immobility.

Perform a swallowing assessment before initiating oral intake to reduce aspiration pneumonia risk.

Maintain permissive hypertension in acute ischemic stroke (if no thrombolysis) to ensure cerebral perfusion.

Aggressively treat fever and hyperglycemia, as both are associated with worse neurological outcomes.

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