Stroke Practice Questions

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?

Accepted Answer

Mechanical thrombectomy

Answer

Aspirin

Answer

Mannitol

Answer

IV tPA

Answer

Low molecular weight heparin

Question 2

A 78-year-old woman is accompanied by her family for a routine visit to her primary care provider. The family states that 5 months prior, the patient had a stroke and is currently undergoing physical therapy. Today, her temperature is 98.2°F (36.8°C), blood pressure is 112/72 mmHg, pulse is 64/min, and respirations are 12/min. On exam, she is alert and oriented with no deficits in speech. Additionally, her strength and sensation are symmetric and preserved bilaterally. However, on further neurologic testing, she appears to have some difficulty with balance and a propensity to fall to her right side. Which of the following deficits does the patient also likely have?

Accepted Answer

Truncal ataxia

Answer

Hemiballismus

Answer

Hemispatial neglect

Answer

Intention tremor

Answer

Contralateral eye deviation

Question 3

A 67-year-old man with a past medical history of poorly-controlled type 2 diabetes mellitus (T2DM) is brought to the emergency department for acute onset nausea and vomiting. According to the patient, he suddenly experienced vertigo and began vomiting 3 hours ago while watching TV. He reports hiking in New Hampshire with his wife 2 days ago. Past medical history is significant for a myocardial infarction (MI) that was treated with cardiac stenting, T2DM, and hypertension. Medications include lisinopril, aspirin, atorvastatin, warfarin, and insulin. Physical examination demonstrates left-sided facial droop and decreased pinprick sensation at the right arm and leg. What is the most likely etiology of this patient’s symptoms?

Accepted Answer

Embolic stroke at the posterior inferior cerebellar artery (PICA)

Answer

Hypoperfusion of the anterior spinal artery (ASA)

Answer

Labyrinthitis

Answer

Early disseminated Lyme disease

Answer

Thrombotic stroke at the anterior inferior cerebellar artery (AICA)

Question 4

A 57-year-old man presents to the emergency department for evaluation of slurred speech and left arm and leg weakness over the last 3 hours. History reveals hypertension that is being treated with hydrochlorothiazide. Vital signs include: blood pressure of 110/70 mm Hg, heart rate 104/min, respiratory rate 18/min, and temperature 36.6°C (98.0°F). Physical examination reveals 2/5 strength in both left upper and lower extremities. After 2 hours, the patient’s symptoms suddenly disappear. An electrocardiogram (ECG) is obtained (see image). Which of the following medications could prevent ischemic attacks in this patient in the future?

Accepted Answer

Warfarin

Answer

Acetylsalicylic acid

Answer

Enoxaparin

Answer

Heparin

Answer

Clopidogrel

Question 5

A 62-year-old man is brought to the emergency department by his wife because she thinks he has had a stroke. He has hypertension and type 2 diabetes mellitus. Current medications include enalapril and metformin. He has smoked 1 pack of cigarettes per day for the past 35 years. His blood pressure is 162/95 mm Hg. A CT scan of the brain shows a lacunar stroke involving the left subthalamic nucleus. The patient most likely presented with which of the following findings on physical examination?

Accepted Answer

Hemiballismus

Answer

Cogwheel rigidity

Answer

Dystonia

Answer

Hemispatial agnosia

Answer

Vertical gaze palsy

Question 6

A 5-year-old boy is brought to the emergency department by his mother because of a 2-hour history of word-finding difficulty, speech slurring, and weakness and sensory loss of his right arm and leg. He has not had fever, nausea, headache, or diarrhea. His mother reports an episode of severe pain and soft tissue swelling of the dorsum of his hands and feet when he was 12 months old, which self-resolved after 2 weeks. His temperature is 37.7°C (99.8°F), pulse is 90/min, and blood pressure is 110/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 91%. He follows commands but has nonfluent aphasia. Examination shows marked weakness and decreased sensation of the right upper and lower extremities. Deep tendon reflexes are 2+ bilaterally. Babinski sign is present on the right. An MRI scan of the brain shows signs of an evolving cerebral infarction on the patient's left side. Which of the following is the most appropriate initial step in management?

Accepted Answer

Exchange transfusion therapy

Answer

Hydroxyurea therapy

Answer

Heparin therapy

Answer

Intravenous tissue plasminogen activator therapy

Answer

Aspirin therapy

Question 7

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

Accepted Answer

"Can you tell me more about the symptoms you have been experiencing?"

Answer

"Does the diarrhea typically precede the constipation, or vice-versa?"

Answer

"Is the diarrhea foul-smelling?"

Answer

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

Answer

"Are the symptoms worse in the morning or at night?"

Question 8

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?

Accepted Answer

Posterior cerebral artery stroke

Answer

Lacunar stroke

Answer

Middle cerebral artery stroke

Answer

Vertebrobasilar stroke

Answer

Subarachnoid hemorrhage

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.

Accepted Answer

Mechanical thrombectomy based on perfusion imaging criteria

Answer

Intravenous alteplase as salvageable tissue is present

Answer

Intra-arterial thrombolysis combined with mechanical device

Answer

No intervention as she is outside the standard treatment window

Answer

Medical management with antiplatelet and early rehabilitation

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.

Accepted Answer

Contrast extravasation from blood-brain barrier disruption; supportive care and avoid aggressive BP lowering

Answer

Hemorrhagic transformation; reverse anticoagulation immediately

Answer

Cerebral edema from large infarction; emergent decompressive hemicraniectomy

Answer

Reperfusion injury; start high-dose corticosteroids and osmotic therapy

Answer

Recurrent arterial occlusion; emergent repeat angiography and thrombectomy

Stroke

Study Resources

Lessons

Questions

Flashcards

Lessons

Stroke recognition and initial assessment

Ischemic vs hemorrhagic stroke differentiation

Acute ischemic stroke management

Thrombolysis inclusion/exclusion criteria

Mechanical thrombectomy indications

Hemorrhagic stroke management

Blood pressure management in stroke

Stroke unit care principles

Swallowing assessment and management

Secondary stroke prevention

Rehabilitation principles

Management of stroke complications

TIA management and ABCD2 score

Practice Questions

Flashcards

About Stroke for USMLE

Lessons in Stroke

Master Stroke