Stroke recognition and initial assessment — MCQs

10 questions

A 24-year-old man presents to the emergency department after a motor vehicle collision. He was in the front seat and unrestrained driver in a head on collision. His temperature is 99.2°F (37.3°C), blood pressure is 90/65 mmHg, pulse is 152/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam is notable for a young man who opens his eyes spontaneously and is looking around. He answers questions with inappropriate responses but discernible words. He withdraws from pain but does not have purposeful movement. Which of the following is this patient's Glasgow coma scale?

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 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?

A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

A 2-month-old boy is brought to the emergency room by his mother who reports he has appeared lethargic for the past 3 hours. She reports that she left the patient with a new nanny this morning, and he was behaving normally. When she got home in the afternoon, the patient seemed lethargic and would not breastfeed as usual. At birth, the child had an Apgar score of 8/9 and weighed 2.8 kg (6.1 lb). Growth has been in the 90th percentile, and the patient has been meeting all developmental milestones. There is no significant past medical history, and vaccinations are up-to-date. On physical examination, the patient does not seem arousable. Ophthalmologic examination shows retinal hemorrhages. Which of the following findings would most likely be expected on a noncontrast CT scan of the head?

A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. He is immediately sent for a head CT which is normal. What is the most appropriate next step in management?

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 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.

An 80-year-old woman with atrial fibrillation presents 2 hours after acute ischemic stroke. NIHSS is 22. Imaging shows large left MCA territory infarction involving >1/3 of MCA territory with basilar artery occlusion. She lives alone but was independent before this event. Her family requests all possible interventions. Evaluate the management approach considering benefits versus risks.

Q10

A 58-year-old woman with history of TIA 3 weeks ago presents with acute ischemic stroke. Imaging reveals new right MCA infarction and severe (70-99%) symptomatic right carotid stenosis. She received alteplase 6 hours ago with partial improvement. Her NIHSS improved from 14 to 8. Analyze the optimal timing for carotid revascularization.

Stroke recognition and initial assessment US Medical PG Practice Questions and MCQs

Question 1: A 24-year-old man presents to the emergency department after a motor vehicle collision. He was in the front seat and unrestrained driver in a head on collision. His temperature is 99.2°F (37.3°C), blood pressure is 90/65 mmHg, pulse is 152/min, respirations are 16/min, and oxygen saturation is 100% on room air. Physical exam is notable for a young man who opens his eyes spontaneously and is looking around. He answers questions with inappropriate responses but discernible words. He withdraws from pain but does not have purposeful movement. Which of the following is this patient's Glasgow coma scale?

A. 9
B. 15
C. 7
D. 11 (Correct Answer)
E. 13

Explanation: ***11*** - **Eye-opening (E)**: The patient opens his eyes spontaneously, scoring **E4**. - **Verbal response (V)**: He gives inappropriate responses but discernible words, scoring **V3**. - **Motor response (M)**: He withdraws from pain but does not have purposeful movement, scoring **M4**. - Therefore, the total Glasgow Coma Scale (GCS) score is **E4 + V3 + M4 = 11**. *9* - This score would imply a lower verbal or motor response, such as **incomprehensible sounds (V2)** or **abnormal flexion (M3)**, which is not consistent with the patient's presentation. - For example, E4 + V2 + M3 would equal 9. *15* - A GCS of 15 indicates **normal neurological function**, meaning the patient would be fully oriented, obey commands, and open eyes spontaneously, which is not the case here. - This score is for a patient who is fully conscious and responsive. *7* - A GCS of 7 suggests a **severe brain injury**, which would typically present with a much poorer response, such as **no verbal response (V1)** or **abnormal extension (M2)**. - For example, E4 + V1 + M2 would equal 7. *13* - This score would mean a higher level of consciousness, such as **confused conversation (V4)** or **localizing pain (M5)**, which is better than the patient's described responses. - For example, E4 + V4 + M5 would equal 13.

Question 2: 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 3: A 78-year-old man is brought in to the emergency department by ambulance after his wife noticed that he began slurring his speech and had developed facial asymmetry during dinner approximately 30 minutes ago. His past medical history is remarkable for hypertension and diabetes. His temperature is 99.1°F (37.3°C), blood pressure is 154/99 mmHg, pulse is 89/min, respirations are 12/min, and oxygen saturation is 98% on room air. Neurologic exam reveals right upper and lower extremity weakness and an asymmetric smile. Which of the following is the next best step in management?

A. Alteplase
B. MRI brain
C. CT head (Correct Answer)
D. Aspirin
E. CTA head

Explanation: ***CT head*** - A **non-contrast CT head** is the immediate priority to differentiate between ischemic and hemorrhagic stroke, which is critical for guiding subsequent treatment decisions. - Given the patient's acute neurological deficits (slurred speech, facial asymmetry, weakness) and vascular risk factors (hypertension, diabetes), **stroke is highly suspected**, and identifying intracerebral hemorrhage is crucial before considering thrombolytic therapy. *Alteplase* - **Alteplase** (tPA) is a thrombolytic agent used for acute ischemic stroke, but its administration is **contraindicated in hemorrhagic stroke**. - Initiating alteplase without first ruling out hemorrhage with a CT scan could lead to catastrophic bleeding. *MRI brain* - While an **MRI brain** can provide more detailed imaging of stroke, it is typically **not the initial imaging modality** in the emergency setting due to longer acquisition times and limited availability, especially when emergent differentiation between ischemic and hemorrhagic stroke is needed. - Its use is usually reserved for cases where the CT is inconclusive or for later evaluation. *Aspirin* - **Aspirin** is an antiplatelet agent used in the management of ischemic stroke, but it should **not be given until a hemorrhagic stroke has been ruled out** via CT head. - Administering aspirin in the context of an intracerebral hemorrhage could worsen bleeding. *CTA head* - A **CT angiography (CTA) head** is used to visualize the cerebral vasculature and identify large vessel occlusions, which can guide thrombectomy decisions in ischemic stroke. - However, performing a **non-contrast CT head is a prerequisite** to rule out hemorrhage before proceeding with CTA or any other advanced imaging or therapeutic interventions.

Question 4: A 77-year-old woman is brought by ambulance to the emergency department after she developed weakness of her right arm along with a right-sided facial droop. By the time the ambulance arrived, she was having difficulty speaking. Past medical history is significant for hypertension, diabetes mellitus type II, and hyperlipidemia. She takes lisinopril, hydrochlorothiazide, metformin, and atorvastatin. On arrival to the emergency department, her vital signs are within normal limits. On physical examination, she is awake and alert but the right side of her mouth is dropping, making it difficult for her to speak clearly. Her heart has a regular rate and rhythm and her lungs are clear to auscultation bilaterally. Fingerstick glucose is 85 mg/dL. Her right upper extremity strength is 2/5 and her left upper extremity strength is 5/5. Which of the following is the best next step in management?

A. Obtain transcranial doppler
B. Start tissue plasminogen activator (tPA)
C. Consult cardiology
D. Intubate the patient
E. Obtain noncontrast CT of the brain (Correct Answer)

Explanation: ***Obtain noncontrast CT of the brain*** - An **urgent noncontrast CT of the brain** is the **most crucial initial step** in managing acute neurological deficits suggestive of stroke. - This imaging is essential to **rule out hemorrhagic stroke** before considering thrombolytic therapy like tPA. *Obtain transcranial doppler* - **Transcranial Doppler (TCD)** can be used to assess cerebral blood flow and identify vascular stenosis but is not the immediate first-line diagnostic imaging for an acute stroke presentation. - TCD is typically performed **after initial imaging** to determine the presence of large vessel occlusion or monitor for vasospasm, not to differentiate between ischemic and hemorrhagic stroke. *Start tissue plasminogen activator (tPA)* - While **tPA** is a treatment for acute ischemic stroke, it is **contraindicated in hemorrhagic stroke**. - Without a **noncontrast CT scan to rule out hemorrhage**, administering tPA can be life-threatening. *Consult cardiology* - Consulting cardiology is important for evaluating potential cardiac sources of emboli (e.g., atrial fibrillation) as a cause of stroke but it is **not the immediate next step** in managing acute stroke symptoms. - The **immediate priority is diagnosing the type of stroke** and determining eligibility for acute interventions. *Intubate the patient* - **Intubation** is reserved for patients with compromise of their **airway, breathing, or circulation (ABCs)**, or a significantly decreased level of consciousness (e.g., GCS < 8). - This patient is described as **awake and alert**, making intubation unnecessary at this stage.

Question 5: A 2-month-old boy is brought to the emergency room by his mother who reports he has appeared lethargic for the past 3 hours. She reports that she left the patient with a new nanny this morning, and he was behaving normally. When she got home in the afternoon, the patient seemed lethargic and would not breastfeed as usual. At birth, the child had an Apgar score of 8/9 and weighed 2.8 kg (6.1 lb). Growth has been in the 90th percentile, and the patient has been meeting all developmental milestones. There is no significant past medical history, and vaccinations are up-to-date. On physical examination, the patient does not seem arousable. Ophthalmologic examination shows retinal hemorrhages. Which of the following findings would most likely be expected on a noncontrast CT scan of the head?

A. Lens-shaped hematoma
B. Cortical atrophy
C. Crescent-shaped hematoma (Correct Answer)
D. Blood in the basal cisterns
E. Multiple cortical and subcortical infarcts

Explanation: ***Crescent-shaped hematoma*** - The clinical presentation with **lethargy**, a history of being with a **new caregiver**, and **retinal hemorrhages** strongly suggests **abusive head trauma** (shaken baby syndrome). - This typically results in a **subdural hematoma**, which appears as a **crescent-shaped collection of blood** on a noncontrast CT scan, reflecting bleeding into the potential space between the dura mater and arachnoid mater. *Lens-shaped hematoma* - A **lens-shaped (biconvex) hematoma** on CT is characteristic of an **epidural hematoma**, which typically results from a **skull fracture** tearing a meningeal artery. - While head trauma is present, the specific findings (retinal hemorrhages, lack of skull fracture mention, and mechanism of shaking) are more consistent with subdural rather than epidural bleeding. *Cortical atrophy* - **Cortical atrophy** refers to the shrinking of brain tissue and is typically seen in chronic conditions like **neurodegenerative diseases** or **long-standing severe malnutrition**. - It does not explain the acute onset of lethargy and retinal hemorrhages immediately following a potential traumatic event in an otherwise healthy infant. *Blood in the basal cisterns* - **Blood in the basal cisterns** is characteristic of **subarachnoid hemorrhage**, which can be caused by ruptured aneurysms (rare in infants), arteriovenous malformations, or severe trauma. - While abusive head trauma can sometimes cause subarachnoid bleeding, the primary finding in shaken baby syndrome is usually subdural hemorrhage, and retinal hemorrhages specifically point towards the shearing forces causing subdural bleeding. *Multiple cortical and subcortical infarcts* - **Multiple cortical and subcortical infarcts** indicate areas of brain tissue death due to **interrupted blood supply**, as seen in severe stroke or vasculitis. - This is not the primary or most likely finding in abusive head trauma, though severe head trauma can sometimes lead to secondary ischemic injury due to increased intracranial pressure or vascular disruption.

Question 6: A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. He is immediately sent for a head CT which is normal. What is the most appropriate next step in management?

A. Ultrasound
B. Lumbar puncture (Correct Answer)
C. Alteplase
D. Ibuprofen, acetaminophen, metoclopramide, and diphenhydramine
E. MRI

Explanation: ***Lumbar puncture*** - The patient's symptoms (acute severe headache, nausea, vomiting, neck pain) and risk factors (hypertension, smoking history) are highly suggestive of a **subarachnoid hemorrhage (SAH)**, even with a normal initial **non-contrast head CT**. - A **lumbar puncture (LP)** is the next critical diagnostic step to detect **xanthochromia** (due to bilirubin degradation from red blood cells) or elevated red blood cell count in the cerebrospinal fluid (CSF), which would confirm SAH. - CT has approximately **95% sensitivity in the first 6 hours**, but sensitivity decreases over time, making LP essential when clinical suspicion remains high. *Ultrasound* - **Ultrasound** is not a standard diagnostic tool for acute neurological symptoms like severe headache or suspected SAH. - It is primarily used for evaluating soft tissues, abdominal organs, and vascular structures like carotid arteries, but offers limited utility for intracranial bleeding. *Alteplase* - **Alteplase** (tissue plasminogen activator, tPA) is a thrombolytic agent used in acute ischemic stroke, characterized by focal neurological deficits due to arterial occlusion. - Administering alteplase in the setting of headache and neck pain without focal deficits, while SAH is suspected, could be fatal as it would worsen bleeding. *Ibuprofen, acetaminophen, metoclopramide, and diphenhydramine* - This combination of medications is used for **symptomatic relief** of headache and nausea but does not address the underlying potentially life-threatening cause. - Treating symptoms without a definitive diagnosis in suspected SAH could lead to delayed intervention and worse outcomes. *MRI* - While **MRI with specific sequences (FLAIR, GRE, SWI)** has high sensitivity for detecting SAH and is increasingly used in clinical practice, **lumbar puncture remains the traditional and most widely recommended next step** after a negative CT in suspected SAH. - LP directly detects **xanthochromia** (present 6-12 hours after bleeding) and RBCs in CSF, providing definitive evidence of SAH. - MRI may not always be readily available in the emergency setting, takes longer to perform, and requires patient stability and cooperation. - For standardized exams, **LP is the classic correct answer** when CT is negative but clinical suspicion for SAH remains high.

Question 7: 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.

Question 8: 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.

A. Hemorrhagic transformation; reverse anticoagulation immediately
B. Cerebral edema from large infarction; emergent decompressive hemicraniectomy
C. Reperfusion injury; start high-dose corticosteroids and osmotic therapy
D. Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering (Correct Answer)
E. Recurrent arterial occlusion; emergent repeat angiography and thrombectomy

Explanation: ***Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering*** - Post-thrombectomy **hyperdensity** on CT often represents contrast that leaked through an ischemic **blood-brain barrier**, which can mimic hemorrhage but lacks significant **mass effect**. - Management is **supportive care** because the contrast is typically reabsorbed within 24–48 hours; avoiding aggressive **blood pressure lowering** prevents secondary ischemia in the penumbra. *Hemorrhagic transformation; reverse anticoagulation immediately* - While **hemorrhagic transformation** is a risk, true blood usually demonstrates higher density earlier and is associated with rapid clinical decline and **midline shift**. - Reversing anticoagulation without confirming blood on a follow-up **dual-energy CT** or MRI may lead to **stent thrombosis** or re-occlusion. *Cerebral edema from large infarction; emergent decompressive hemicraniectomy* - **Cerebral edema** typically peaks between 72–96 hours post-stroke; a presentation within 4 hours is too acute for **malignant MCA syndrome**. - While edema causes lethargy, the hyperdensity on CT more specifically points toward **contrast staining** or blood rather than simple cytotoxic edema. *Reperfusion injury; start high-dose corticosteroids and osmotic therapy* - **Corticosteroids** are not indicated for stroke-related edema or reperfusion injury as they do not improve outcomes and may increase **infection risk**. - **Osmotic therapy** is reserved for patients with clear clinical or radiologic signs of **elevated intracranial pressure**, not isolated hyperdensity on CT. *Recurrent arterial occlusion; emergent repeat angiography and thrombectomy* - **Recurrent occlusion** usually presents with a sudden recurrence of the original **focal neurological deficits** (e.g., hemiplegia, aphasia) rather than progressive lethargy. - The presence of **hyperdensity** in the stroke territory on CT is specifically indicative of material (contrast or blood) being present, which is not a feature of a simple **re-occlusion**.

Question 9: An 80-year-old woman with atrial fibrillation presents 2 hours after acute ischemic stroke. NIHSS is 22. Imaging shows large left MCA territory infarction involving >1/3 of MCA territory with basilar artery occlusion. She lives alone but was independent before this event. Her family requests all possible interventions. Evaluate the management approach considering benefits versus risks.

A. Comfort measures only given poor prognosis and age
B. Thrombolysis alone as thrombectomy unlikely to benefit with established large infarction
C. Proceed with thrombolysis and thrombectomy given the therapeutic window
D. Thrombectomy only for basilar occlusion, avoid thrombolysis due to large infarction (Correct Answer)
E. Delay intervention and repeat imaging in 6 hours to assess progression

Explanation: ***Thrombectomy only for basilar occlusion, avoid thrombolysis due to large infarction*** - Intravenous **thrombolysis (IV alteplase)** is generally contraindicated or highly risky when imaging shows an established infarction involving **>1/3 of the MCA territory** due to the high risk of **hemorrhagic transformation**. - **Basilar artery occlusion** is a life-threatening emergency with a broader treatment window; mechanical **thrombectomy** can be lifesaving and is indicated even if thrombolysis is withheld. *Comfort measures only given poor prognosis and age* - Age is not a primary contraindication for intervention, especially since the patient was **independent** prior to the event (low **pre-stroke mRS**). - Family requests all possible interventions, and **basilar occlusion** has a catastrophic natural history that may be mitigated by mechanical intervention. *Thrombolysis alone as thrombectomy unlikely to benefit with established large infarction* - Thrombolysis is dangerous in this context due to the **large infarct volume** seen on imaging, which increases the likelihood of fatal **intracerebral hemorrhage**. - Thrombolysis is notably less effective for large vessel occlusions compared to **mechanical thrombectomy**, which is the gold standard for **basilar artery** recanalization. *Proceed with thrombolysis and thrombectomy given the therapeutic window* - While the patient is within the 4.5-hour window for thrombolysis, the presence of **established early ischemic changes** (>1/3 MCA territory) is a relative contraindication. - Attempting both increases the risk of **secondary hemorrhage** in the damaged MCA territory without providing significant additional benefit over thrombectomy alone for the **basilar occlusion**. *Delay intervention and repeat imaging in 6 hours to assess progression* - Delaying treatment in the setting of **basilar artery occlusion** is inappropriate, as "time is brain" and outcomes worsen significantly with every minute of **brainstem ischemia**. - Immediate decision-making is required based on the initial imaging, which already confirmed the **large-vessel occlusion** needing intervention.

Question 10: A 58-year-old woman with history of TIA 3 weeks ago presents with acute ischemic stroke. Imaging reveals new right MCA infarction and severe (70-99%) symptomatic right carotid stenosis. She received alteplase 6 hours ago with partial improvement. Her NIHSS improved from 14 to 8. Analyze the optimal timing for carotid revascularization.

A. Wait 4-6 weeks to reduce hemorrhagic transformation risk
B. Carotid stenting immediately after thrombolysis
C. Emergent carotid endarterectomy within 24 hours
D. Carotid endarterectomy within 2 weeks of symptom onset (Correct Answer)
E. Medical management only due to recent thrombolysis

Explanation: ***Carotid endarterectomy within 2 weeks of symptom onset*** - For patients with **symptomatic carotid stenosis** (70-99%), early revascularization within **2 weeks** (ideally within 48 hours to 7 days) provides the maximum benefit in preventing recurrent stroke. - Current guidelines suggest that once the patient is **neurologically stable** and the infarct size is not massive, the risk of recurrence outweighs the risk of **hemorrhagic transformation**. *Wait 4-6 weeks to reduce hemorrhagic transformation risk* - This represents older clinical practice; modern evidence shows the risk of **recurrent stroke** is highest in the first 2 weeks, making this delay dangerous. - Waiting this long is only typically reserved for patients with a **large territory infarct** (high NIHSS) or those at very high risk for bleeding complications. *Carotid stenting immediately after thrombolysis* - Immediate stenting right after **alteplase** administration increases the risk of **intracranial hemorrhage** and local bleeding at the access site due to systemic fibrinolysis. - While **Carotid Artery Stenting (CAS)** is an alternative, it is generally not preferred over **Carotid Endarterectomy (CEA)** in older patients unless specific surgical contraindications exist. *Emergent carotid endarterectomy within 24 hours* - Performing surgery within the first 24 hours after **thrombolytic therapy** carries a significant risk of **hemorrhagic transformation** of the fresh infarct. - Most surgeons prefer to wait at least **24-48 hours** post-alteplase to ensure the fibrinolytic effects have resolved and the patient's neurological status is stable. *Medical management only due to recent thrombolysis* - Medical management alone is insufficient for **symptomatic stenosis >70%**, as the risk of a disabling stroke remains high without mechanical intervention. - **Dual antiplatelet therapy** and statins are vital, but they serve as an adjunct to, rather than a replacement for, **surgical revascularization** in fit patients.

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