Acute Stroke Therapeutics — MCQs
All of the following come under priority of Stroke control programme EXCEPT:
All of the following decrease cerebral blood flow and intracranial pressure except:
A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
A 60-year-old man with atrial fibrillation presents with sudden right arm and leg weakness, speech loss, and right facial droop that started 2 hours ago. CT scan shows no bleeding. What is the next step in management?
The treatment of acute myocardial infarction includes which of the following?
In ACLS, which antiarrhythmic drug can be given following ventricular fibrillation after cardiac arrest other than epinephrine?
Investigation of choice for acute intracerebral hemorrhage is -
A patient comes to the casualty with a severe headache. His BP was found to be 160/100 mmHg. CT scan revealed a subarachnoid hemorrhage. What is the next best step in the management of this patient?
A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
A 70-year-old man presents with sudden onset of left-sided weakness, slurred speech, and right-sided facial droop. A CT scan reveals an infarct in the right middle cerebral artery territory. Which of the following is the most appropriate initial treatment?
Acute Stroke Therapeutics Indian Medical PG Practice Questions and MCQs
Question 1: All of the following come under priority of Stroke control programme EXCEPT:
- A. Control of alcoholism (Correct Answer)
- B. Control of smoking
- C. Control of diabetes
- D. Control of hypertension
Explanation: ***Control of alcoholism*** - While **alcoholism** is a health concern, its direct and immediate impact as a primary modifiable risk factor for stroke in large-scale stroke control programs is generally less emphasized compared to other factors. - Stroke control programs typically prioritize risk factors with a more direct and significant impact on stroke incidence and severity, such as hypertension, diabetes, and dyslipidemia. *Control of smoking* - **Smoking** is a major modifiable risk factor for stroke, significantly increasing the risk of both ischemic and hemorrhagic stroke due to its effects on atherosclerosis and clotting. - Quitting smoking is a cornerstone of any stroke prevention strategy, and thus its control is a high priority. *Control of diabetes* - **Diabetes** significantly increases the risk of stroke by promoting atherosclerosis and affecting blood vessel health. - Strict glycemic control is essential in preventing stroke and is a priority in stroke control programs. *Control of hypertension* - **Hypertension** is the most important modifiable risk factor for stroke, contributing to both ischemic and hemorrhagic strokes. - Effective blood pressure management is critical for primary and secondary stroke prevention and is a top priority in stroke control programs.
Question 2: All of the following decrease cerebral blood flow and intracranial pressure except:
- A. Ketamine (Correct Answer)
- B. Thiopentone
- C. Propofol
- D. Etomidate
Explanation: ***Ketamine*** - Ketamine is an exception as it is known to **increase cerebral blood flow (CBF)** and **intracranial pressure (ICP)** due to its dissociative anesthetic properties. - It causes cerebral vasodilation and increased cerebral metabolic rate, making it generally avoided in patients with elevated ICP or head trauma. *Thiopentone* - Thiopentone (a barbiturate) is a potent cerebral vasoconstrictor that **decreases cerebral blood flow (CBF)** and **intracranial pressure (ICP)**. - It achieves this by reducing the cerebral metabolic rate of oxygen consumption (CMRO2), thus coupling metabolism and flow. *Propofol* - Propofol significantly **reduces cerebral blood flow (CBF)** and **intracranial pressure (ICP)** by causing widespread cerebral vasoconstriction. - Its rapid onset and offset, along with its neuroprotective properties, make it a favorable agent for neuroanesthesia. *Etomidate* - Etomidate is an imidazole derivative that causes a significant **reduction in cerebral blood flow (CBF)** and **intracranial pressure (ICP)** comparable to barbiturates. - It achieves this by reducing cerebral metabolic rate and causing cerebral vasoconstriction, without significantly altering systemic hemodynamics.
Question 3: A man presents to the emergency department with a head injury following a vehicular accident. What is the investigation of choice?
- A. MRI
- B. CECT
- C. NCCT (Correct Answer)
- D. X-ray
Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** of the head is the **investigation of choice** for acute head trauma due to its rapid acquisition, wide availability, and excellent sensitivity for detecting acute hemorrhage, fractures, and mass effects. - It rapidly identifies life-threatening conditions such as **epidural, subdural, and intracerebral hemorrhages**, which require immediate intervention. *MRI* - **MRI** is superior for detecting subtle brain tissue injuries, diffuse axonal injury, and non-hemorrhagic lesions but is generally **not the first-line investigation** in acute trauma due to longer scan times, limited availability in the emergency setting, and inability to detect acute hemorrhage as clearly as CT. - Its use is typically reserved for follow-up studies or when CT findings are inconclusive or specific soft tissue detail is required. *CECT* - **Contrast-enhanced CT (CECT)** of the head is reserved for specific indications like evaluating vascular lesions (e.g., aneurysms, arteriovenous malformations) or tumors, which are generally **not the primary concern** in the initial assessment of acute head trauma. - Administering contrast agents can delay imaging, may pose risks to patients with renal impairment or allergies, and does not significantly improve the detection of acute traumatic hemorrhage compared to NCCT. *X-ray* - **X-rays** of the skull are useful for detecting **skull fractures**, but they provide **limited information** regarding intracranial injuries or soft tissue damage, which are critical in head trauma. - They have largely been superseded by CT scans, which offer a more comprehensive view of both bony structures and intracranial contents.
Question 4: A 60-year-old man with atrial fibrillation presents with sudden right arm and leg weakness, speech loss, and right facial droop that started 2 hours ago. CT scan shows no bleeding. What is the next step in management?
- A. Intravenous thrombolysis (Correct Answer)
- B. Surgical thrombectomy
- C. Heparin
- D. Aspirin
Explanation: No change to the explanation was requested other than the addition of citations. ***Intravenous thrombolysis*** - The patient presents with **acute ischemic stroke symptoms** [1] within the 4.5-hour window from symptom onset , and the CT scan shows no hemorrhage , making him a candidate for **tPA**. - **Atrial fibrillation** puts the patient at high risk for cardioembolic stroke , which can be effectively treated with tPA if given early . *Surgical thrombectomy* - This is an intervention for **large vessel occlusion** but is typically considered for patients who are outside the IV tPA window (usually 4.5 hours) or have contraindications, and it often has a longer therapeutic window (up to 24 hours in select cases). - While it may be considered for this patient, **IV thrombolysis** is the immediate next step given he is within the 4.5-hour window and has no contraindications. *Heparin* - **Anticoagulation with unfractionated heparin** is not recommended for acute ischemic stroke without clear indications due to the increased risk of hemorrhagic transformation. - While the patient has atrial fibrillation, starting anticoagulation acutely is usually deferred for at least 24 hours after tPA administration or in cases of larger infarcts due to the risk of bleeding. *Aspirin* - **Aspirin** is an antiplatelet agent used for **secondary stroke prevention** and in some cases for acute ischemic stroke, but it is less effective than tPA for acute reperfusion . - While it may be given later, it is not the primary immediate treatment for acute ischemic stroke eligible for thrombolysis.
Question 5: The treatment of acute myocardial infarction includes which of the following?
- A. Oral anticoagulants
- B. Aspirin (Correct Answer)
- C. Heparin
- D. Alteplase
Explanation: ***Aspirin*** - **Aspirin** is a cornerstone of acute myocardial infarction treatment due to its **antiplatelet effects**, which reduce thrombus formation in the coronary arteries [4]. - It works by **irreversibly inhibiting cyclooxygenase-1 (COX-1)**, thereby preventing the synthesis of thromboxane A2, a potent platelet aggregator [4]. *Heparin* - **Heparin** (unfractionated or low molecular weight) is an **anticoagulant** often used adjunctively in acute MI, particularly in patients undergoing percutaneous coronary intervention (PCI) or with concurrent atrial fibrillation [1]. - Its primary role is to **prevent further clot formation** rather than directly dissolving existing clots, making it not the initial, primary treatment for MI itself. *Alteplase* - **Alteplase** is a **fibrinolytic agent** used in acute ST-elevation myocardial infarction (STEMI) to **dissolve existing clots** and restore blood flow [3]. - While effective, it is not universally indicated for *all* acute MI cases and has specific contraindications, making it a secondary rather than primary initial treatment choice in many scenarios when compared to aspirin [2]. *Oral anticoagulants* - **Oral anticoagulants** (e.g., warfarin, direct oral anticoagulants) are primarily used for **long-term prevention** of thromboembolic events, such as in atrial fibrillation or after venous thromboembolism. - They are generally **not used in the immediate acute phase of MI** as the primary treatment due to their slower onset of action and different mechanisms compared to antiplatelet drugs like aspirin.
Question 6: In ACLS, which antiarrhythmic drug can be given following ventricular fibrillation after cardiac arrest other than epinephrine?
- A. Amiodarone (Correct Answer)
- B. Dopamine
- C. Adenosine
- D. Atropine
Explanation: ***Amiodarone*** - **Amiodarone** is a Class III antiarrhythmic agent recommended in ACLS for **refractory ventricular fibrillation (VF)** or pulseless ventricular tachycardia (pVT) after initial defibrillation and epinephrine. - It works by blocking potassium channels, prolonging repolarization, and increasing the **refractory period** in the heart. *Dopamine* - **Dopamine** is a **vasopressor** used to improve **hemodynamics** in patients with symptomatic hypotension, not primarily as an antiarrhythmic for VF. - Its effects include increasing heart rate, myocardial contractility, and blood pressure. *Adenosine* - **Adenosine** is a drug of choice for **supraventricular tachycardia (SVT)** to interrupt reentry pathways in the AV node. - It is not indicated for ventricular fibrillation, as it would be ineffective in this rhythm. *Atropine* - **Atropine** is an **anticholinergic agent** used to treat **symptomatic bradycardia** by increasing heart rate. - It has no role in the management of ventricular fibrillation.
Question 7: Investigation of choice for acute intracerebral hemorrhage is -
- A. NCCT (Correct Answer)
- B. MRI
- C. PET scan
- D. None of the options
Explanation: ***NCCT*** - **Non-contrast Computed Tomography (NCCT)** is the investigation of choice for acute intracerebral hemorrhage because it can **rapidly and reliably detect acute blood** within the brain parenchyma. - Acute hemorrhage appears as a **hyperdense (bright) lesion** on NCCT, allowing for quick diagnosis and management vital in emergency settings. *MRI* - While MRI can detect hemorrhage, its sensitivity for **acute hemorrhage** can be variable, and it is **less readily available** and takes longer to perform than NCCT. - MRI is generally preferred for subacute or chronic hemorrhage, or to investigate the **underlying cause** of the bleed (e.g., tumor, vascular malformation). *PET scan* - **Positron Emission Tomography (PET) scan** primarily measures **metabolic activity** and blood flow within the brain. - It is **not suitable for detecting acute bleeding** and is typically used for diagnosing conditions like tumors, epilepsy, or neurodegenerative diseases. *None of the options* - This option is incorrect because **NCCT** is indeed the gold standard for diagnosing acute intracerebral hemorrhage.
Question 8: A patient comes to the casualty with a severe headache. His BP was found to be 160/100 mmHg. CT scan revealed a subarachnoid hemorrhage. What is the next best step in the management of this patient?
- A. Nimodipine
- B. Angiography (Correct Answer)
- C. Surgery
- D. Fibrinolytic therapy
Explanation: ***Angiography*** - Following the diagnosis of **subarachnoid hemorrhage (SAH)** by CT scan, **cerebral angiography** is the next crucial step to identify the source of bleeding. - This procedure helps locate and characterize the **aneurysm** or other vascular malformations, which is essential for planning definitive treatment. *Nimodipine* - **Nimodipine** is a calcium channel blocker used to prevent and treat **vasospasm**, a common complication after SAH. - While important in SAH management, it is typically initiated after the source of bleeding has been identified and secured, or as an adjunct immediately after diagnosis, but not the *next best step* before identifying the source. *Surgery* - **Surgical clipping** or **endovascular coiling** are definitive treatments for ruptured aneurysms after SAH. - However, surgery is performed *after* the aneurysm has been identified and localized through angiography, making angiography the prerequisite next step. *Fibrinolytic therapy* - **Fibrinolytic therapy** is used to dissolve blood clots in conditions like ischemic stroke or myocardial infarction. - It is **contraindicated** in hemorrhagic stroke, including subarachnoid hemorrhage, as it would worsen the bleeding.
Question 9: A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
- A. Emergency surgical repair (Correct Answer)
- B. BP control and monitoring
- C. Stenting
- D. Balloon dilatation
Explanation: ***Emergency surgical repair*** - The combination of **excruciating chest pain**, a history of **hypertension**, and **unequal radial pulses** is highly suggestive of an **acute aortic dissection**. - **Unequal radial pulses** indicate involvement of the **ascending aorta** (Type A dissection), affecting the brachiocephalic or subclavian arteries that branch proximally from the aortic arch. - **Type A aortic dissections**, involving the ascending aorta, are life-threatening emergencies requiring immediate **surgical repair** to prevent rupture, cardiac tamponade, aortic regurgitation, and organ malperfusion. *BP control and monitoring* - While **blood pressure control** is a crucial initial step in managing aortic dissection to reduce shear stress on the aorta and prevent propagation, it is insufficient as the primary treatment for an **ascending (Type A) aortic dissection**. - Continuous monitoring is necessary but cannot resolve a progressing dissection that poses an immediate threat to life. - Medical management alone is reserved for **uncomplicated Type B dissections**. *Stenting* - **Endovascular stenting** (thoracic endovascular aortic repair, TEVAR) is primarily used for **Type B aortic dissections** (involving the descending aorta) in stable patients or those with complicated features. - It is generally not the first-line treatment for **Type A dissections** due to the anatomical challenges and urgent need for surgical repair in this location. *Balloon dilatation* - **Balloon dilatation** or angioplasty is a procedure used to open narrowed arteries, typically in the context of atherosclerotic disease (e.g., coronary artery disease or peripheral artery disease). - It has no role in the management of an **aortic dissection**, which involves a tear in the aortic wall rather than a simple narrowing.
Question 10: A 70-year-old man presents with sudden onset of left-sided weakness, slurred speech, and right-sided facial droop. A CT scan reveals an infarct in the right middle cerebral artery territory. Which of the following is the most appropriate initial treatment?
- A. Intravenous thrombolysis (Correct Answer)
- B. Endovascular thrombectomy
- C. Aspirin therapy
- D. Anticoagulation therapy
Explanation: ***Intravenous thrombolysis*** - This patient presents with acute ischemic stroke symptoms (weakness, slurred speech, facial droop) and a CT scan showing an **infarct in the right middle cerebral artery (MCA) territory**. [1] - **Intravenous thrombolysis** with tissue plasminogen activator (tPA) is the standard initial treatment for acute ischemic stroke if administered within **4.5 hours of symptom onset** and if no contraindications are present. [1] *Endovascular thrombectomy* - **Endovascular thrombectomy** is a procedure used for **large vessel occlusions** in acute ischemic stroke. - While it may be considered in addition to IV thrombolysis for certain patients within a longer window (up to 24 hours in select cases), **IV thrombolysis** is generally the **first-line therapy** if eligible. [1] *Aspirin therapy* - **Aspirin** is an **antiplatelet agent** primarily used secondary prevention of stroke or for patients who are not candidates for thrombolysis. [1] - It is often initiated after thrombolysis or once hemorrhage has been ruled out, but it is **not the most appropriate initial treatment** for a patient eligible for thrombolysis due to its slower onset of action and less potent thrombolytic effect. [1] *Anticoagulation therapy* - **Anticoagulation therapy** (e.g., with heparin or warfarin) aims to prevent new clot formation and propagation. - It is **not indicated in the acute management of ischemic stroke** as an initial treatment because it carries an increased risk of hemorrhagic transformation without significant acute benefit and is typically reserved for stroke prevention in specific conditions like atrial fibrillation.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free