ASC Evidence-Based Stroke Protocols 3 — Questions and Answers
Question 1: According to evidence-based stroke protocols, which antiplatelet regimen is recommended for secondary prevention after a minor ischemic stroke or high-risk TIA (ABCD2 ≥4)?
- Aspirin monotherapy 325 mg daily
- Clopidogrel monotherapy 75 mg daily
- Dual antiplatelet therapy with aspirin and clopidogrel for 21 days (Correct answer)
- Warfarin with target INR 2–3
Correct answer: Dual antiplatelet therapy with aspirin and clopidogrel for 21 days
Based on the POINT and CHANCE trials, dual antiplatelet therapy (aspirin + clopidogrel) for 21 days significantly reduces early recurrent stroke after minor stroke or high-risk TIA.
Question 2: In hemorrhagic stroke management, which evidence-based target systolic BP is recommended for patients with ICH and initial SBP between 150–220 mmHg?
- SBP < 180 mmHg
- SBP < 160 mmHg
- SBP < 140 mmHg (Correct answer)
- SBP < 120 mmHg
Correct answer: SBP < 140 mmHg
AHA/ASA guidelines support rapid lowering of SBP to <140 mmHg for ICH patients with initial SBP 150–220 mmHg, as supported by the ATACH-2 and INTERACT2 trials.
Question 3: Which finding on CT angiography most strongly predicts hematoma expansion in intracerebral hemorrhage?
- Hyperdense hematoma on NCCT
- Subarachnoid extension of hemorrhage
- Spot sign (contrast extravasation within hematoma) (Correct answer)
- Perilesional edema
Correct answer: Spot sign (contrast extravasation within hematoma)
The CT angiography 'spot sign' — active contrast extravasation within the hematoma — is a strong independent predictor of hematoma expansion and poor outcome.
Question 4: Per AHA/ASA guidelines, which patient with cryptogenic stroke has the strongest indication for prolonged cardiac monitoring (≥30 days)?
- 65-year-old with lacunar infarct and hypertension
- 55-year-old with embolic stroke of undetermined source (ESUS) after negative standard workup (Correct answer)
- 70-year-old with known atrial fibrillation on anticoagulation
- 45-year-old with PFO and first-ever TIA
Correct answer: 55-year-old with embolic stroke of undetermined source (ESUS) after negative standard workup
Prolonged cardiac monitoring is most strongly indicated in ESUS patients without a detected source after standard workup, to detect paroxysmal atrial fibrillation.
Question 5: The CHANCE-2 trial demonstrated that ticagrelor-aspirin was superior to clopidogrel-aspirin for minor stroke/TIA prevention specifically in patients with:
- Diabetes mellitus
- CYP2C19 loss-of-function variants (Correct answer)
- Renal impairment
- Prior stroke history
Correct answer: CYP2C19 loss-of-function variants
CHANCE-2 showed ticagrelor-aspirin was superior to clopidogrel-aspirin in minor stroke/TIA patients carrying CYP2C19 loss-of-function alleles who have reduced clopidogrel metabolism.
Question 6: Evidence-based protocols for acute large vessel occlusion recommend mechanical thrombectomy up to how many hours from symptom onset in selected patients with favorable perfusion imaging?
- 6 hours
- 12 hours
- 24 hours (Correct answer)
- 36 hours
Correct answer: 24 hours
Based on DAWN and DEFUSE 3 trials, mechanical thrombectomy can be performed up to 24 hours from symptom onset in selected patients with favorable clinical-imaging mismatch criteria.
Question 7: Which statement about tenecteplase (TNK) versus alteplase in acute ischemic stroke is supported by current evidence?
- TNK has a significantly higher intracranial hemorrhage rate than alteplase
- TNK requires a 60-minute infusion like alteplase
- TNK 0.25 mg/kg single bolus is at least as effective as alteplase for LVO patients undergoing thrombectomy (Correct answer)
- TNK is approved only for posterior circulation strokes
Correct answer: TNK 0.25 mg/kg single bolus is at least as effective as alteplase for LVO patients undergoing thrombectomy
The AcT trial and meta-analyses support tenecteplase 0.25 mg/kg as a single IV bolus as non-inferior to alteplase, particularly facilitating workflow for patients undergoing thrombectomy.
ASC Evidence-Based Stroke Protocols 3
According to evidence-based stroke protocols, which antiplatelet regimen is recommended for secondary prevention after a minor ischemic stroke or high-risk TIA (ABCD2 ≥4)?