ASC Acute Stroke Care & Treatment 2 — Questions and Answers
Question 1: A patient with acute ischemic stroke presents 2 hours after symptom onset with NIHSS of 18 and large vessel occlusion on CTA. What is the preferred reperfusion strategy?
- IV tPA alone and observation
- Mechanical thrombectomy with or without IV tPA (Correct answer)
- Intra-arterial tPA only
- Anticoagulation with heparin
Correct answer: Mechanical thrombectomy with or without IV tPA
Large vessel occlusion with high NIHSS and presentation within the thrombectomy window warrants mechanical thrombectomy, which can be combined with IV tPA if eligible.
Question 2: Which blood pressure target is recommended for eligible patients BEFORE administration of IV alteplase?
- < 185/110 mmHg (Correct answer)
- < 200/120 mmHg
- < 160/90 mmHg
- < 220/130 mmHg
Correct answer: < 185/110 mmHg
Blood pressure must be below 185/110 mmHg before alteplase administration to reduce hemorrhagic transformation risk.
Question 3: A patient receives IV tPA and 30 minutes later develops a severe headache with 20-point NIHSS increase. What is the FIRST action?
- Stop the tPA infusion and obtain STAT CT head (Correct answer)
- Complete the infusion then obtain CT
- Administer antihypertensive medications
- Order MRI brain with diffusion
Correct answer: Stop the tPA infusion and obtain STAT CT head
Sudden neurological deterioration during tPA infusion suggests symptomatic intracranial hemorrhage; stop infusion immediately and obtain emergent CT.
Question 4: What is the maximum dose of IV alteplase for an 85 kg patient with acute ischemic stroke?
- 76.5 mg
- 85 mg
- 90 mg (Correct answer)
- 100 mg
Correct answer: 90 mg
The maximum dose of IV alteplase is capped at 90 mg regardless of body weight, even though the dose is 0.9 mg/kg.
Question 5: Tenecteplase (TNK) compared to alteplase for acute ischemic stroke has which pharmacological advantage?
- Longer half-life requiring 60-minute infusion
- Single IV bolus administration with higher fibrin specificity (Correct answer)
- Lower risk of intracranial hemorrhage at all doses
- Requires no blood pressure control before administration
Correct answer: Single IV bolus administration with higher fibrin specificity
Tenecteplase is administered as a single IV bolus and has greater fibrin specificity than alteplase, simplifying administration logistics.
Question 6: Which finding on non-contrast CT is a CONTRAINDICATION to IV thrombolysis in acute ischemic stroke?
- Hyperdense MCA sign
- Loss of insular ribbon
- Early ischemic change involving >1/3 of MCA territory (Correct answer)
- Sulcal effacement in one hemisphere
Correct answer: Early ischemic change involving >1/3 of MCA territory
Extensive early ischemic changes involving more than one-third of the MCA territory on CT indicate high hemorrhage risk and contraindicate tPA.
Question 7: After IV tPA administration, at what blood pressure level should antihypertensive treatment be initiated during the first 24 hours?
- ≥ 160/90 mmHg
- ≥ 180/100 mmHg
- ≥ 185/110 mmHg (Correct answer)
- ≥ 220/120 mmHg
Correct answer: ≥ 185/110 mmHg
Post-tPA, blood pressure should be maintained below 180/105 mmHg, treating when values reach ≥ 180/105 to prevent hemorrhagic transformation.
ASC Acute Stroke Care & Treatment 2
A patient with acute ischemic stroke presents 2 hours after symptom onset with NIHSS of 18 and large vessel occlusion on CTA.
What is the preferred reperfusion strategy?