Stroke Flashcard 1
Rationale
A. Rationale: Ischemic stroke is the most common type of stroke (87%). The second most common type is hemorrhagic stroke.
Question
A 57-year-old man has developed facial drooping, slurred speech, and weakness on his left side. Suspecting the patient has had a stroke, you need to plan either surgical or pharmacologic treatment, depending on the type of stroke. Which of the following is the most common type of stroke?
a. ischemic
b. subarachnoid hemorrhagic
c. intracranial hemorrhagic
d. subdural hemorrhagic
Answer
a. ischemic
Rationale
C. Rationale: The patient has met all of the inclusion criteria for tPA except for his blood pressure. He needs acute management of his blood pressure to bring it below 185/110 mm Hg to receive rtPA. This can be done with IV labetalol. It would be unwise to give the patient aspirin now, which may increase the risk for bleeding if he becomes eligible for IV rtPA. Intra-arterial rtPA is a second-line therapy for stroke and typically is only done if the patient does not meet criteria for IV rtPA. The patient is still within the timeframe for lowering his blood pressure to become a candidate for rtPA.
Question
A 65-year-old man has sudden vision loss and difficulty speaking with an onset approximately 90 minutes ago. CT imaging is normal, and an examination reveals persistent facial droop, dysarthria, and aphasia. His history is significant for hypertension. He does not take anticoagulants, has no recent bleeding, trauma, or surgery, and all other laboratory work is normal. Blood pressure is 195/105 mm Hg. What is the best next step for the management of this patient’s condition?
a. intravenous rtPA
b. intra-arterial rtPA
c. IV labetalol
d. aspirin
Answer
c. IV labetalol
Rationale
C. Rationale: The patient has met all the inclusion criteria for tPA except for his blood pressure. He needs acute management of his blood pressure to bring it below 185/110 mm Hg to receive rtPA. This can be done with IV labetalol. It would be unwise to give the patient aspirin now as this may increase the risk of bleeding were he to become eligible for IV rtPA. Intra-arterial rtPA is a second-line therapy for stroke, typically only given if the patient does not meet criteria for IV rtPA.
Question
A 65-year-old man has sudden vision loss and difficulty speaking, beginning approximately 90 minutes ago. CT imaging is normal, and his examination reveals persistent facial droop, dysarthria, and aphasia. His history is significant for hypertension. He does not take anticoagulants, has no recent bleeding, trauma, or surgery, and all other laboratory work is normal. Blood pressure is 195/105 mm Hg. What is the best next step in management for this patient?
a. Intravenous rtPA
b. Intra-arterial rtPA
c. IV labetalol
d. Aspirin
Answer
c. IV labetalol
Rationale
D. Rationale: Admission to a stroke unit or a critical care unit should be within 3 hours from when the patient has entered the emergency department.
Question
A patient should be admitted to a stroke unit or critical care unit within how many hours of being brought to the emergency department?
a. 12 hours
b. 8 hours
c. 6 hours
d. 3 hours
Answer
d. 3 hours
Rationale
B. Rationale: The NINDS recommends the following interventions be done once a patient with suspected stroke has reached the emergency department: (1) general assessment (10 minutes), (2) neurologic assessment with CT scan (25 minutes), (3) CT scan interpretation (45 minutes), (4) fibrinolytic therapy (60 minutes), and (5) admission to stroke unit (180 minutes).
Question
According to the National Institute of Neurological Disorders (NINDS), the critical time frame for obtaining a head CT scan for a patient with suspected stroke is how long after they arrive to the emergency department?
a. 10 minutes
b. 25 minutes
c. 45 minutes
d. 60 minutes
Answer
b. 25 minutes
Rationale
C. Rationale: The inclusion criterion is that the onset of symptoms must be < 3 hours before beginning treatment. This time frame may be extended to 4.5 hours; more than 4.5 hours would exclude the patient from fibrinolytic therapy.
Question
Before giving fibrinolytic therapy, some guidelines must be met to ensure that the harmful effects of this therapy are avoided. All of the following criteria must be met for the use of fibrinolytic therapy EXCEPT:
a. CT scan does not show the presence of intracerebral hemorrhage.
b. The patient has a measurable neurologic deficit.
c. The onset of symptoms was < 12 hours before beginning treatment.
d. The patient is 18 years old or older.
Answer
c. The onset of symptoms was < 12 hours before beginning treatment.
Rationale
C. Rationale: Endovascular therapy must be given within 6 hours of the onset of symptoms to achieve good neurologic outcomes. These patients must be transferred to treatment facilities that are adept in managing acute stroke patients.
Question
Endovascular therapy must be given to patients with embolic stroke in which one of the following time frames?
a. within 3 hours of symptoms onset
b. within 4 hours of symptoms onset
c. within 6 hours of symptoms onset
d. within 8 hours of symptoms onset
Answer
c. within 6 hours of symptoms onset
Rationale
C. Rationale: Intracranial hemorrhage is the most significant adverse effect of fibrinolytic therapy.
Question
Fibrinolytic therapy must only be given to select patients for the treatment of stroke. Otherwise, it causes more harm than good. What is the most significant adverse effect to avoid when giving fibrinolytic therapy to a patient with ischemic stroke?
a. upper GI bleed
b. intraocular hemorrhage
c. intracranial hemorrhage
d. anaphylaxis
Answer
c. intracranial hemorrhage
Rationale
A. Rationale: A CT scan of the head is the most important diagnostic modality for determining the type of stroke and to plan fibrinolytic therapy when it is secondary to ischemia.
Question
Healthcare providers must immediately treat a stroke patient in the emergency department to prevent the patient from deteriorating. What is the most important diagnostic modality needed to determine the use of fibrinolytic therapy in patients with acute stroke?
a. CT scan of the head
b. ECG
c. Doppler ultrasound
d. Chest X-ray
Answer
a. CT scan of the head
Rationale
D. Rationale: Endovascular therapy given within 6 hours of the onset of symptoms has shown the greatest benefit for patients after ischemic stroke.
Question
The neurovascular surgeon is planning to use endovascular therapy to treat a patient with thromboembolic stroke. He asks the emergency physician about the timing of symptom onset for the patient to receive the full benefit of the therapy. When is the optimal time to provide endovascular therapy to a stroke patient?
a. within 24 hours of symptom onset
b. within 12 hours of symptom onset
c. within 8 hours of symptom onset
d. within 6 hours of symptom onset
Answer
d. within 6 hours of symptom onset