Stroke Practice Questions

Q: A 68-year-old man presents to the emergency department with sudden onset right-sided weakness and slurred speech that began 90 minutes ago. His blood pressure is 185/100 mmHg, heart rate is 88/min, and he is alert and oriented. CT scan of the head shows no hemorrhage. His NIHSS score is 14. What is the most appropriate next step in management?

Administer intravenous alteplase immediately. ***Administer intravenous alteplase immediately*** - The patient presents within the **4.5-hour therapeutic window** for IV thrombolysis, and the **non-contrast CT head** has already ruled out intracranial hemorrhage. - His blood pressure (**185/100 mmHg**) is within the acceptable limit for starting **alteplase** (threshold is <185/110 mmHg), making immediate administration the priority. *Perform mechanical thrombectomy without thrombolysis* - **Mechanical thrombectomy** is indicated for large vessel occlusions, but it should be performed in addition to, not instead of, **IV thrombolysis** in eligible patients. - Skipping thrombolysis is only appropriate if there are specific **contraindications** to alteplase, which are not present here. *Obtain CT angiography before any intervention* - While **CT angiography** is useful to identify large vessel occlusions, it should **not delay** the initiation of IV alteplase in eligible patients. - "Time is brain," and the standard of care is to start **thrombolytic therapy** as soon as hemorrhage is ruled out and eligibility is confirmed. *Start dual antiplatelet therapy with aspirin and clopidogrel* - **Dual antiplatelet therapy** is used for minor ischemic strokes or high-risk TIAs but is contraindicated within the first **24 hours** after receiving IV alteplase. - Starting antiplatelets now would significantly increase the **risk of bleeding** and is not the primary treatment for a major stroke (NIHSS 14). *Lower blood pressure to <140/90 mmHg before treatment* - For patients eligible for alteplase, the blood pressure target is **<185/110 mmHg**; lowering it too aggressively can worsen **ischemic penumbra** perfusion. - A target of **<140/90 mmHg** is not indicated in the acute phase of an ischemic stroke and may lead to clinical deterioration.

Question 1

A 55-year-old woman with atrial fibrillation on warfarin presents with acute left hemiparesis and dysarthria for 2 hours. Her INR is 2.8. CT head shows no hemorrhage. CT angiography reveals a right MCA occlusion. Her NIHSS score is 18. What is the most appropriate management strategy?

Accepted Answer

Administer alteplase and proceed with mechanical thrombectomy

Answer

Reverse anticoagulation with vitamin K and wait 24 hours

Answer

Lower INR to <1.7 before considering any intervention

Answer

Perform mechanical thrombectomy alone without thrombolysis

Answer

Start aspirin and observe for spontaneous improvement

Question 2

A 68-year-old man presents to the emergency department with sudden onset right-sided weakness and slurred speech that began 90 minutes ago. His blood pressure is 185/100 mmHg, heart rate is 88/min, and he is alert and oriented. CT scan of the head shows no hemorrhage. His NIHSS score is 14. What is the most appropriate next step in management?

Accepted Answer

Administer intravenous alteplase immediately

Answer

Perform mechanical thrombectomy without thrombolysis

Answer

Obtain CT angiography before any intervention

Answer

Start dual antiplatelet therapy with aspirin and clopidogrel

Answer

Lower blood pressure to <140/90 mmHg before treatment

Stroke — MCQs

Stroke — MCQs

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