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IM18.1-16 | Cerebrovascular Accident — Practice Quiz
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A 62-year-old man with hypertension presents with sudden-onset right hemiplegia and global aphasia. The FIRST investigation to be performed in the emergency department is:
Correct. Non-contrast CT (NCCT) brain is always the first imaging in acute stroke. Its primary role is to exclude haemorrhage — haemorrhage appears hyperdense (bright white) on NCCT within minutes of onset. This distinction is essential before any thrombolytic therapy is considered, since giving tPA to a haemorrhagic stroke is fatal. MRI-DWI is more sensitive for early ischaemia but is slower and less universally available.
The most dangerous error in acute stroke is giving thrombolysis to a haemorrhagic stroke. NCCT brain excludes haemorrhage (hyperdense on CT) and is always the first investigation.
The first imaging in any acute stroke is non-contrast CT brain to exclude haemorrhage. Giving thrombolytics to a haemorrhagic stroke is catastrophic. NCCT is fast, widely available, and reliably detects haemorrhage within minutes — always the first step.
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A 58-year-old woman presents with acute stroke symptoms that began 3 hours ago. NCCT brain shows no haemorrhage. Her BP is 178/100 mmHg. She has no history of prior stroke, seizures, or recent surgery. Which is the MOST appropriate next step?
Correct. For IV thrombolysis eligibility, BP must be brought below 185/110 mmHg — this is the specific threshold. If achieved safely (usually with labetalol or nicardipine IV), alteplase can be given. Lowering BP further to 140/90 before thrombolysis is unnecessary and wastes precious time. The window is symptom onset within 4.5 hours.
The BP ceiling for IV thrombolysis is 185/110 mmHg. If BP exceeds this, treat with IV labetalol or nicardipine to bring it below the threshold, then give alteplase. Do not over-lower BP.
The BP threshold for safe IV thrombolysis is 185/110 mmHg — not lower. If BP can be brought below this threshold with short-acting IV antihypertensives, alteplase should proceed within the 4.5-hour window.
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A 70-year-old man has a left MCA territory infarct on CT. He arrives within 2 hours of symptom onset. NIHSS is 18. CT angiography shows a left M1 segment occlusion. BP is 160/90 mmHg after treatment. He has no contraindications. What is the BEST management?
Correct. For eligible patients with large vessel occlusion (LVO) presenting within the thrombolysis window, the standard of care is bridging therapy: IV alteplase followed immediately by mechanical thrombectomy. Thrombectomy is indicated for proximal LVO (ICA, M1, basilar) within 6 hours of onset (or 6-24 hours in selected patients with salvageable penumbra on imaging). The two therapies are complementary, not alternatives.
Proximal large vessel occlusion + thrombolysis-eligible = bridging therapy: IV alteplase then mechanical thrombectomy within 6 hours (selected cases up to 24 hours). These are complementary, not alternative treatments.
For large vessel occlusion within the thrombolysis window, bridging therapy — IV alteplase followed by mechanical thrombectomy — is the standard of care. Thrombectomy alone is used only if thrombolysis is contraindicated. Heparin has no role in acute ischaemic stroke.
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During history-taking from a stroke patient, which one of the following is the MOST critical piece of information to establish first?
Correct. The time of last known well (or symptom onset) is the most critical datum in acute stroke because it governs all time-sensitive interventions. IV thrombolysis must be given within 4.5 hours and thrombectomy within 6 hours (or up to 24 hours in selected cases) of last known well. Without this anchor, no reperfusion therapy can be safely initiated.
In stroke history, the most critical question is: when was the patient last known to be well? This time governs thrombolysis (within 4.5 hours) and thrombectomy eligibility.
The first and most critical information in stroke history is the exact onset time (or last known well time) — this determines eligibility for thrombolysis (within 4.5 hours) and thrombectomy (within 6 hours). All other information is important but secondary.
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A patient has sudden-onset right leg weakness with preserved arm strength, right cortical sensory loss over the leg, and urinary incontinence. Which arterial territory is MOST likely affected?
Correct. The anterior cerebral artery (ACA) supplies the medial surface of the frontal and parietal lobes, which contains the leg area of the motor and sensory homunculus. ACA territory stroke produces contralateral leg weakness (greater than arm), contralateral cortical leg sensory loss, and urinary incontinence from involvement of the frontal micturition centre. Right-sided deficits indicate a left ACA infarct.
ACA territory infarct: contralateral leg weakness greater than arm, cortical sensory loss in the leg, urinary incontinence. Contrasts with MCA (arm/face predominant, aphasia if left hemisphere).
Leg-predominant contralateral weakness with cortical sensory loss and urinary incontinence is the classic anterior cerebral artery (ACA) syndrome — the ACA supplies the medial cortex where the leg representation lies. Right-sided weakness implies a left ACA territory infarct.
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A 45-year-old man presents with sudden-onset severe occipital headache, vomiting, and neck stiffness with no focal neurological deficit. CT brain shows no haemorrhage. What is the MOST appropriate next step?
Correct. A thunderclap headache (sudden-onset severe headache, worst of life) with meningism but normal CT should be followed by lumbar puncture to detect xanthochromia — yellow discolouration of CSF due to haemoglobin breakdown products present from 2 hours to 2 weeks after subarachnoid haemorrhage (SAH). Up to 15% of SAH are CT-negative; LP is the definitive investigation in this scenario.
Thunderclap headache + normal NCCT = perform lumbar puncture for xanthochromia. Up to 15% of SAH are CT-negative. Xanthochromia appears after 2 hours and persists for up to 2 weeks.
A thunderclap headache with normal CT is a sentinel bleed (subarachnoid haemorrhage) until proven otherwise. Up to 15% of SAHs are CT-negative — lumbar puncture for xanthochromia is the definitive next step. Never discharge without LP in this scenario.
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A 67-year-old woman with known atrial fibrillation is admitted with ischaemic stroke. Which score is used to determine her CHA2DS2-VASc score, and what threshold mandates anticoagulation for secondary prevention?
Correct. In the CHA2DS2-VASc scoring system, prior stroke or TIA scores 2 points — the highest individual item weight — which by itself mandates long-term anticoagulation in AF patients. The score includes: CHF (1), Hypertension (1), Age 75+ (2), Diabetes (1), prior Stroke/TIA (2), Vascular disease (1), Age 65-74 (1), Sex category female (1). A stroke patient with AF therefore has a minimum CHA2DS2-VASc of 2 and anticoagulation with a DOAC or warfarin is indicated.
CHA2DS2-VASc: prior stroke/TIA = 2 points alone. Any patient with AF and prior stroke mandates oral anticoagulation (DOAC preferred). Antiplatelet agents are inferior to anticoagulation for AF-related stroke prevention.
In CHA2DS2-VASc scoring, prior stroke or TIA alone scores 2 points — enough to mandate anticoagulation on its own. AF plus prior stroke means anticoagulation with a DOAC (preferred) or warfarin is definitively indicated for secondary prevention.
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A 55-year-old man presents with acute-onset left-sided facial droop, left arm and leg weakness, and deviation of gaze to the RIGHT. The findings MOST likely localise the stroke to:
Correct. The key rule for gaze deviation: in a cortical hemisphere stroke, the eyes deviate TOWARDS the side of the lesion (the intact contralateral frontal gaze centre drives the eyes away from it). Left-sided hemiplegia + gaze deviation to the right indicates a right hemisphere infarct. If gaze deviated toward the PARETIC side, it would suggest a pontine lesion (where the gaze centre ipsilateral to the lesion is affected).
Conjugate gaze deviation: toward lesion in hemisphere stroke (cortical/subcortical), away from lesion (toward weak side) in pontine stroke. Left hemiplegia + rightward gaze deviation = right hemisphere lesion.
Gaze deviation toward the side of the hemiplegia (left weakness + rightward gaze) indicates a right hemisphere lesion. Cortical rules: eyes deviate toward the lesion in hemisphere strokes; eyes deviate away from the lesion (toward the weak limbs) in pontine strokes.
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A patient presents with isolated haemorrhagic stroke. BP is 210/120 mmHg. CT shows a 25 mL basal ganglia haematoma with no intraventricular extension. GCS is 13. The MOST appropriate initial management is:
Correct. Haemorrhagic stroke management: (1) thrombolytics are absolutely contraindicated; (2) acute BP lowering to SBP 130-140 mmHg is safe and may reduce haematoma expansion (INTERACT2/ATACH-2 trials); (3) reverse anticoagulation if on warfarin (Vitamin K + PCC) or DOAC (reversal agents); (4) supportive care (airway, glucose, temperature). Surgery for basal ganglia haemorrhage at 25 mL with preserved consciousness is NOT indicated — surgical benefit is shown only for cerebellar haemorrhage and specific indications.
ICH management: no thrombolytics (absolute CI), lower SBP to 130-140 mmHg, reverse anticoagulation, supportive care. Surgery for ICH: cerebellar >3 cm or causing brainstem compression; basal ganglia haemorrhage is generally managed medically.
Haemorrhagic stroke: thrombolytics are absolutely contraindicated. Target SBP is 130-140 mmHg (INTERACT2/ATACH-2). Surgical evacuation for a 25 mL basal ganglia haematoma in a conscious patient is not indicated — surgery is reserved for cerebellar haemorrhage and specific large lobar haematomas with herniation.
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A 35-year-old woman presents with sudden-onset right hemiplegia while 6 weeks post-partum. She has no hypertension or cardiac history. Protein C activity is 18% (normal >70%). MRI brain shows a left MCA territory infarct. The MOST likely aetiology is:
Correct. Young stroke (age <45 years) requires an extended aetiological workup including thrombophilia screen. Protein C deficiency (with low Protein C activity <70%) is a heritable hypercoagulable state that increases risk of arterial and venous thrombosis. The post-partum state further increases the thrombotic risk. Young stroke without conventional vascular risk factors should prompt a thrombophilia screen (Protein C, Protein S, antithrombin III, Factor V Leiden, antiphospholipid antibody).
Young stroke (age <45) requires extended workup: thrombophilia screen (Protein C/S, ATIII, Factor V Leiden, APLA), cardiac bubble echo (PFO), cervical artery dissection (T1 fat-sat MRI neck), vasculitis, and illicit drug use. Post-partum hypercoagulability amplifies thrombophilia risk.
Young stroke with low Protein C activity and recent post-partum state indicates inherited thrombophilia as the most likely cause. Young stroke workup must always include thrombophilia screen, antiphospholipid antibodies, cardiac sources (echo with bubble study), and arterial dissection imaging.
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