A 67-year-old man presents to the emergency department for a headache. The patient states his symptoms started thirty minutes ago. He states he experienced a sudden and severe headache while painting his house, causing him to fall off the ladder and hit his head. He has also experienced two episodes of vomiting and difficulty walking since the fall. The patient has a past medical history of hypertension, obesity, and atrial fibrillation. His current medications include lisinopril, rivaroxaban, atorvastatin, and metformin. His temperature is 99.5°F (37.5°C), blood pressure is 150/105 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient localizes his headache to the back of his head. Cardiac exam reveals a normal rate and rhythm. Pulmonary exam reveals minor bibasilar crackles. Neurological exam is notable for minor weakness of the muscles of facial expression. Examination of cranial nerve three reveals a notable nystagmus. Heel to shin exam is abnormal bilaterally. The patient's gait is notably ataxic. A non-contrast CT scan of the head is currently pending. Which of the following is the most likely diagnosis?
Q2
A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition?
Q3
A 72-year-old woman is brought to the emergency department by her son after he noticed that she was slurring her speech. He also noticed that she appeared to have difficulty using her fork about halfway through dinner when the speech problems started. He brought her to the emergency department immediately and he estimates that only 1 hour has passed since the beginning of the symptoms. An immediate exam is conducted. A medication is administered to ameliorate the effects of this patient's condition that would not be available for use if the patient had presented significantly later. An hour later the patient's condition becomes significantly worse and new deficits are found. Which of the following agents should be used at this point?
Q4
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?
Q5
A new treatment for hemorrhagic stroke, which is a life-threatening clinical condition that occurs when a diseased blood vessel in the brain ruptures or leaks, was evaluated as soon as it hit the market by an international group of neurology specialists. In those treated with the new drug, a good outcome was achieved in 30%, while those treated with the current standard of care had a good outcome in just 10% of cases. The clinicians involved in this cohort study concluded that the newer drug is more effective and prompted for urgent changes in the guidelines addressing hemorrhagic stroke incidents. According to the aforementioned percentages, how many patients must be treated with the new drug to see 1 additional good outcome?
Q6
A 74-year-old man presents to the emergency department by paramedics for slurred speech and weakness in the left arm and leg for 1 hour. The patient was playing with his grandson when the symptoms started and his wife immediately called an ambulance. There is no history of head trauma or recent surgery. The patient takes captopril for hypertension. The vital signs include: pulse 110/min, respiratory rate 22/min, and blood pressure 200/105 mm Hg. The physical examination shows that the patient is alert and conscious, but speech is impaired. Muscle strength is 0/5 in the left arm and leg and 5/5 in the right arm and leg. A non-contrast CT of the head shows no evidence of intracranial bleeding. The lab results are as follows:
Serum glucose 90 mg/dL
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 1.3 mg/dL
Blood urea nitrogen 20 mg/dL
Cholesterol, total 240 mg/dL
HDL-cholesterol 38 mg/dL
LDL-cholesterol 100 mg/dL
Triglycerides 190 mg/dL
Hemoglobin (Hb%) 15.3 g/dL
Mean corpuscular volume (MCV) 83 fL
Reticulocyte count 0.8%
Erythrocyte count 5.3 million/mm3
Platelet count 130,000/mm3
Partial thromboplastin time (aPTT) 30 sec
Prothrombin time (PT) 12 sec
Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?
Q7
A 44-year-old man comes to the emergency department because of a severe headache and blurry vision for the past 3 hours. He has hypertension treated with hydrochlorothiazide. He has missed taking his medication for the past week as he was traveling. He is only oriented to time and person. His temperature is 37.1°C (98.8°F), pulse is 92/min and regular, and blood pressure is 245/115 mm Hg. Cardiopulmonary examination shows no abnormalities. Fundoscopy shows bilateral retinal hemorrhages and exudates. Neurologic examination shows no focal findings. A complete blood count and serum concentrations of electrolytes, glucose, and creatinine are within the reference range. A CT scan of the brain shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?
Q8
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?
Q9
A 75-year-old woman presents with sudden loss of vision. She says that she was reading when suddenly she was not able to see the print on half of the page. Her symptoms started 4 hours ago and are accompanied by a severe posterior headache. Vital signs reveal the following: blood pressure 119/76 mm Hg, pulse 89/min, SpO2 98% on room air. The patient was unable to recognize her niece when she arrived to see her. A noncontrast CT of the head shows no evidence of hemorrhagic stroke. What is the most likely diagnosis in this patient?
Q10
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.
Hemorrhagic stroke management US Medical PG Practice Questions and MCQs
Question 1: A 67-year-old man presents to the emergency department for a headache. The patient states his symptoms started thirty minutes ago. He states he experienced a sudden and severe headache while painting his house, causing him to fall off the ladder and hit his head. He has also experienced two episodes of vomiting and difficulty walking since the fall. The patient has a past medical history of hypertension, obesity, and atrial fibrillation. His current medications include lisinopril, rivaroxaban, atorvastatin, and metformin. His temperature is 99.5°F (37.5°C), blood pressure is 150/105 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 98% on room air. On physical exam, the patient localizes his headache to the back of his head. Cardiac exam reveals a normal rate and rhythm. Pulmonary exam reveals minor bibasilar crackles. Neurological exam is notable for minor weakness of the muscles of facial expression. Examination of cranial nerve three reveals a notable nystagmus. Heel to shin exam is abnormal bilaterally. The patient's gait is notably ataxic. A non-contrast CT scan of the head is currently pending. Which of the following is the most likely diagnosis?
A. Pontine hemorrhage
B. Cerebellar hemorrhage (Correct Answer)
C. Subarachnoid hemorrhage
D. Thalamic hemorrhage
E. Subdural hematoma
Explanation: ***Cerebellar hemorrhage***
- The sudden onset of a **severe headache**, localized to the back of the head, combined with **ataxia**, nystagmus, and minor facial weakness, in a patient on **anticoagulation** (rivaroxaban) for atrial fibrillation, strongly suggests a cerebellar hemorrhage.
- **Vomiting** and **difficulty walking** are common symptoms due to the cerebellar involvement and increased intracranial pressure.
*Pontine hemorrhage*
- Pontine hemorrhages typically present with **quadriplegia**, profound **coma**, and **pinpoint pupils**, which are not observed in this patient.
- While it can cause sudden headache and vomiting, the specific neurological deficits (ataxia, nystagmus, mild facial weakness) are less characteristic of a pontine lesion.
*Subarachnoid hemorrhage*
- Characterized by a **"thunderclap" headache** (sudden and severe), often described as the "worst headache of my life," and can cause focal neurological deficits depending on the location of rupture.
- While the sudden onset and severity fit, the specific cerebellar signs (**nystagmus**, **ataxia**, posterior headache) point more directly to a cerebellar lesion, and the fall causing head trauma suggests a hemorrhage within the brain parenchyma.
*Thalamic hemorrhage*
- Thalamic hemorrhages commonly present with **contralateral hemisensory loss**, hemiparesis, and sometimes pupillary abnormalities.
- The patient's presentation with prominent **ataxia**, nystagmus, and posterior headache is less typical for a thalamic hemorrhage.
*Subdural hematoma*
- Subdural hematomas usually result from **trauma** and can have a more **insidious onset** (especially chronic subdural hematomas in elderly or anticoagulated patients).
- While the fall might suggest this, the acute onset of severe headache and the specific neurological signs like **ataxia** and nystagmus are more indicative of an intraparenchymal hemorrhage (like cerebellar) rather than a subdural collection compressing the brain surface.
Question 2: A 48-year-old man presents to the ER with a sudden-onset, severe headache. He is vomiting and appears confused. His wife, who accompanied him, says that he has not had any trauma, and that the patient has no relevant family history. He undergoes a non-contrast head CT that shows blood between the arachnoid and pia mater. What is the most likely complication from this condition?
A. Hemorrhagic shock
B. Arterial Vasospasm (Correct Answer)
C. Renal failure
D. Bacterial Meningitis
E. Blindness
Explanation: **Arterial Vasospasm**
- **Arterial vasospasm** is a major delayed complication of **subarachnoid hemorrhage (SAH)**, typically occurring 3-14 days after the initial bleed.
- The presence of blood products in the subarachnoid space can irritate cerebral arteries, leading to their narrowing and subsequent **delayed cerebral ischemia** or infarction.
*Hemorrhagic shock*
- **Subarachnoid hemorrhage (SAH)** typically involves bleeding within the confines of the skull, which is usually not extensive enough to cause systemic **hypovolemia** or **hemorrhagic shock**.
- **Hemorrhagic shock** would require significant external blood loss or internal bleeding into a large body cavity, which is not characteristic of an isolated SAH.
*Renal failure*
- **Renal failure** is not a direct or common complication of **subarachnoid hemorrhage (SAH)**.
- While systemic complications can sometimes arise in critically ill patients, there is no direct pathophysiological link between SAH and primary kidney injury.
*Bacterial Meningitis*
- The presence of blood in the **subarachnoid space** can cause a **chemical meningitis** due to irritation, mimicking some symptoms of bacterial meningitis.
- However, it does not typically predispose to **bacterial infection** unless there's an iatrogenic cause (e.g., lumbar puncture contamination).
*Blindness*
- While damage to the **optic nerves** or visual pathways can occur with severe neurological events or increased intracranial pressure, **blindness** is not a common or direct complication specifically arising from the bleed itself or its immediate sequelae in SAH.
- Visual disturbances are possible due to elevated **intracranial pressure** or specific anatomical lesion, but not primary blindness.
Question 3: A 72-year-old woman is brought to the emergency department by her son after he noticed that she was slurring her speech. He also noticed that she appeared to have difficulty using her fork about halfway through dinner when the speech problems started. He brought her to the emergency department immediately and he estimates that only 1 hour has passed since the beginning of the symptoms. An immediate exam is conducted. A medication is administered to ameliorate the effects of this patient's condition that would not be available for use if the patient had presented significantly later. An hour later the patient's condition becomes significantly worse and new deficits are found. Which of the following agents should be used at this point?
A. Protamine sulfate
B. Antivenin
C. Aminocaproic acid
D. Plasma transfusion (Correct Answer)
E. Vitamin K
Explanation: ***Plasma transfusion***
- The patient's clinical presentation (acute focal neurological deficits within 1 hour) indicates **ischemic stroke**, and the "medication administered to ameliorate effects...not available if presented significantly later" is **tissue plasminogen activator (tPA/alteplase)**, which must be given within 3-4.5 hours of symptom onset.
- The subsequent **worsening with new deficits** after initial tPA administration strongly suggests **hemorrhagic transformation** of the ischemic stroke, a known complication of thrombolytic therapy.
- **Fresh frozen plasma (FFP)** is the appropriate treatment because tPA depletes **fibrinogen and clotting factors** through systemic fibrinolysis, and FFP directly replaces these consumed clotting factors to help control bleeding.
- Management of tPA-related hemorrhage includes: stopping tPA, emergent neuroimaging, and administration of **cryoprecipitate** (to replace fibrinogen) and/or **FFP** (to replace clotting factors).
*Aminocaproic acid*
- **Aminocaproic acid** is an antifibrinolytic agent that inhibits plasminogen activation.
- While it can theoretically help in fibrinolytic-related bleeding, it is **NOT first-line therapy** for tPA-associated hemorrhagic transformation.
- **Cryoprecipitate and FFP** are preferred because they directly replace the fibrinogen and clotting factors depleted by tPA, addressing the underlying coagulopathy.
*Protamine sulfate*
- **Protamine sulfate** reverses **heparin** anticoagulation by binding to and inactivating heparin.
- This patient received tPA (a thrombolytic), not heparin, so protamine would not be effective.
*Antivenin*
- **Antivenin** is used to neutralize venom from snake or spider bites.
- This patient's presentation is consistent with stroke and tPA complication, not envenomation.
*Vitamin K*
- **Vitamin K** reverses **warfarin** by promoting hepatic synthesis of vitamin K-dependent clotting factors (II, VII, IX, X).
- Warfarin reversal takes hours to days; in acute bleeding, **FFP or prothrombin complex concentrate (PCC)** provides immediate factor replacement.
- This patient's complication is related to tPA (thrombolytic), not warfarin.
Question 4: 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
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.
Question 5: A new treatment for hemorrhagic stroke, which is a life-threatening clinical condition that occurs when a diseased blood vessel in the brain ruptures or leaks, was evaluated as soon as it hit the market by an international group of neurology specialists. In those treated with the new drug, a good outcome was achieved in 30%, while those treated with the current standard of care had a good outcome in just 10% of cases. The clinicians involved in this cohort study concluded that the newer drug is more effective and prompted for urgent changes in the guidelines addressing hemorrhagic stroke incidents. According to the aforementioned percentages, how many patients must be treated with the new drug to see 1 additional good outcome?
A. 5 (Correct Answer)
B. 30
C. 20
D. 15
E. 10
Explanation: ***Correct: 5***
- This is calculated using the concept of **Number Needed to Treat (NNT)**, which tells us how many patients need to receive the new treatment to see one additional good outcome compared to standard care.
- The **Absolute Risk Reduction (ARR)** is the difference in good outcome rates: 30% - 10% = 20% (or 0.20 as a proportion).
- **NNT = 1 / ARR = 1 / 0.20 = 5**
- Therefore, treating 5 patients with the new drug will result in 1 additional patient with a good outcome compared to standard care.
*Incorrect: 30*
- This represents the **percentage of patients** who achieved a good outcome with the new drug, not the number needed to treat.
- It does not account for the baseline effectiveness of standard treatment, which is essential for calculating the marginal benefit.
- This is the absolute event rate in the treatment group, not a comparative measure.
*Incorrect: 20*
- This is the **Absolute Risk Reduction (ARR)** expressed as a percentage (30% - 10% = 20%).
- While this is a key component in calculating NNT, it is not the NNT itself.
- The NNT requires taking the reciprocal of the ARR when expressed as a proportion: 1/0.20 = 5.
*Incorrect: 15*
- This number does not correspond to any standard epidemiological or biostatistical measure in this context.
- It is neither the ARR, NNT, relative risk, nor any other interpretable value from the given data.
- This is an arbitrary distractor with no mathematical basis.
*Incorrect: 10*
- This represents the **percentage of patients** who achieved a good outcome with standard care (the control group).
- It is the baseline event rate, not a measure of treatment effect or comparative effectiveness.
- Like option 30, it does not reflect the additional benefit from the new treatment.
Question 6: A 74-year-old man presents to the emergency department by paramedics for slurred speech and weakness in the left arm and leg for 1 hour. The patient was playing with his grandson when the symptoms started and his wife immediately called an ambulance. There is no history of head trauma or recent surgery. The patient takes captopril for hypertension. The vital signs include: pulse 110/min, respiratory rate 22/min, and blood pressure 200/105 mm Hg. The physical examination shows that the patient is alert and conscious, but speech is impaired. Muscle strength is 0/5 in the left arm and leg and 5/5 in the right arm and leg. A non-contrast CT of the head shows no evidence of intracranial bleeding. The lab results are as follows:
Serum glucose 90 mg/dL
Sodium 140 mEq/L
Potassium 4.1 mEq/L
Chloride 100 mEq/L
Serum creatinine 1.3 mg/dL
Blood urea nitrogen 20 mg/dL
Cholesterol, total 240 mg/dL
HDL-cholesterol 38 mg/dL
LDL-cholesterol 100 mg/dL
Triglycerides 190 mg/dL
Hemoglobin (Hb%) 15.3 g/dL
Mean corpuscular volume (MCV) 83 fL
Reticulocyte count 0.8%
Erythrocyte count 5.3 million/mm3
Platelet count 130,000/mm3
Partial thromboplastin time (aPTT) 30 sec
Prothrombin time (PT) 12 sec
Although he is within the time frame for the standard therapy of the most likely condition, the treatment cannot be started because of which of the following contraindications?
A. A platelet count of 130,000/mm3
B. Age of 74 years
C. Cholesterol level of 240 mg/dL
D. Creatinine level of 1.3 mg/dL
E. Systolic blood pressure of 200 mm Hg (Correct Answer)
Explanation: ***Systolic blood pressure of 200 mm Hg***
- The patient presents with symptoms highly suggestive of an **acute ischemic stroke**, including **slurred speech** and **left-sided weakness**.
- For patients with acute ischemic stroke who are candidates for **thrombolytic therapy (e.g., alteplase)**, a **systolic blood pressure consistently >185 mm Hg or diastolic >110 mm Hg is a contraindication** due to increased risk of hemorrhagic transformation.
*A platelet count of 130,000/mm3*
- A platelet count of 130,000/mm³ is above the **contraindication threshold for thrombolytic therapy**, which is typically <100,000/mm³.
- Therefore, this platelet count would **not prevent** the initiation of tPA.
*Age of 74 years*
- While older age was once considered a relative contraindication, current guidelines **do not consider age alone (including 74 years old) as an absolute contraindication** for thrombolytic therapy in acute ischemic stroke.
- Eligibility is determined by a comprehensive risk-benefit assessment, not solely by age.
*Cholesterol level of 240 mg/dL*
- An elevated **cholesterol level** is a **risk factor for atherosclerosis** and ischemic stroke, but it is **not a contraindication for acute thrombolytic therapy**.
- It relates to the underlying cause of the stroke rather than the immediate treatment decision.
*Creatinine level of 1.3 mg/dL*
- A **creatinine level of 1.3 mg/dL** indicates **mild renal impairment**, but it is **not a contraindication for thrombolytic therapy**.
- Renal function more significantly impacts the use of certain anticoagulants, but not typically alteplase in the acute setting.
Question 7: A 44-year-old man comes to the emergency department because of a severe headache and blurry vision for the past 3 hours. He has hypertension treated with hydrochlorothiazide. He has missed taking his medication for the past week as he was traveling. He is only oriented to time and person. His temperature is 37.1°C (98.8°F), pulse is 92/min and regular, and blood pressure is 245/115 mm Hg. Cardiopulmonary examination shows no abnormalities. Fundoscopy shows bilateral retinal hemorrhages and exudates. Neurologic examination shows no focal findings. A complete blood count and serum concentrations of electrolytes, glucose, and creatinine are within the reference range. A CT scan of the brain shows no abnormalities. Which of the following is the most appropriate pharmacotherapy?
A. Sublingual nifedipine
B. Oral captopril
C. Intravenous nitroprusside (Correct Answer)
D. Oral clonidine
E. Intravenous mannitol
Explanation: ***Intravenous nitroprusside***
- The patient presents with **hypertensive emergency**, characterized by **severe hypertension** (245/115 mmHg) with **acute end-organ damage**, including altered mental status and retinal hemorrhages/exudates.
- **Intravenous nitroprusside** is a potent, rapidly acting vasodilator making it an excellent choice for immediate and controlled reduction of blood pressure in such critical situations.
*Sublingual nifedipine*
- **Sublingual nifedipine** can cause a sudden and uncontrolled drop in blood pressure, leading to **ischemia** due to inadequate perfusion of vital organs.
- It also has a less predictable and slower onset of action compared to intravenous agents, making it unsuitable for acute hypertensive emergencies.
*Oral captopril*
- **Oral captopril** has a slower onset of action and is less suitable for the acute management of a **hypertensive emergency** where immediate and precise blood pressure control is crucial.
- While an ACE inhibitor, its oral administration does not provide the rapid titratability needed to safely lower dangerously high blood pressures.
*Oral clonidine*
- **Oral clonidine** also has a relatively slow onset of action and its effects can be variable, making it less ideal for the acute, emergent management of **severe hypertension** with end-organ damage.
- It is more appropriate for urgent but non-emergent hypertension or chronic management, not for situations requiring immediate and controlled blood pressure reduction.
*Intravenous mannitol*
- **Intravenous mannitol** is an osmotic diuretic primarily used to reduce **intracranial pressure** or to promote diuresis.
- It does not directly lower blood pressure effectively in a hypertensive emergency and is not a primary antihypertensive agent.
Question 8: 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
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.
Question 9: A 75-year-old woman presents with sudden loss of vision. She says that she was reading when suddenly she was not able to see the print on half of the page. Her symptoms started 4 hours ago and are accompanied by a severe posterior headache. Vital signs reveal the following: blood pressure 119/76 mm Hg, pulse 89/min, SpO2 98% on room air. The patient was unable to recognize her niece when she arrived to see her. A noncontrast CT of the head shows no evidence of hemorrhagic stroke. What is the most likely diagnosis in this patient?
A. Lacunar stroke
B. Middle cerebral artery stroke
C. Vertebrobasilar stroke
D. Subarachnoid hemorrhage
E. Posterior cerebral artery stroke (Correct Answer)
Explanation: ***Posterior cerebral artery stroke***
- The sudden severe posterior headache along with **unilateral vision loss** and **prosopagnosia** (inability to recognize familiar faces) are characteristic signs of a **posterior cerebral artery (PCA) stroke**.
- PCA occlusion often affects the **occipital lobe** (vision) and can extend to the **temporal lobe** (facial recognition).
*Lacunar stroke*
- This type of stroke results from the occlusion of small penetrating arteries and typically causes **pure motor** or **pure sensory deficits**, not complex visual or recognition problems.
- While headache can occur, the specific combination of symptoms points away from a lacunar infarct.
*Middle cerebral artery stroke*
- MCA stroke commonly presents with **contralateral hemiparesis**, **aphasia** (if dominant hemisphere), and **hemianopia** but usually not isolated unilateral vision loss or severe posterior headache with prosopagnosia.
- The symptoms are more consistent with involvement of the posterior circulation.
*Vertebrobasilar stroke*
- A vertebrobasilar stroke can cause **visual disturbances**, but it is typically associated with other **brainstem symptoms** like vertigo, ataxia, or cranial nerve deficits, which are not described here.
- The specific presentation of unilateral vision loss and prosopagnosia is less typical for a vertebrobasilar stroke affecting widespread brainstem structures.
*Subarachnoid hemorrhage*
- While a **sudden severe headache (thunderclap headache)** is a hallmark of SAH, it usually presents with meningeal irritation symptoms like **neck stiffness** and often altered mental status, and the visual deficits are usually different (e.g., oculomotor nerve palsy).
- The patient's focal neurological deficits, specifically prosopagnosia and unilateral visual field loss, are more indicative of an ischemic event in a specific vascular territory.
Question 10: 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
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.
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