ACLS Acute Stroke Care 5 — Questions and Answers
Question 1: A patient with acute ischemic stroke is on a direct oral anticoagulant (DOAC). When can IV tPA be safely administered?
- Any time if the last DOAC dose was > 12 hours ago
- Only if specific reversal agent was administered and coagulation assays are normal (Correct answer)
- Immediately if clinical need is high
- Never; DOACs are an absolute contraindication regardless of timing
Correct answer: Only if specific reversal agent was administered and coagulation assays are normal
IV tPA may be considered after DOAC reversal (e.g., idarucizumab for dabigatran) with confirmation that coagulation tests are normal.
Question 2: Which ECG finding is most commonly associated with acute ischemic stroke and requires cardiac monitoring?
- Right bundle branch block
- Atrial fibrillation (Correct answer)
- First-degree AV block
- Sinus bradycardia
Correct answer: Atrial fibrillation
Atrial fibrillation is the most clinically significant arrhythmia associated with cardioembolic stroke and requires continuous monitoring to detect paroxysmal episodes.
Question 3: A patient with acute stroke has blood glucose of 35 mg/dL. What is the appropriate management?
- Administer IV tPA first, then treat hypoglycemia
- Treat hypoglycemia with IV dextrose; reassess neurological status after normalization (Correct answer)
- Assume stroke is the cause and proceed with stroke protocol only
- Give glucagon IM and proceed with tPA
Correct answer: Treat hypoglycemia with IV dextrose; reassess neurological status after normalization
Hypoglycemia (glucose < 50–60 mg/dL) mimics stroke and must be corrected immediately before attributing symptoms to ischemic stroke.
Question 4: The concept of 'time is brain' refers to approximately how many neurons lost per minute in untreated ischemic stroke?
- 190,000 neurons/minute
- 1.9 million neurons/minute (Correct answer)
- 19 million neurons/minute
- 190 million neurons/minute
Correct answer: 1.9 million neurons/minute
Approximately 1.9 million neurons are lost every minute during large vessel occlusion, underscoring the urgency of rapid reperfusion.
Question 5: Which of the following is a RELATIVE contraindication (not absolute) to IV tPA in acute ischemic stroke?
- Intracranial hemorrhage on CT
- Active internal bleeding
- Ischemic stroke or head trauma in the past 3 months
- Rapidly improving or minor neurological deficits (Correct answer)
Correct answer: Rapidly improving or minor neurological deficits
Minor or rapidly improving symptoms are a relative contraindication; clinical judgment determines whether the deficit is disabling enough to justify tPA risk.
Question 6: For a suspected stroke patient in the ED, what is the AHA target time from door to CT interpretation?
- 15 minutes
- 25 minutes (Correct answer)
- 45 minutes
- 60 minutes
Correct answer: 25 minutes
The AHA/ASA guidelines recommend CT interpretation within 25 minutes of ED arrival to facilitate rapid tPA decision-making.
Question 7: A stroke patient develops worsening cerebral edema on day 2 with midline shift. Which intervention may be life-saving?
- Increasing tPA infusion
- Decompressive hemicraniectomy (Correct answer)
- Systemic corticosteroids
- Aggressive hyperventilation to PaCO₂ < 30 mmHg
Correct answer: Decompressive hemicraniectomy
Decompressive hemicraniectomy within 48 hours reduces mortality in malignant MCA infarction with significant cerebral edema and midline shift.
ACLS Acute Stroke Care 5
A patient with acute ischemic stroke is on a direct oral anticoagulant (DOAC).
When can IV tPA be safely administered?