How Well You Know About Stroke? Quiz!

1. The majority of strokes are caused by ischemia.

True

False

Approximately 84% of strokes are ischemic and can be caused by clots that lodge in the cerebral vasculature. The other 16% are hemorrhagic, due to an aneurysm or high blood pressure causing the rupture of a blood vessel. Of note, hypertension could also cause an ischemic stroke indirectly by contributing to atherosclerosis and thus clot formation. This is an incentive for the patient to take his or her antihypertensive medication!

Explanation

Approximately 84% of strokes are ischemic and can be caused by clots that lodge in the cerebral vasculature. The other 16% are hemorrhagic, due to an aneurysm or high blood pressure causing the rupture of a blood vessel. Of note, hypertension could also cause an ischemic stroke indirectly by contributing to atherosclerosis and thus clot formation. This is an incentive for the patient to take his or her antihypertensive medication!

2. A stroke is a sudden onset of a focal neurologic deficit.

True

False

Before we get started with questions regarding stroke, it helps to know what a stroke entails. Please note that cerebrovascular disease/accident refers to any type of vascular disease in the brain.

Explanation

Before we get started with questions regarding stroke, it helps to know what a stroke entails. Please note that cerebrovascular disease/accident refers to any type of vascular disease in the brain.

3. tPA (alteplase) is the preferred fibrinolytic for stroke treatment.

True

False

Alteplase is the preferred fibrinolytic agent for stroke treatment. Streptokinase actually increased morbidity and mortality.

Explanation

Alteplase is the preferred fibrinolytic agent for stroke treatment. Streptokinase actually increased morbidity and mortality.

4. Aspirin 325 mg is a viable option for secondary prophylaxis in stroke patients.

True

False

The higher dose of aspirin, 325 mg, is an option; give within 24-48 hours of the stroke. 81 mg is also acceptable.

Explanation

The higher dose of aspirin, 325 mg, is an option; give within 24-48 hours of the stroke. 81 mg is also acceptable.

5. Fibrinolytic therapy may be used for hemorrhagic strokes.

True

False

The patient has just suffered a massive bleeding episode in his or her cranium, so do not administer another agent that will seriously increase their bleeding. In such situations (hemorrhagic strokes), there are few therapeutic options but focus on controlling hypertension (note the special goals), reverse warfarin if the patient was taking, and use mannitol to maintain serum osmolality and arterial pressure.

Explanation

The patient has just suffered a massive bleeding episode in his or her cranium, so do not administer another agent that will seriously increase their bleeding. In such situations (hemorrhagic strokes), there are few therapeutic options but focus on controlling hypertension (note the special goals), reverse warfarin if the patient was taking, and use mannitol to maintain serum osmolality and arterial pressure.

6. A transient ischemic attack (TIA), also known as a mini-stroke, is of no concern, as it will recede in no more than 24 hours.

True

False

TIAs are neurological deficits in which blood flow to the brain decreases; they last from a few seconds to 24 hours. Symptoms may include transient motor and sensory loss in the face, arm, or hand; vertigo; and numbness. However, they should be taken seriously, as a stroke can occur soon after a TIA.

Explanation

TIAs are neurological deficits in which blood flow to the brain decreases; they last from a few seconds to 24 hours. Symptoms may include transient motor and sensory loss in the face, arm, or hand; vertigo; and numbness. However, they should be taken seriously, as a stroke can occur soon after a TIA.

7. Besides the tests such as CT scans or MRI that are necessary for establishing the diagnosis of ischemic stroke, which is the one test that may preclude the initiation of IV tPA, if IV tPA is appropriate?

Blood glucose

CK-MB

CRP

Troponin

Blood glucose is the only assessment that must precede the initiation of IV tPA.

Explanation

Blood glucose is the only assessment that must precede the initiation of IV tPA.

8. Which of the following are signs of a stroke?

Decreased urination

Difficulty speaking

Dizziness

Pain that radiates from the chest to the left arm

Sudden changes in vision

Sudden numbness/weakness of face, arm, or leg, especially on one side of the body

Sudden severe headache

The symptoms selected (sudden numbness/weakness of the face, arm, or leg, especially on one side of the body; difficulty speaking; sudden changes in vision; and sudden severe headache) are signs of a stroke and should be presented to patients as situations that require emergency assistance. Decreased urination is not related to a stroke. Pain radiating from the chest to the left arm is a sign of myocardial infarction.

Explanation

The symptoms selected (sudden numbness/weakness of the face, arm, or leg, especially on one side of the body; difficulty speaking; sudden changes in vision; and sudden severe headache) are signs of a stroke and should be presented to patients as situations that require emergency assistance. Decreased urination is not related to a stroke. Pain radiating from the chest to the left arm is a sign of myocardial infarction.

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9. What is the blood pressure goal to establish a patient for fibrinolytic therapy?

< 140/90 mmHg

< 160/90 mmHg

< 185/110 mmHg

< 205/120 mmHg

The blood pressure goal for a patient receiving fibrinolytic therapy is less than 185/110 mmHg. High blood pressure is keeping the blood supply to the brain, so antihypertensive medications should not be given unless the blood pressure is greater than 185/110 mmHg and fibrinolytic therapy is desired. For the 24 hours following tPA, the blood pressure should be maintained at less than 185/105 mmHg.

Explanation

The blood pressure goal for a patient receiving fibrinolytic therapy is less than 185/110 mmHg. High blood pressure is keeping the blood supply to the brain, so antihypertensive medications should not be given unless the blood pressure is greater than 185/110 mmHg and fibrinolytic therapy is desired. For the 24 hours following tPA, the blood pressure should be maintained at less than 185/105 mmHg.

10. For patients who do not receive fibrinolytic therapy, utilize blood pressure medications to lower blood pressure by 15% during the first 24 hours of stroke onset only if the patient's blood pressure is above what threshold?

>140/90 mmHg

>160/90 mmHg

>185/110 mmHg

>220/120 mmHg

As mentioned in the previous question, high blood pressure during a stroke is key for preserving perfusion to the brain. Therefore, only utilize medications to lower blood pressure if the patient's blood pressure is greater than 220/120 mmHg.

Explanation

As mentioned in the previous question, high blood pressure during a stroke is key for preserving perfusion to the brain. Therefore, only utilize medications to lower blood pressure if the patient's blood pressure is greater than 220/120 mmHg.

11. How often should blood pressure and neurological assessment be obtained during alteplase therapy?

Hours 1-2: Every 15 minutes

Hours 1-2: Every 30 minutes

Hours 1-2: Every 60 minutes

Hours 2-8: Every 15 minutes

Hours 2-8: Every 30 minutes

Hours 2-8: Every 60 minutes

Hours 8-24: Every 15 minutes

Hours 8-24: Every 30 minutes

Hours 8-24: Every 60 minutes

Please note the intense monitoring required during and after tPA therapy. Stroke patients are often admitted to an ICU or stroke unit. Of note, increase the frequency of monitoring if the patient has blood pressure greater than 180/105 mmHg and administer medications to keep the blood pressure below 180/105 mmHg.

Explanation

Please note the intense monitoring required during and after tPA therapy. Stroke patients are often admitted to an ICU or stroke unit. Of note, increase the frequency of monitoring if the patient has blood pressure greater than 180/105 mmHg and administer medications to keep the blood pressure below 180/105 mmHg.

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12. Patients must be treated with fibrinolytic therapy no more than 3 hours from the onset of symptoms.

True

False

This is false; in certain circumstances, the fibrinolytic may be used up to 4.5 hours after the onset of symptoms.

Explanation

This is false; in certain circumstances, the fibrinolytic may be used up to 4.5 hours after the onset of symptoms.

13. Check the potentially modifiable risk factors for having a stroke.

Atrial fibrillation

Diabetes

Dyslipidemia

Family history of cardiovascular disease

Hypertension

Smoking

Atrial fibrillation can lead to clots, which can enter the cerebral vasculature and cause a stroke. Diabetes is yet another modifiable risk factor, but controlled diabetes will minimize the risk of a stroke. Dyslipidemia can lead to emboli that cause an ischemic stroke. Unfortunately, there is nothing possible to solve a family history, other than to be extra healthy with diet and exercise! Hypertension is a major factor in causing strokes, so keep the patient's blood pressure under control. Smoking cessation will also decrease the risk of cardiac morbidities such as a stroke.

Explanation

Atrial fibrillation can lead to clots, which can enter the cerebral vasculature and cause a stroke. Diabetes is yet another modifiable risk factor, but controlled diabetes will minimize the risk of a stroke. Dyslipidemia can lead to emboli that cause an ischemic stroke. Unfortunately, there is nothing possible to solve a family history, other than to be extra healthy with diet and exercise! Hypertension is a major factor in causing strokes, so keep the patient's blood pressure under control. Smoking cessation will also decrease the risk of cardiac morbidities such as a stroke.

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14. Select the correct dosing for tPA (Alteplase) in acute ischemic stroke; check all that apply to the dosing.

Infuse 0.9 mg/kg (max dose 100 mg) over 60 minutes

Infuse 0.9 mg/kg (max dose 90 mg) over 60 minutes

Administer 25% of the dose as a bolus over 1 minute

Administer 10% of the dose as a bolus over 1 minute

The dosing for Alteplase is 0.9 mg/kg (max dose 90 mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. For a 100 kg patient, the dose would be 90 mg total, with 9 mg given as the bolus and 81 mg given over the rest of the hour. For a 70 kg patient, the dose would be 63 kg total, with 6.3 mg given as a bolus and 56.7 mg given over the rest of the hour.

Explanation

The dosing for Alteplase is 0.9 mg/kg (max dose 90 mg) over 60 minutes, with 10% of the dose given as a bolus over 1 minute. For a 100 kg patient, the dose would be 90 mg total, with 9 mg given as the bolus and 81 mg given over the rest of the hour. For a 70 kg patient, the dose would be 63 kg total, with 6.3 mg given as a bolus and 56.7 mg given over the rest of the hour.

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15. Which of the following medications are needed for secondary prophylaxis in stroke patients?

Antihypertensives

Aspirin

Statin

Warfarin

Of note, ACE-I plus diuretic is the recommended choice for antihypertensive medication. The addition of a statin is without regard to prior use; the pleiotropic effects of statins will be of benefit in preventing further emboli.

Explanation

Of note, ACE-I plus diuretic is the recommended choice for antihypertensive medication. The addition of a statin is without regard to prior use; the pleiotropic effects of statins will be of benefit in preventing further emboli.

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16. Match the following INR goals with the patient's condition.

Bioprosthetic Aortic valve

Bioprosthetic Mitral valve

Mechanical Aortic valve

Mechanical Mitral valve

Mechanical valves have greater risks for clotting than bioprosthetic valves, so they need greater anticoagulation or antiplatelet therapy. The mitral valve is of lower pressure than is the aortic valve, so in general mitral valves require more aggressive therapy (higher INR goal, etc) to prevent clot formation.

Explanation

Mechanical valves have greater risks for clotting than bioprosthetic valves, so they need greater anticoagulation or antiplatelet therapy. The mitral valve is of lower pressure than is the aortic valve, so in general mitral valves require more aggressive therapy (higher INR goal, etc) to prevent clot formation.

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17. Which of the following are exclusion criteria for receiving fibrinolytic therapy?

Active internal bleeding

Blood glucose < 90 mg/dL

Blood pressure >185/110 mmHg

INR>1.7

Stroke within 3 months

Any indications of increased risk of bleeding preclude the use of a fibrinolytic, which can cause life-threatening bleeding. Blood glucose should be normoglycemic: above 50 mg/dL. Of note is if the patient had a stroke within the past 3 months, then the patient is precluded from receiving a fibrinolytic. Also, blood pressure must be lower than 185/110 mmHg.

Explanation

Any indications of increased risk of bleeding preclude the use of a fibrinolytic, which can cause life-threatening bleeding. Blood glucose should be normoglycemic: above 50 mg/dL. Of note is if the patient had a stroke within the past 3 months, then the patient is precluded from receiving a fibrinolytic. Also, blood pressure must be lower than 185/110 mmHg.

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