Thrombolysis and Thrombectomy — MCQs
In all of the following conditions, neuraxial blockade is absolutely contraindicated, except:
A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
Which of the following is the best way of preventing the development of deep vein thrombosis (DVT) in the postoperative period?
Which of the following anticoagulants is given orally?
A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
All are used in management of overdosage of Fibrinolytics except?
An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?
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?
What is the most common complication of TIPS (Transjugular Intrahepatic Portosystemic Shunt) procedure?
Transjugular intrahepatic portosystemic shunt (TIPS) is contraindicated in which of the following conditions?
Thrombolysis and Thrombectomy Indian Medical PG Practice Questions and MCQs
Question 1: In all of the following conditions, neuraxial blockade is absolutely contraindicated, except:
- A. Patient refusal
- B. Severe hypovolemia
- C. Pre-existing neurological deficits (Correct Answer)
- D. Coagulopathy
Explanation: ***Pre-existing neurological deficits*** - While careful consideration is needed, pre-existing neurological deficits are generally a **relative contraindication** rather than an absolute one for neuraxial blockade. - The decision depends on the nature and stability of the deficit, potential for worsening, and the benefits of neuraxial anesthesia versus the risks. *Patient refusal* - **Patient refusal** is always an absolute contraindication for any medical procedure, including neuraxial blockade. - Informed consent requires the patient's voluntary agreement, and a refusal must be respected. *Severe hypovolemia* - **Severe hypovolemia** is an absolute contraindication for neuraxial blockade due to the risk of profound hypotension. - Neuraxial blockade causes sympathetic blockade, leading to vasodilation and reduced venous return, which can be catastrophic in an already hypovolemic patient. *Coagulopathy* - **Coagulopathy**, whether intrinsic or iatrogenic, is an absolute contraindication due to the high risk of **epidural hematoma** or **spinal hematoma**. - These hematomas can cause nerve compression, leading to devastating neurological complications like paraplegia.
Question 2: A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
- A. IV thrombolysis (Correct Answer)
- B. MRI Brain
- C. Antihypertensive therapy
- D. CT Angiography
Explanation: ***IV thrombolysis*** - This patient presents with **acute ischemic stroke** symptoms (right-sided weakness and aphasia) with an onset within 4.5 hours of symptom onset, making them a candidate for **IV thrombolysis** [1]. - A **clear NCCT** of the head within this timeframe rules out **hemorrhage**, confirming the safety profile for thrombolytic administration under appropriate blood pressure control [1]. *MRI Brain* - While an MRI brain is highly sensitive for **detecting acute ischemic changes**, it is typically not the initial emergent imaging choice in suspected stroke due to its longer acquisition time and limited availability compared to CT [1]. - The primary goal in acute stroke evaluation is to **rule out hemorrhage** quickly to determine eligibility for thrombolytics, which NCCT achieves effectively [1]. *Antihypertensive therapy* - While the patient's **blood pressure is elevated**, aggressive lowering is generally avoided in acute ischemic stroke unless it exceeds 220/120 mmHg (for non-thrombolysis candidates) or 185/110 mmHg (for thrombolysis candidates). - Rapidly lowering blood pressure can **reduce cerebral perfusion pressure** and worsen ischemic injury in the acute setting due to impaired autoregulation. *CT Angiography* - **CT angiography** can help identify large vessel occlusions that might be amenable to **endovascular thrombectomy** [1]. - However, the immediate priority after a clear NCCT and within the narrow time window is to initiate IV thrombolysis if no contraindications exist, as it provides systemic thrombolysis. CTA is usually performed concurrently or immediately after initial thrombolysis consideration/initiation if endovascular therapy is also being considered [1].
Question 3: Which of the following is the best way of preventing the development of deep vein thrombosis (DVT) in the postoperative period?
- A. Early ambulation
- B. Physiotherapy
- C. Prophylactic heparin (Correct Answer)
- D. Low dose aspirin
Explanation: ***Prophylactic heparin*** - **Prophylactic heparin** (either unfractionated or low molecular weight heparin) is a highly effective pharmacological intervention that directly prevents thrombus formation by inhibiting clotting factors. - It is particularly crucial for patients undergoing surgery, as the **hypercoagulable state** induced by surgery significantly increases DVT risk. *Early ambulation* - **Early ambulation** helps prevent DVT by promoting blood flow and reducing venous stasis, but it is often insufficient on its own for high-risk surgical patients. - It may be difficult or contraindicated immediately post-surgery depending on the type of procedure and patient's condition. *Physiotherapy* - **Physiotherapy**, including leg exercises and mobilization, can improve circulation and muscle pump function, which helps reduce venous stasis. - However, similar to early ambulation, it is generally considered an adjunct and not the primary method for preventing DVT in high-risk postoperative settings. *Low dose aspirin* - **Low-dose aspirin** has antiplatelet effects, which can reduce the risk of arterial thrombosis and, to a lesser extent, venous thrombosis, particularly in prolonged risk scenarios. - For acute high-risk postoperative DVT prevention, its efficacy is generally considered inferior to that of anticoagulants like heparin.
Question 4: Which of the following anticoagulants is given orally?
- A. Argatraban
- B. Alteplase
- C. Rivaroxaban (Correct Answer)
- D. Fondaparinux
Explanation: ***Rivaroxaban*** - Rivaroxaban is a **direct oral anticoagulant (DOAC)** that specifically inhibits **Factor Xa**. - It is administered orally and does not require routine coagulation monitoring. *Argatraban* - Argatroban is a **direct thrombin inhibitor (DTI)** primarily used intravenously, especially in patients with **heparin-induced thrombocytopenia (HIT)**. - It is not an orally administered anticoagulant. *Alteplase* - Alteplase is a **thrombolytic agent** (clot buster), not an anticoagulant, that works by converting **plasminogen to plasmin**. - It is administered intravenously to dissolve existing clots. *Fondaparinux* - Fondaparinux is a **synthetic pentasaccharide** that selectively inhibits **Factor Xa** by binding to antithrombin. - It is administered **subcutaneously**, not orally.
Question 5: A 50-year-old man suddenly developed right-sided weakness and aphasia within 2 hours. His BP recorded was 160/110mmHg and NCCT was clear. What is the next step in management?
- A. Tab labetalol 10 mg stat
- B. MRI brain with DWI
- C. Thrombolysis
- D. CT angiography to look for large vessel occlusion (Correct Answer)
Explanation: ***CT angiography to look for large vessel occlusion*** - The patient presents with **acute neurological deficits** (right-sided weakness and aphasia) occurring within 2 hours, making him a candidate for acute stroke intervention. A **clear NCCT** rules out hemorrhage but doesn't exclude an ischemic stroke [1]. - Given the acute onset and significant neurological deficits, it is crucial to determine if there is a **large vessel occlusion (LVO)** that could be treatable with endovascular thrombectomy, especially if the window for IV thrombolysis is closing or contraindicated [1]. *Tab labetalol 10 mg stat* - While the patient's **blood pressure is elevated (160/110 mmHg)**, aggressive lowering of blood pressure in acute ischemic stroke can worsen outcomes by reducing cerebral perfusion, especially before reperfusion strategies are initiated. - Blood pressure management guidelines for acute ischemic stroke without clear reperfusion options generally suggest allowing for higher blood pressure to maintain cerebral perfusion, unless it's excessively high (e.g., >220/120 mmHg or >185/110 mmHg if considering thrombolysis). *MRI brain with DWI* - **Diffusion-weighted imaging (DWI)** is highly sensitive for **acute ischemic changes** within minutes of onset and would confirm an ischemic stroke [2]. - However, in the hyperacute setting, especially with significant neurological deficits, the priority is to identify an LVO quickly for potential thrombectomy, which **CT angiography (CTA)** can provide more rapidly than MRI in many emergency settings [1]. *Thrombolysis* - **Intravenous thrombolysis** can be considered if the patient meets criteria, typically within **4.5 hours of symptom onset**. - While thrombolysis is a potential treatment, the **next most critical step** after ruling out hemorrhage in a potential LVO case is to identify the occlusion with CTA to determine eligibility for endovascular thrombectomy, which may be beneficial even beyond the IV thrombolysis window [1].
Question 6: All are used in management of overdosage of Fibrinolytics except?
- A. DDAVP (Correct Answer)
- B. Epsilon amino Caproic Acid
- C. Tranexamic Acid
- D. FFP
Explanation: ***DDAVP*** - **DDAVP (Desmopressin)** is primarily used to treat certain bleeding disorders like **von Willebrand disease** and **hemophilia A** by increasing factor VIII and von Willebrand factor. - It does not directly counteract the fibrinolytic activity or mechanisms involved in **fibrinolytic overdose**. *Epsilon amino Caproic Acid* - **Epsilon aminocaproic acid (EACA)** is an **antifibrinolytic agent** that inhibits plasminogen activation, thus preventing the breakdown of fibrin clots. - It is often used to treat bleeding due to hyperfibrinolysis, including that caused by **fibrinolytic overdose**. *Tranexamic Acid* - **Tranexamic acid (TXA)** is another potent **antifibrinolytic agent** that works by reversibly blocking lysine binding sites on plasminogen, preventing its conversion to plasmin. - It is frequently used to manage and prevent excessive bleeding, including in situations of **fibrinolytic overdose**. *FFP* - **Fresh frozen plasma (FFP)** contains all coagulation factors, including **fibrinogen** and other factors consumed or degraded during fibrinolytic therapy. - It is used to replenish clotting factors and improve hemostasis, making it a critical component in managing severe bleeding from **fibrinolytic overdose**.
Question 7: An 85-year-old patient was brought to the ER, BP: 180/100, right hemiparesis was seen. What is the next best step in management?
- A. Reduce BP
- B. NCCT (Correct Answer)
- C. MRI
- D. Aspirin 300mg and anticoagulants
Explanation: ***NCCT*** - A **non-contrast CT (NCCT) scan of the brain** is the most crucial initial step to differentiate between **ischemic stroke** and **hemorrhagic stroke** [1]. - This distinction is vital because management, especially the use of thrombolytics or anticoagulants, differs significantly based on stroke type [1]. *Reduce BP* - While blood pressure management is important in stroke, immediate and aggressive lowering of BP in acute ischemic stroke can **worsen cerebral perfusion** and **increase infarct size**. - In hemorrhagic stroke, BP control is often necessary, but the decision to lower BP and by how much depends on the cause and extent of the bleed, and this can only be determined after imaging [1]. *MRI* - **MRI** is more sensitive for detecting acute ischemic changes than CT, especially in the posterior fossa [1]. - However, **MRI is not typically the first-line imaging** in an emergency setting for an acute stroke due to its longer acquisition time and potential contraindications (e.g., pacemakers, metallic implants) [1]. *Aspirin 300mg and anticoagulants* - These medications are indicated for **ischemic stroke** (aspirin is an antiplatelet, anticoagulants may be used in specific cases like cardioembolic stroke). - Administering these agents in the event of a **hemorrhagic stroke** would be contraindicated and could significantly worsen the bleeding, leading to severe neurological damage or death [1].
Question 8: 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.
Question 9: What is the most common complication of TIPS (Transjugular Intrahepatic Portosystemic Shunt) procedure?
- A. Heart failure
- B. Hepatic Encephalopathy (Correct Answer)
- C. Thrombosis
- D. Recurrent Variceal bleed
Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is an artificial channel created between the high-pressure portal vein and the low-pressure hepatic vein to treat complications of portal hypertension. **Why Hepatic Encephalopathy (HE) is the correct answer:** The primary mechanism of TIPS involves bypassing the liver’s filtration system. By creating a shunt, portal blood (rich in ammonia and other neurotoxins derived from the gut) enters the systemic circulation directly without being detoxified by hepatocytes. This leads to **Hepatic Encephalopathy in approximately 25–45% of patients**, making it the most frequent complication post-procedure. **Analysis of Incorrect Options:** * **A. Heart Failure:** While the sudden increase in venous return to the right atrium (preload) can precipitate acute heart failure in patients with underlying cardiac disease, it is far less common than HE. * **C. Thrombosis:** Shunt stenosis or thrombosis was common with bare-metal stents; however, with the modern use of **PTFE-covered stents**, the incidence of thrombosis has significantly decreased. * **D. Recurrent Variceal Bleed:** TIPS is highly effective at decompressing varices. Re-bleeding usually only occurs if the shunt becomes occluded or stenosed, which is a secondary event. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Refractory variceal bleeding (most common indication) and refractory ascites. * **Absolute Contraindications:** Severe congestive heart failure (Right-sided), polycystic liver disease, and severe active systemic infection/sepsis. * **Technical Goal:** To reduce the **Portosystemic Pressure Gradient (PSG) to <12 mmHg** to prevent re-bleeding. * **Stent Type:** PTFE-covered stents (e.g., VIATORR) are the gold standard to maintain patency.
Question 10: Transjugular intrahepatic portosystemic shunt (TIPS) is contraindicated in which of the following conditions?
- A. Post-shunt encephalopathy
- B. Cirrhosis
- C. Portal vein thrombosis (Correct Answer)
- D. Variceal bleeding
Explanation: **Explanation:** **Transjugular Intrahepatic Portosystemic Shunt (TIPS)** is an interventional procedure where a shunt is created between the hepatic vein and the portal vein to reduce portal hypertension. **Why Portal Vein Thrombosis (PVT) is the correct answer:** The success of a TIPS procedure depends on the ability to access and pass a wire through the portal vein to establish the shunt. In cases of **extensive or cavernous portal vein thrombosis**, the target vessel is either occluded or replaced by small collateral vessels, making the procedure technically impossible or highly hazardous. While partial PVT is sometimes managed by experienced interventionists, complete PVT remains a classic **absolute contraindication** in standard practice. **Analysis of Incorrect Options:** * **Post-shunt encephalopathy (A):** This is a common **complication** of TIPS, not a contraindication for the initial procedure. However, pre-existing severe hepatic encephalopathy is a relative contraindication. * **Cirrhosis (B):** Cirrhosis with portal hypertension is the **primary indication** for TIPS (specifically for refractory ascites or variceal bleeding). * **Variceal bleeding (D):** This is a **major indication** for TIPS, especially when bleeding is refractory to endoscopic management (Rescue TIPS). **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Severe congestive heart failure (R-sided), severe pulmonary hypertension, and multiple hepatic cysts/polycystic liver disease. * **Relative Contraindications:** Active systemic infection, severe coagulopathy, and rapidly progressing hepatoma. * **MELD Score:** A MELD score >18 is associated with higher mortality post-TIPS. * **Mechanism:** TIPS bypasses the liver parenchyma, effectively converting sinusoidal portal hypertension into a side-to-side portocaval shunt.
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