ACLS Acute Stroke Care 2 — Questions and Answers
Question 1: A patient presents with sudden onset aphasia and right-sided weakness. CT head shows no hemorrhage. Last known well was 90 minutes ago. What is the next priority intervention?
- Administer IV tPA immediately
- Obtain MRI brain before treatment
- Perform CT angiography to evaluate large vessel occlusion (Correct answer)
- Start aspirin 325 mg
Correct answer: Perform CT angiography to evaluate large vessel occlusion
CT angiography should be obtained to assess for large vessel occlusion (LVO), which determines eligibility for mechanical thrombectomy in addition to IV tPA.
Question 2: Which blood pressure threshold must be achieved and maintained BEFORE administering IV alteplase for acute ischemic stroke?
- < 220/120 mmHg
- < 185/110 mmHg (Correct answer)
- < 160/90 mmHg
- < 140/80 mmHg
Correct answer: < 185/110 mmHg
BP must be < 185/110 mmHg before alteplase administration and maintained < 180/105 mmHg for at least 24 hours afterward.
Question 3: A 78-year-old patient with known atrial fibrillation on warfarin presents with acute ischemic stroke. INR is 1.7. Is IV tPA indicated?
- Yes, INR < 2.0 permits tPA administration (Correct answer)
- No, any anticoagulant use is an absolute contraindication
- Yes, if onset was less than 3 hours ago
- No, INR > 1.7 is a contraindication to tPA
Correct answer: Yes, INR < 2.0 permits tPA administration
IV tPA can be given if INR is ≤ 1.7; an INR > 1.7 in a patient on warfarin is a contraindication.
Question 4: What is the maximum time window for mechanical thrombectomy in selected patients with large vessel occlusion and favorable imaging?
- 4.5 hours from onset
- 6 hours from onset
- 16 hours from onset
- 24 hours from onset (Correct answer)
Correct answer: 24 hours from onset
Trials (DAWN, DEFUSE 3) support mechanical thrombectomy up to 24 hours from last known well in selected patients with target mismatch on imaging.
Question 5: During stroke assessment, a patient scores 4 points on the Los Angeles Prehospital Stroke Screen (LAPSS). What does this indicate?
- Stroke is unlikely; reassess for other diagnoses
- Hemorrhagic stroke is confirmed
- Stroke is likely; activate the stroke team immediately (Correct answer)
- The patient requires only aspirin therapy
Correct answer: Stroke is likely; activate the stroke team immediately
A positive LAPSS (all criteria met) indicates high likelihood of stroke, prompting immediate stroke team activation and transport to a stroke center.
Question 6: Which finding on non-contrast CT head is an absolute contraindication to IV tPA in acute ischemic stroke?
- Hyperdense MCA sign
- Early ischemic changes in less than 1/3 of MCA territory
- Hemorrhagic transformation (Correct answer)
- Loss of gray-white differentiation in basal ganglia
Correct answer: Hemorrhagic transformation
Any intracranial hemorrhage on CT is an absolute contraindication to IV tPA administration.
Question 7: A stroke patient receiving IV alteplase develops sudden severe headache, hypertension, and neurological deterioration 45 minutes into the infusion. What is the immediate action?
- Increase the infusion rate to complete the dose faster
- Stop the infusion and obtain emergent CT head (Correct answer)
- Administer labetalol and continue infusion
- Give cryoprecipitate and continue monitoring
Correct answer: Stop the infusion and obtain emergent CT head
Symptomatic intracranial hemorrhage must be suspected; the tPA infusion should be stopped immediately and emergent CT obtained.
ACLS Acute Stroke Care 2
A patient presents with sudden onset aphasia and right-sided weakness.
CT head shows no hemorrhage.
Last known well was 90 minutes ago.
What is the next priority intervention?