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Self-Assessment Questions

Neurology

Stroke: Review Questions

Matthew Brandon Maas, MD, and Joseph Safdieh, MD

Dr. Maas is a neurology fellow, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Dr. Safdieh is an assistant professor of neurology, Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York, NY.


Choose the single best answer for each question.

1. A 65-year-old right-handed man presents to the emergency department (ED) for evaluation of a possible transient ischemic attack. He reports right arm weakness and unsteady walking. The patient also states that he had difficulty speaking for 10 minutes on the previous day. A computed tomography (CT) angiogram reveals 60% and 80% stenosis of the right internal carotid artery and left middle cerebral artery, respectively. He takes no medications. In addition to assessing relevant risk factors, which intervention is most appropriate at this time?
  1. Initiate aspirin
  2. Initiate aspirin-dipyridamole and refer for carotid endarterectomy (CEA)
  3. Initiate clopidogrel and refer for intracranial angioplasty and stenting
  4. Initiate warfarin
  5. Refer for intracranial angioplasty and stenting
Click here to compare your answer.


2. A 75-year-old woman presents to the ED with abrupt onset of left-sided weakness that began 1 hour ago. Assuming all imaging tests are immediately available and there are no contraindications to the following imaging modalities, which test should initially be performed in routine clinical care?

  1. CT angiogram of the head and neck
  2. CT scan of the head without contrast
  3. Magnetic resonance image (MRI) of the brain
  4. MRI of the brain and magnetic resonance angiogram (MRA) of the head and neck
Click here to compare your answer.


3. A 57-year-old woman presents to the ED 45 minutes after the onset of severe expressive aphasia, right hemiparesis, and hemisensory loss. Her National Institutes of Health Stroke Scale (NIHSS) score is 16. Past medical history is significant for coronary artery disease, coronary angioplasty and stent placement 4 years ago, and surgery on her left foot 5 days ago. On initial presentation, the patient’s blood pressure was 190/100 mm Hg and is now 170/90 mm Hg. The patient reports taking aspirin and clopidogrel for coronary artery disease. Emergent laboratory studies, electrocardiogram, and CT scan of the head performed over the next half hour are normal. After the initial evaluation and testing, the patient’s symptoms improve to a NIHSS score of 3. Which of the following is a contraindication to this patient receiving intravenous (IV) recombinant tissue plasminogen activator (rt-PA)?

  1. Current use of aspirin and clopidogrel
  2. Fluctuating blood pressure readings between 190/110 and 170/90 mm Hg
  3. NIHSS score of 3
  4. Rapidly resolving symptoms
  5. Recent minor surgery
Click here to compare your answer.


Questions 4 and 5 refer to the following case.

A 50-year-old woman with no past history of venous or arterial thrombosis presents to the ED with acute-onset left hemiparesis. The patient takes lisinopril for hypertension and a daily multivitamin. Brain MRI confirms an infarct in the right frontal lobe. MRA of the head and neck is normal. Cardiac rhythm on Holter monitor is also normal. Hypercoagulability studies are unremarkable. The patient is scheduled for echocardiography.


 



Figure. Noncontrast computed tomography scan of the head performed in the patient described in question 6 showing an acute intracerebral hemorrhage in the posterior limb of the left internal capsule adjacent to the thalamus and bordered by edema.

 

4. For an accurate diagnosis, which of the following stroke-associated cardiac conditions requires transesophageal echocardiography (TEE) rather than transthoracic echocardiography (TTE)?
  1. Dilated cardiomyopathy
  2. Interatrial shunt
  3. Left atrial thrombus
  4. Left ventricular thrombus
  5. Valvular vegetation
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5. A small patent foramen ovale (PFO) is discovered on echocardiography. Minimal right to left shunting is seen only on Valsalva maneuver. Which of the following is the most appropriate treatment for this patient?

  1. Initiate aspirin 325 mg/day
  2. Initiate warfarin with a target international normalized ratio (INR) of 1.5 to 2.5
  3. Initiate warfarin with a target INR of 1.5 to 2.5 and aspirin 81 mg/day
  4. Initiate warfarin with a target INR of 1.5 to 2.5 and refer for PFO closure
  5. Initiate warfarin with a target INR of 2 to 3
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6. A 66-year-old man with a history of atrial fibrillation presents to the ED with acute onset of right-sided weakness and sensory loss that occurred 25 minutes prior to presentation. He is alert and swallows normally. Blood pressure is 195/120 mm Hg, and heart rate is irregular at approximately 90 bpm. Serum glucose level is 358 mg/dL. Prothrombin time is elevated beyond therapeutic range. The patient currently takes warfarin. Emergent noncontrast CT scan of the head is performed (Figure). All of the following are indicated in the management of this patient EXCEPT

  1. Fresh frozen plasma
  2. Insulin
  3. IV labetalol
  4. IV vitamin K
  5. Phenytoin
Click here to compare your answer.


 

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