ACLS Acute Stroke Care 4 — Questions and Answers
Question 1: A patient with acute stroke is found to have a platelet count of 85,000/μL. IV tPA is being considered. What is the correct action?
- Administer tPA; platelet count is not a contraindication
- Withhold tPA; platelet count < 100,000/μL is a contraindication (Correct answer)
- Transfuse platelets first, then give tPA
- Administer half-dose tPA
Correct answer: Withhold tPA; platelet count < 100,000/μL is a contraindication
Platelet count < 100,000/μL is a contraindication to IV tPA in acute ischemic stroke due to increased hemorrhage risk.
Question 2: Which type of stroke most commonly results from cardioembolic sources such as atrial fibrillation?
- Lacunar infarct
- Large artery atherosclerotic stroke
- Cardioembolic stroke (Correct answer)
- Cryptogenic stroke
Correct answer: Cardioembolic stroke
Atrial fibrillation causes cardioembolism, typically producing large cortical infarcts often involving multiple vascular territories.
Question 3: After IV tPA, when should antiplatelet therapy (aspirin) be initiated in acute ischemic stroke?
- Immediately after tPA bolus
- Within 1 hour of tPA completion
- 24 hours after tPA, once imaging excludes hemorrhage (Correct answer)
- 48 hours after tPA regardless of imaging
Correct answer: 24 hours after tPA, once imaging excludes hemorrhage
Antiplatelet agents should be withheld for 24 hours after tPA administration; a repeat CT should confirm no hemorrhage before starting.
Question 4: A 55-year-old patient presents with sudden onset of the 'worst headache of my life.' CT head is normal. What is the next diagnostic step?
- Reassure and discharge with follow-up
- MRI brain with DWI
- Lumbar puncture to detect xanthochromia (Correct answer)
- CT angiography only
Correct answer: Lumbar puncture to detect xanthochromia
A normal CT does not exclude subarachnoid hemorrhage; lumbar puncture should be performed to detect xanthochromia when SAH is suspected.
Question 5: In a patient with hemorrhagic stroke due to warfarin, which reversal agent is preferred for rapid INR correction?
- Vitamin K alone
- Fresh frozen plasma (FFP) alone
- 4-factor prothrombin complex concentrate (4F-PCC) (Correct answer)
- Protamine sulfate
Correct answer: 4-factor prothrombin complex concentrate (4F-PCC)
4F-PCC rapidly reverses warfarin anticoagulation with smaller volume than FFP and faster INR correction, making it preferred in hemorrhagic stroke.
Question 6: What NIHSS score range generally indicates a SEVERE stroke?
- 1–4
- 5–15
- 16–20
- ≥ 21 (Correct answer)
Correct answer: ≥ 21
NIHSS ≥ 21 indicates very severe stroke; scores 1–4 are minor, 5–15 moderate, and 16–20 moderate-to-severe.
Question 7: Which intervention should be avoided in the acute phase of ischemic stroke to prevent worsening cerebral ischemia?
- Elevating head of bed to 30 degrees
- Aggressive lowering of BP below 140 systolic in non-tPA candidates (Correct answer)
- Initiating swallowing evaluation
- Continuous cardiac monitoring
Correct answer: Aggressive lowering of BP below 140 systolic in non-tPA candidates
Aggressive BP reduction below 140 mmHg in non-tPA candidates can reduce perfusion pressure in the ischemic penumbra and worsen outcomes.
ACLS Acute Stroke Care 4
A patient with acute stroke is found to have a platelet count of 85,000/μL.
IV tPA is being considered.
What is the correct action?