A 69-year-old man is brought in by his wife with acute onset aphasia for the past 5 hours. The patient's wife says that they were sitting having dinner when suddenly he was not able to speak. They delayed coming to the hospital because he had a similar episode 2 months ago which resolved within an hour. His past medical history is significant for hypercholesterolemia, managed with rosuvastatin, and a myocardial infarction (MI) 2 months ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina. His family history is significant for his father who died of MI at age 60. The patient reports a 15-pack-year smoking history but denies any alcohol or recreational drug use. The vital signs include: temperature 37.0℃ (98.6℉), blood pressure 125/85 mm Hg, pulse 96/min, and respiratory rate 19/min. On physical examination, the patient has expressive aphasia. There is a weakness of the right-sided lower facial muscles. The strength in his upper and lower extremities is 4/5 on the right and 5/5 on the left. There is also a decreased sensation on his right side. A noncontrast computed tomography (CT) scan of the head is unremarkable. CT angiography (CTA) and diffusion-weighted magnetic resonance imaging (MRI) of the brain are acquired, and the findings are shown in the exhibit (see image). Which of the following is the best course of treatment in this patient?
Q2
A 71-year-old woman presents with a transient episode of right arm and hand weakness that resolved in approximately one hour. Her symptoms started while she was gardening. Her past medical history is notable for hypertension, diabetes, anxiety, and dyslipidemia. Her current medications include insulin, metformin, and fluoxetine. Examination reveals a left carotid bruit. Ultrasound duplex of her carotid arteries demonstrates right and left carotid stenosis of 35% and 50%, respectively. Which of the following is the best next step in management?
Q3
A 61-year-old man is brought to the emergency room with slurred speech. According to the patient's wife, they were watching a movie together when he developed a minor headache. He soon developed difficulty speaking in complete sentences, at which point she decided to take him to the emergency room. His past medical history is notable for hypertension and hyperlipidemia. He takes aspirin, lisinopril, rosuvastatin. The patient is a retired lawyer. He has a 25-pack-year smoking history and drinks 4-5 beers per day. His father died of a myocardial infarction, and his mother died of breast cancer. His temperature is 98.6°F (37°C), blood pressure is 143/81 mmHg, pulse is 88/min, and respirations are 21/min. On exam, he can understand everything that is being said to him and is able to repeat statements without difficulty. However, when asked to speak freely, he hesitates with every word and takes 30 seconds to finish a short sentence. This patient most likely has an infarct in which of the following vascular distributions?
Q4
A 45-year-old man presents to the emergency department with complaints of right-sided weakness and slurring of speech for 1 hour. There is no history of head trauma, myocardial infarction, recent surgery, gastrointestinal or urinary bleeding. He has hypertension, chronic atrial fibrillation, and a 20 pack-year cigarette smoking history. The medication list includes valsartan and rivaroxaban. The vital signs include: blood pressure 180/92 mm Hg, pulse 144/min and irregular, and temperature 37.2°C (99.0°F). On physical examination, there is a facial asymmetry with a deviation of angle of mouth to the left side on smiling. Muscle strength is reduced in both upper and lower limbs on the right side while on the left side it’s normal. Random blood glucose is 104 mg/dL. A complete blood count is normal. A CT scan of the head is shown in the image. What is the most appropriate next step in the management of this patient?
Q5
A 72-year-old woman comes to the emergency department 1 hour after the sudden onset of a diffuse, dull, throbbing headache. She also reports blurred vision, nausea, and one episode of vomiting. She has a history of poorly controlled hypertension. A photograph of her fundoscopic examination is shown. Which of the following is the most likely underlying cause of this patient's symptoms?
Q6
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?
Q7
A 73-year-old man noted a rapid onset of severe dizziness and difficulty swallowing while watching TV at home. His wife reports that he had difficulty forming sentences and his gait was unsteady at this time. Symptoms were severe within 1 minute and began to improve spontaneously after 10 minutes. He has had type 2 diabetes mellitus for 25 years and has a 50 pack-year smoking history. On arrival to the emergency department 35 minutes after the initial development of symptoms, his manifestations have largely resolved with the exception of a subtle nystagmus and ataxia. His blood pressure is 132/86 mm Hg, the heart rate is 84/min, and the respiratory rate is 15/min. After 45 minutes, his symptoms are completely resolved, and neurological examination is unremarkable. Which of the following is the most likely cause of this patient’s condition?
Q8
A 62-year-old man is brought to the emergency department because of right-sided weakness and subjective decreased sensation that started 30 minutes ago. The patient reports that his symptoms started to ease 5 minutes after onset and have now completely resolved. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 40 years. His current medications include lisinopril, metformin, and sitagliptin. He is 183 cm (6 ft 0 in) tall and weighs 105 kg (220 lb); BMI is 32 kg/m2. He appears well. His temperature is 36.5°C (97.7°F), pulse is 80/min, and blood pressure is 150/88 mm Hg. Neurological examination shows no abnormalities. Cardiac examination shows regular rate and rhythm and a left-sided carotid bruit. Complete blood count, serum glucose, and electrolytes are within the reference ranges. An ECG shows sinus rhythm and left axis deviation. A CT scan of the head without contrast shows no abnormalities. Carotid doppler ultrasound shows 45% stenosis in the left carotid artery and 15% stenosis in the right. Which of the following is the most appropriate next step in management?
Q9
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.
Q10
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.
TIA management and ABCD2 score US Medical PG Practice Questions and MCQs
Question 1: A 69-year-old man is brought in by his wife with acute onset aphasia for the past 5 hours. The patient's wife says that they were sitting having dinner when suddenly he was not able to speak. They delayed coming to the hospital because he had a similar episode 2 months ago which resolved within an hour. His past medical history is significant for hypercholesterolemia, managed with rosuvastatin, and a myocardial infarction (MI) 2 months ago, status post percutaneous transluminal coronary angioplasty complicated by residual angina. His family history is significant for his father who died of MI at age 60. The patient reports a 15-pack-year smoking history but denies any alcohol or recreational drug use. The vital signs include: temperature 37.0℃ (98.6℉), blood pressure 125/85 mm Hg, pulse 96/min, and respiratory rate 19/min. On physical examination, the patient has expressive aphasia. There is a weakness of the right-sided lower facial muscles. The strength in his upper and lower extremities is 4/5 on the right and 5/5 on the left. There is also a decreased sensation on his right side. A noncontrast computed tomography (CT) scan of the head is unremarkable. CT angiography (CTA) and diffusion-weighted magnetic resonance imaging (MRI) of the brain are acquired, and the findings are shown in the exhibit (see image). Which of the following is the best course of treatment in this patient?
A. Aspirin
B. Mannitol
C. Mechanical thrombectomy (Correct Answer)
D. IV tPA
E. Low molecular weight heparin
Explanation: ***Mechanical thrombectomy***
- The patient presents with **acute ischemic stroke** symptoms (aphasia, right-sided weakness, sensory deficits) at **5 hours from symptom onset**. Imaging (CTA showing large vessel occlusion and MRI confirming diffusion restriction) demonstrates a **large vessel occlusion**, making him a candidate for **mechanical thrombectomy**.
- Since the patient is **beyond the 4.5-hour window for IV tPA**, mechanical thrombectomy is the **primary reperfusion therapy** indicated for large vessel occlusion strokes up to **24 hours** (with appropriate imaging showing salvageable tissue).
- Mechanical thrombectomy offers the best chance for complete recanalization and improved neurological outcomes in large vessel occlusion strokes, particularly when IV tPA is not an option.
*Aspirin*
- While **aspirin** is crucial for **secondary stroke prevention**, it is not the primary acute treatment for a large vessel occlusion stroke due to its limited ability to achieve rapid and complete recanalization.
- Aspirin (or other antiplatelet therapy) is typically initiated **within 24-48 hours after stroke onset**, but only after excluding hemorrhagic transformation and after acute reperfusion therapies have been considered or completed.
*Mannitol*
- **Mannitol** is an osmotic diuretic used to reduce **intracranial pressure (ICP)** in cases of severe cerebral edema, which can be a complication of large ischemic strokes.
- It is not a primary treatment for the acute ischemic event itself, but rather a supportive measure used to manage life-threatening complications if **cerebral edema** develops and causes significant mass effect or herniation risk.
*IV tPA*
- **Intravenous tissue plasminogen activator (IV tPA)** is the first-line pharmacologic treatment for acute ischemic stroke if administered **within 4.5 hours of symptom onset** in eligible patients.
- This patient presents at **5 hours**, which is **beyond the approved time window** for IV tPA administration, making him **ineligible** for thrombolytic therapy.
- Even if within the time window, patients with large vessel occlusion often require mechanical thrombectomy in addition to or instead of IV tPA for optimal outcomes.
*Low molecular weight heparin*
- **Low molecular weight heparin (LMWH)** is primarily used for **deep vein thrombosis (DVT)** prophylaxis in immobilized patients or for the treatment of established DVT/pulmonary embolism.
- It is generally **not recommended for acute ischemic stroke treatment** due to an increased risk of hemorrhagic transformation without proven benefit in recanalization or clinical outcomes.
Question 2: A 71-year-old woman presents with a transient episode of right arm and hand weakness that resolved in approximately one hour. Her symptoms started while she was gardening. Her past medical history is notable for hypertension, diabetes, anxiety, and dyslipidemia. Her current medications include insulin, metformin, and fluoxetine. Examination reveals a left carotid bruit. Ultrasound duplex of her carotid arteries demonstrates right and left carotid stenosis of 35% and 50%, respectively. Which of the following is the best next step in management?
A. Bilateral carotid endarterectomy
B. Left carotid endarterectomy only
C. Aspirin (Correct Answer)
D. Observation
E. Warfarin
Explanation: ***Aspirin***
- This patient suffered a **transient ischemic attack (TIA)** given her transient focal neurological deficit. Given that her carotid stenosis is **moderate (35% and 50%)**, **antiplatelet therapy** with aspirin is the initial and best next step to prevent future strokes.
- Aspirin helps prevent platelet aggregation, reducing the risk of **thrombus formation** in already stenotic vessels.
*Bilateral carotid endarterectomy*
- This is not the best next step, as **carotid endarterectomy** is generally reserved for symptomatic patients with **high-grade stenosis** (e.g., typically >70%).
- Performing bilateral procedures at once carries higher risks than staged procedures or medical management for moderate stenosis.
*Left carotid endarterectomy only*
- This is not indicated. While symptoms occurred on the right side (implying a left-sided lesion), a **left carotid endarterectomy** is primarily considered for **high-grade stenosis** in symptomatic patients.
- Her left carotid stenosis is 50%, which is considered moderate and not an immediate indication for surgery.
*Observation*
- This is inappropriate as the patient has experienced a **TIA**, indicating a high risk of future stroke.
- Without intervention, including antiplatelet therapy, the risk of a debilitating stroke is significantly increased.
*Warfarin*
- **Warfarin** is an anticoagulant used for conditions like atrial fibrillation or deep vein thrombosis but is **not the primary treatment for TIA due to carotid stenosis**.
- Its use in this context may increase the risk of bleeding without providing superior benefit to aspirin in preventing arterial clots from carotid plaques.
Question 3: A 61-year-old man is brought to the emergency room with slurred speech. According to the patient's wife, they were watching a movie together when he developed a minor headache. He soon developed difficulty speaking in complete sentences, at which point she decided to take him to the emergency room. His past medical history is notable for hypertension and hyperlipidemia. He takes aspirin, lisinopril, rosuvastatin. The patient is a retired lawyer. He has a 25-pack-year smoking history and drinks 4-5 beers per day. His father died of a myocardial infarction, and his mother died of breast cancer. His temperature is 98.6°F (37°C), blood pressure is 143/81 mmHg, pulse is 88/min, and respirations are 21/min. On exam, he can understand everything that is being said to him and is able to repeat statements without difficulty. However, when asked to speak freely, he hesitates with every word and takes 30 seconds to finish a short sentence. This patient most likely has an infarct in which of the following vascular distributions?
A. Proximal middle cerebral artery
B. Inferior division of the middle cerebral artery
C. Middle cerebral artery and posterior cerebral artery watershed area
D. Superior division of the middle cerebral artery (Correct Answer)
E. Anterior cerebral artery and middle cerebral artery watershed area
Explanation: ***Superior division of the middle cerebral artery***
- The patient's inability to speak spontaneously coupled with intact comprehension and repetition is characteristic of **Broca's aphasia**, which results from damage to **Broca's area** in the dominant frontal lobe.
- Broca's area is supplied by the **superior division of the middle cerebral artery (MCA)**.
*Proximal middle cerebral artery*
- An infarct in the proximal MCA, or the main stem, would typically lead to global aphasia if the dominant hemisphere is affected, characterized by **severe deficits in comprehension, repetition, and speech production**.
- This presentation does not align with the patient's ability to understand and repeat statements.
*Inferior division of the middle cerebral artery*
- The inferior division of the MCA supplies Wernicke's area in the dominant hemisphere.
- Damage here causes **Wernicke's aphasia**, characterized by **fluent but nonsensical speech** with **impaired comprehension** and **repetition**, which is contrary to the patient's symptoms.
*Middle cerebral artery and posterior cerebral artery watershed area*
- Watershed infarcts, especially between the MCA and posterior cerebral artery (PCA), can cause **transcortical sensory aphasia** if in the dominant hemisphere.
- This type of aphasia involves impaired comprehension but **intact repetition**, which differs from Broca's aphasia where spontaneous speech is the main deficit.
*Anterior cerebral artery and middle cerebral artery watershed area*
- Infarcts in the watershed area between the anterior cerebral artery (ACA) and MCA can result in **transcortical motor aphasia** if in the dominant hemisphere.
- This condition presents with **non-fluent speech** and **intact repetition**, similar to Broca's aphasia, but Broca's area itself is located specifically within the MCA superior division territory.
Question 4: A 45-year-old man presents to the emergency department with complaints of right-sided weakness and slurring of speech for 1 hour. There is no history of head trauma, myocardial infarction, recent surgery, gastrointestinal or urinary bleeding. He has hypertension, chronic atrial fibrillation, and a 20 pack-year cigarette smoking history. The medication list includes valsartan and rivaroxaban. The vital signs include: blood pressure 180/92 mm Hg, pulse 144/min and irregular, and temperature 37.2°C (99.0°F). On physical examination, there is a facial asymmetry with a deviation of angle of mouth to the left side on smiling. Muscle strength is reduced in both upper and lower limbs on the right side while on the left side it’s normal. Random blood glucose is 104 mg/dL. A complete blood count is normal. A CT scan of the head is shown in the image. What is the most appropriate next step in the management of this patient?
A. Heparin
B. Amiodarone
C. Metoprolol
D. Tissue plasminogen activator
E. Aspirin (Correct Answer)
Explanation: ***Aspirin***
- The patient presents with acute onset **neurological deficits** (right-sided weakness, slurred speech) consistent with an **ischemic stroke** in the setting of **atrial fibrillation**.
- The CT scan shows no evidence of hemorrhage (hypodense or normal appearance), confirming **ischemic stroke**.
- While the patient is on **rivaroxaban**, the question addresses the **within-window acute management**. In the acute setting (within 1 hour of symptom onset), after ruling out hemorrhage on CT, **aspirin 325 mg** is considered as initial antiplatelet therapy for ischemic stroke.
- **Note:** Current guidelines suggest holding rivaroxaban temporarily and avoiding dual therapy (anticoagulation + antiplatelet) due to bleeding risk. However, aspirin remains the safest acute intervention among the choices provided for confirmed ischemic stroke.
*Tissue plasminogen activator (tPA)*
- **tPA** is the preferred thrombolytic for acute ischemic stroke **within 3-4.5 hours** of symptom onset.
- However, it is **absolutely contraindicated** in patients on **direct oral anticoagulants** (like rivaroxaban) due to **dramatically increased risk of intracranial hemorrhage** (up to 10-fold increase).
- Even with normal PT/INR, patients on DOACs cannot receive tPA safely without reversal agents.
*Heparin*
- **Heparin** provides additional anticoagulation on top of rivaroxaban, which would **significantly increase bleeding risk** (both intracranial and systemic).
- Not indicated in acute ischemic stroke management, especially when patient is already therapeutically anticoagulated.
- May be considered in specific scenarios (e.g., crescendo TIAs, arterial dissection) but not first-line here.
*Metoprolol*
- **Metoprolol** is a beta-blocker used for **rate control in atrial fibrillation** (patient has pulse 144/min - rapid ventricular response).
- While rate control is important, **acute blood pressure lowering in ischemic stroke can worsen cerebral perfusion** and extend the infarct.
- Current guidelines recommend **permissive hypertension** in acute stroke (allow BP up to 220/120 unless giving tPA).
- Rate control can be addressed after acute stroke management is initiated.
*Amiodarone*
- **Amiodarone** is an antiarrhythmic used for rhythm control in atrial fibrillation.
- Does **not treat the acute stroke** and is not indicated for emergency management of stroke.
- Rhythm control is not the priority in the acute stroke setting; the focus is on salvaging brain tissue and preventing further ischemia.
Question 5: A 72-year-old woman comes to the emergency department 1 hour after the sudden onset of a diffuse, dull, throbbing headache. She also reports blurred vision, nausea, and one episode of vomiting. She has a history of poorly controlled hypertension. A photograph of her fundoscopic examination is shown. Which of the following is the most likely underlying cause of this patient's symptoms?
A. Hemorrhagic lacunar stroke
B. Transient ischemic attack
C. Giant cell arteritis
D. Hypertensive emergency (Correct Answer)
E. Epidural hematoma
Explanation: ***Hypertensive emergency***
- The patient's presentation of a **sudden headache**, along with **blurred vision** and nausea, suggests increased intracranial pressure due to severely elevated blood pressure.
- Poorly controlled hypertension is a significant risk factor, leading to possible **end-organ damage** such as hypertensive retinopathy with papilledema or hypertensive encephalopathy.
- Fundoscopic examination showing **papilledema** confirms elevated intracranial pressure, consistent with malignant hypertension.
*Hemorrhagic lacunar stroke*
- Lacunar strokes are **small subcortical infarcts** caused by occlusion of penetrating arteries and are typically **ischemic, not hemorrhagic**.
- They present with focal neurological deficits (pure motor stroke, pure sensory stroke, ataxic hemiparesis) rather than the **diffuse symptoms** and papilledema seen here.
- While hypertension is a risk factor, lacunar infarcts do not cause increased intracranial pressure or papilledema.
*Transient ischemic attack*
- Characterized by temporary neurological deficits that resolve within 24 hours, typically without severe headaches or sustained symptoms.
- Patients may experience **focal weakness or sensory changes** but would not have papilledema or signs of increased intracranial pressure.
- The persistent nature of this patient's symptoms makes TIA unlikely.
*Giant cell arteritis*
- This condition usually presents with **temporal headaches**, jaw claudication, and potential vision loss from arteritic anterior ischemic optic neuropathy.
- Vision loss in GCA is due to ischemic optic nerve damage, not papilledema from increased intracranial pressure.
- More common in older adults but is associated with systemic symptoms like fever, malaise, and elevated ESR/CRP.
*Epidural hematoma*
- Typically follows head trauma and presents with a **lucid interval**, followed by rapid deterioration from expanding hematoma.
- Usually caused by middle meningeal artery injury with classic lens-shaped hematoma on CT.
- The lack of trauma history and the chronic hypertension make this diagnosis unlikely.
Question 6: 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 7: A 73-year-old man noted a rapid onset of severe dizziness and difficulty swallowing while watching TV at home. His wife reports that he had difficulty forming sentences and his gait was unsteady at this time. Symptoms were severe within 1 minute and began to improve spontaneously after 10 minutes. He has had type 2 diabetes mellitus for 25 years and has a 50 pack-year smoking history. On arrival to the emergency department 35 minutes after the initial development of symptoms, his manifestations have largely resolved with the exception of a subtle nystagmus and ataxia. His blood pressure is 132/86 mm Hg, the heart rate is 84/min, and the respiratory rate is 15/min. After 45 minutes, his symptoms are completely resolved, and neurological examination is unremarkable. Which of the following is the most likely cause of this patient’s condition?
A. Anterior cerebral artery occlusion
B. Middle cerebral artery occlusion
C. Posterior cerebral artery occlusion
D. Lenticulostriate artery occlusion
E. Vertebral artery occlusion (Correct Answer)
Explanation: ***Vertebral artery occlusion***
- The patient's symptoms of **severe dizziness**, **difficulty swallowing**, **dysarthria**, **unsteady gait**, **nystagmus**, and **ataxia** are classic manifestations of **posterior circulation ischemia**, which is supplied by the vertebral and basilar arteries.
- The rapid onset, transient nature, and complete resolution of symptoms suggest a **transient ischemic attack (TIA)** affecting the posterior cerebral circulation, often due to **vertebral artery stenosis** or a **vertebral artery embolus**.
*Anterior cerebral artery occlusion*
- Occlusion of the anterior cerebral artery typically causes **contralateral leg weakness**, sensory loss, and behavioral changes, which are not seen in this patient.
- Symptoms like dizziness and dysphagia are **not characteristic** of anterior cerebral artery involvement.
*Middle cerebral artery occlusion*
- Middle cerebral artery occlusion commonly presents with **contralateral arm and facial weakness**, aphasia (if the dominant hemisphere is affected), and visual field defects.
- The patient's symptoms are localized to the **brainstem/cerebellum**, not the MCA territory.
*Posterior cerebral artery occlusion*
- While the posterior cerebral artery is part of the posterior circulation, its occlusion primarily causes **contralateral homonymous hemianopia** and, if severe, memory deficits or alexia.
- It typically **does not cause severe dizziness**, dysphagia, or gait ataxia as prominent initial symptoms.
*Lenticulostriate artery occlusion*
- Lenticulostriate arteries supply deep structures like the **basal ganglia** and **internal capsule**. Occlusion typically leads to **pure motor** or **pure sensory lacunar strokes**.
- This patient's constellation of symptoms (dizziness, dysphagia, ataxia) is **too widespread for a typical lacunar infarct** in the lenticulostriate territory.
Question 8: A 62-year-old man is brought to the emergency department because of right-sided weakness and subjective decreased sensation that started 30 minutes ago. The patient reports that his symptoms started to ease 5 minutes after onset and have now completely resolved. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 40 years. His current medications include lisinopril, metformin, and sitagliptin. He is 183 cm (6 ft 0 in) tall and weighs 105 kg (220 lb); BMI is 32 kg/m2. He appears well. His temperature is 36.5°C (97.7°F), pulse is 80/min, and blood pressure is 150/88 mm Hg. Neurological examination shows no abnormalities. Cardiac examination shows regular rate and rhythm and a left-sided carotid bruit. Complete blood count, serum glucose, and electrolytes are within the reference ranges. An ECG shows sinus rhythm and left axis deviation. A CT scan of the head without contrast shows no abnormalities. Carotid doppler ultrasound shows 45% stenosis in the left carotid artery and 15% stenosis in the right. Which of the following is the most appropriate next step in management?
A. Antiplatelet therapy (Correct Answer)
B. Carotid endarterectomy
C. Transthoracic echocardiogram
D. Carotid artery stenting
E. Intravenous alteplase therapy
Explanation: **Antiplatelet therapy**
- This patient experienced a **transient ischemic attack (TIA)** due to the sudden onset and complete resolution of symptoms. Antiplatelet therapy with **aspirin** or **clopidogrel** is crucial for secondary prevention of stroke in patients with TIA, especially given his multiple vascular risk factors and carotid bruit.
- The combination of **hypertension, hyperlipidemia, type 2 diabetes, smoking history, and obesity** significantly increases his risk of recurrent cerebrovascular events, making antiplatelet therapy an immediate and appropriate intervention.
*Carotid endarterectomy*
- **Carotid endarterectomy** is typically indicated for symptomatic carotid stenosis of **70% or greater** in patients with a TIA or non-disabling stroke, or for asymptomatic stenosis of 60% or greater in selected patients.
- This patient's carotid doppler ultrasound showed only **45% stenosis** in the left carotid artery, which is below the threshold for surgical intervention.
*Transthoracic echocardiogram*
- A **transthoracic echocardiogram (TTE)** may be considered to evaluate for a cardiac source of emboli (e.g., atrial fibrillation, patent foramen ovale, left ventricular thrombus) if the cause of TIA is unclear after initial workup.
- Given the presence of a **carotid bruit** and known vascular risk factors, carotid artery disease is the more likely etiology, and antiplatelet therapy is a more urgent initial step.
*Carotid artery stenting*
- **Carotid artery stenting** is generally reserved for patients with symptomatic carotid stenosis who are at high surgical risk for endarterectomy or have anatomical features that make endarterectomy difficult.
- Similar to endarterectomy, the **45% stenosis** in this patient's carotid artery is not severe enough to warrant stenting at this time.
*Intravenous alteplase therapy*
- **Intravenous alteplase** is indicated for acute ischemic stroke within a specific time window (typically 3-4.5 hours from symptom onset) when there is persistent neurological deficit.
- This patient's symptoms have **completely resolved**, indicating a TIA, not an acute ischemic stroke, thus making alteplase therapy inappropriate and potentially harmful.
Question 9: 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 10: 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**.
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