III.1. The most common cause of ischemic stroke is which of the
following?
a. Coagulation disorder
b. Large-vessel extracranial atherosclerosis
c. Vasculitis
d. Cardioembolic cause
e. Embolic stroke of undetermined source
III.1. Answer d.
Approximately 30% to 40% of ischemic strokes are due to a
cardioembolic cause, with atrial fibrillation being the most
common.
III.2. For which of the following cases is carotid endarterectomy defi-
nitely indicated within 2 weeks?
a. Amaurosis fugax in the right eye with 80% internal carotid artery
stenosis by magnetic resonance angiography (MRA) of the neck
b. Transient right hemiplegia and aphasia with 50% internal carotid
artery stenosis by ultrasonography
c. Left hemispheric stroke with National Institutes of Health Stroke
Scale score of 30 and left internal carotid artery stenosis measur-
ing 90% by computed tomographic angiography (CTA)
d. Incidental 50% left internal carotid artery stenosis in an 85-year-
old patient
e. Transient weakness of the left face and arm and 100% occlusion
of the right internal carotid artery of a 75-year-old female
patient
III.2. Answer a.
Carotid intervention is recommended for patients with
symptomatic internal carotid artery stenosis measuring 70%
to 99% by noninvasive studies (MRA, CTA, or ultrasonogra-
phy) or greater than 50% by cerebral angiography. Carotid
intervention is not recommended early on for patients with
severe deficit because of the risk of reperfusion injury.
Carotid intervention in the clinical setting of asymptomatic
disease is a matter of debate for patients with internal carotid
artery stenosis greater than 60%. If the internal carotid artery
stenosis is asymptomatic and less than 60%, medical man-
agement is generally indicated.
III.3. What equally effective alternative to warfarin treatment do patients
with nonvalvular atrial fibrillation have for stroke prevention?
a. Aspirin 325 mg daily
b. Aspirin 81 mg and clopidogrel 75 mg daily
c. Aspirin 81 mg daily and rivaroxaban 2.5 mg twice daily
d. Apixaban 5 mg twice daily
e. Clopidogrel 75 mg daily
III.3. Answer d.
Direct oral anticoagulants are reasonable alternatives to war-
farin for patients with nonvalvular atrial fibrillation, for
stroke prevention. The Watchman Left Atrial Appendage
Closure Device (Boston Scientific Corp) is also a reasonable
alternative if a patient has a high risk of systemic bleeding.
However, patients must be taking an antithrombotic—and
usually an anticoagulant agent—for the first several weeks
after device placement.
III.4. A patient presents with left homonymous hemianopia, left
hemiplegia (face, arm, and leg), and left hemisensory loss (face,
arm, and leg). A magnetic resonance image is shown herein. A
thrombus in which artery might produce this clinical picture?
a. Right recurrent artery of Huebner
b. Right anterior division of middle cerebral artery
c. Right anterior choroidal artery
d. Right posterior cerebral artery
e. Right tuberothalamic artery
III.4. Answer c.
The anterior choroidal artery branches from the internal
carotid artery and supplies the ipsilateral posterior limb of
the internal capsule of the thalamus, including the lateral
geniculate body, piriform cortex, caudate tail, and part of the
hippocampus and amygdala.
III.5. A patient with hypertension and diabetes mellitus presents with
right face, arm, and leg numbness. Examination shows decreased
pin prick response on the right face, arm, and leg. Strength is
normal. Where is the stroke localized?
a. Left anterior thalamus
b. Left lateral thalamus
c. Left medulla
d. Left internal capsule
e. Left insular cortex
III.5. Answer b.
A pure sensory stroke generally localizes to the contralateral
thalamus and particularly the ventral posterolateral and
ventral posteromedial aspects of the thalamus, where sen-
sory fibers synapse.
III.6. A 45-year-old man presents with right hemiparesis without sen-
sory or language impairment. He acknowledges a long-standing
history of migraine headaches. His mother and maternal grand-
father have a history of stroke in their early 50s. Magnetic reso-
nance imaging shows an acute infarct in the left posterior limb
of the internal capsule and diffuse, confluent T2 hyperintensity
within bilateral subcortical white matter and the anterior tem-
poral lobes. Which of the following is most likely the cause of
this patient’s syndrome?
a. Mutation in FBN1 gene
b. Mutation in Notch3 gene
c. Mutation in GLA gene
d. Mutations in α-galactosidase A gene
e. Prothrombin 20210 mutation
III.6. Answer b.
The patient is presenting with a history and imaging find-
ings most suggestive of cerebral autosomal dominant arteri-
opathy with subcortical infarcts and leukoencephalopathy, a
condition secondary to a missense mutation in the Notch3 gene
III.7.
A 41-year-old woman with a past medical history of hyperten-
sion, type 2 diabetes mellitus, migraine headaches, prior stroke
1 year ago with residual mild right hemiparesis, and 2 miscar-
riages is referred for further evaluation of recurrent episodes of
left arm paresthesias. General examination shows a diffuse
lacelike rash of the trunk and all extremities. Neurologic exam-
ination shows mild right hemiparesis in an upper motor neu-
ron pattern but is otherwise unremarkable. Of the following
syndromes and diseases, which is the most likely diagnosis?
a. Eales syndrome
b. Cogan syndrome
c. Kohlmeier-Degos disease
d. Sneddon syndrome
e. Susac syndrome
III.7. Answer d.
The patient most likely has Sneddon syndrome, a nonin-
flammatory vasculopathy that presents with cerebral isch-
emia, seizures, dementia, and a lacelike skin rash (livedo
reticularis). Sneddon syndrome also may be associated with
antiphospholipid syndrome.
III.8. A 30-year-old woman presents 2 weeks’ postpartum for head-
ache and double vision. The headache was initially holoce-
phalic, dull, and only mildly bothersome. However, sudden
worsening of the headache occurred and was followed by hori-
zontal diplopia and graying of her vision whenever she coughed
or sneezed. On examination, she has papilledema and a cranial
nerve VI palsy. What is the most appropriate test to confirm the
most likely diagnosis for this patient?
a. Magnetic resonance imaging
b. Magnetic resonance angiography
c. Magnetic resonance venography (MRV)
d. Lumbar puncture
e. Cerebrospinal fluid analysis
III.8. Answer c.
The patient is presenting with a progressive headache that
acutely worsened and signs of increased intracranial pressure
(ie, papilledema, cranial nerve VI palsy, and visual obscura-
tions). Her presentation is most likely secondary to a cerebral
venous sinus thrombosis. The postpartum period is a risk fac-
tor for cerebral venous sinus thrombosis formation, given the
substantial hormonal changes and fluid shifts, which ulti-
mately result in a hypercoagulable state. An MRV would be the
best study to evaluate for a cerebral venous sinus thrombosis.
III.9. Which of the following is an absolute contraindication to intra-
venous (IV) administration thrombolytics?
a. Small parafalcine meningioma
b. Hypertension with a systolic blood pressure of 200 mm Hg
before antihypertensive treatment
c. Suspicion for endocarditis or aortic dissection
d. Cervical artery dissection
e. Warfarin therapy with an international normalized ratio of 1.6
III.9. Answer c.
For patients with suspected endocarditis, risk of bleeding is
increased and IV thrombolytics would be contraindicated.
Patients who have ischemic stroke due to aortic dissection
may have increased risk of bleeding into the dissected artery,
and IV thrombolytics would generally be contraindicated. However, for cervical arterial dissection, the 2019 Stroke
guidelines states that “alteplase in acute ischemic stroke
with known or suspected to be associated with extracranial
cervical arterial dissection is reasonably safe within 4.5
hours and probably recommended.” IV thrombolytics
should not be used in patients in whom the blood pressure
is 185/110 mm Hg or higher despite treatment. If the blood
pressure can be safely lowered below 185/110 mm Hg with
treatment, the patient could be a candidate for thrombolysis.
III.10. What is the minimum National Institutes of Health Stroke Scale
(NIHSS) score before which intravenous (IV) thrombolytics
should be considered?
a. NIHSS score greater than 2
b. NIHSS score greater than 5
c. NIHSS score greater than 10
d. NIHSS score greater than 15
e. No minimum NIHSS score
III.10. Answer e.
There is no minimum NIHSS score in which IV thrombolyt-
ics should not be given. Patients with isolated gait ataxia,
for example, may have a disabling stroke but have an
NIHSS score of 0. The 2019 American Heart/Stroke
Association guidelines suggest that IV thrombolytics are
reasonable if the NIHSS score is less than 5 AND there is
disability due to the deficit. IV thrombolytics are not rec-
ommended if the NIHSS score is less than 5 and the deficits
are considered nondisabling. Clinical judgment of the dis-
ability caused by the stroke should be used to make deci-
sions about IV thrombolytics.
III.11. A 75-year-old patient who is independent in activities of daily
living and has a history of atrial fibrillation presents with acute
right hemiplegia and aphasia and a National Institutes of
Health Stroke Scale score of 14. Intravenous (IV) thrombolytics
are contraindicated because the patient takes warfarin and has
an international normalized ratio (INR) of 1.8. Computed
tomography (CT) of the brain shows a dense left middle cere-
bral artery with no areas of hypodensity. CT angiography of the
head and neck confirms a left M1 middle cerebral artery occlu-
sion. Tests are completed at 2 hours from symptom onset. The
next best step in management is which of the following?
a. Admit patient to the hospital and start of IV administration of
heparin to bridge until INR is in a therapeutic range
b. Obtain a CT perfusion scan
c. Obtain magnetic resonance imaging of the brain
d. Take the patient to endovascular therapy for embolectomy and
clot retrieval
e. Administer tenecteplase
III.11. Answer d.
This patient is within 6 hours of symptom onset with a nor-
mal Alberta Stroke Program Early Computed Tomography
Score (ASPECTS) and an M1 occlusion. Further imaging is
not helpful. The patient should be taken immediately to the
endovascular suite for clot retrieval.
III.12. A 68-year-old woman awakens in the morning with left hemiplegia and neglect and a National Institutes of Health Stroke
Scale score of 15. She was most recently normal the evening
before at 10 PM. Computed tomography (CT) of the head and CT
angiography of the head and neck show a right carotid terminus occlusion and no acute head CT changes. By now, it is
9 AM. The patient’s blood pressure is 160/85 mm Hg; glucose,
110 mg/dL; and international normalized ratio, normal. What
is the next step in treatment or evaluation?
a. Admit the patient and start aspirin therapy at 325 mg daily
b. Administer intravenous (IV) recombinant tissue plasminogen
activator (r-tPA) at 0.45 mg/kg
c. Obtain CT perfusion or diffusion magnetic resonance imag-
ing (MRI)
d. Administer IV tenecteplase 0.25 mg/kg
e. Pharmacologically increase her blood pressure to 180/100 mm
Hg to increase collateral perfusion
III.12. Answer c.
Patients presenting at more than 6 hours after last known
normal may benefit from the use of advanced imaging to
determine whether there is penumbra to save. CT perfusion
and MRI diffusion are acceptable options. If a penumbra is
found, endovascular therapy could be performed. Emerging
data are evaluating the safety of IV r-tPA in this patient
group.
III.13. Which of the following is not a component of the CHA2DS2-
VASc Score?
a. Age
b. Hypertension
c. Diabetes mellitus
d. Smoking
e. Sex
III.13. Answer d.
The CHA2DS2-VASc abbreviation stands for congestive
heart failure, hypertension, age 75 years or older, diabetes
mellitus, stroke or transient ischemic attack or thromboem-
bolism, vascular disease, age 65 to 74 years, and sex cate-
gory (female).
III.14. Which of the following modifiable risk factors has the greatest
effect on stroke reduction?
a. Hyperlipidemia
b. Diabetes mellitus
c. Hypertension
d. Surgery for asymptomatic carotid stenosis
e. Weight reduction
III.14. Answer c.
Hypertension is an important risk factor for ischemic stroke
and intracerebral hemorrhage. It has the highest popula-
tion-attributable risk of the common risk factors.
III.15. A patient starts treatment with a direct oral anticoagulant (DOAC)
after a transient ischemic attack and concomitant atrial fibrilla-
tion. Which of the following should you monitor at least annually?
a. International normalized ratio
b. Partial thromboplastin time
c. Antifactor Xa
d. Creatinine
e. Liver function
III.15. Answer d.
Because DOACs are excreted renally and dose adjustments
are necessary, kidney function should be monitored at least
annually. Antifactor Xa level is not routinely monitored, but
in the event of a patient having recurrent thromboembolism
despite taking a DOAC, testing for it may prove useful.
III.16. The long-term blood pressure goal for patients after cerebral
ischemia is which of the following?
a. 160/90 mm Hg
b. 150/90 mm Hg
c. 140/90 mm Hg
d. 130/80 mm Hg
e. 120/80 mm Hg
III.16. Answer d.
According to the 2017 American College of Cardiology
Treatment for Hypertension Guidelines, the target blood
pressure for patients who have had an ischemic stroke is
130/80 mm Hg. However, the statement recommends initi-
ating treatment when the blood pressure is greater than
140/90 mm Hg.
III.17. A 78-year-old man presents with a basal ganglia hemorrhage.
The most likely cause in a patient this age with a hemorrhage
in this location is which of the following
a. Hypertension
b. Cerebral amyloid angiopathy
c. Cavernous malformation
d. Arteriovenous malformation
e. Reversible cerebrovasoconstrictive syndrome
III.17. Answer a.
The most common cause of hemorrhage is hypertension.
The basal ganglia location also points toward a hyperten-
sive hemorrhage.
III.18. Corticosteroids should be given in which of the following clini-
cal settings for a patient with cerebral hemorrhage?
a. Reversible cerebrovasoconstrictive syndrome
b. Hypertensive hemorrhage with ventricular extension
c. A large lobar hemorrhage with associated hydrocephalus
d. Warfarin-related intracerebral hemorrhage
e. Generally not given for intracranial hemorrhage
III.18. Answer e.
Corticosteroid use is generally not effective for improving
outcome from intracerebral hemorrhage. In selected cir-
cumstances, corticosteroids may be used in the clinical setting of vasogenic edema associated with a hemorrhagic
neoplasm.
III.19. An 85-year-old man presents with acute hemorrhage in the cer-
ebellum with extension into the fourth ventricle and resultant
hydrocephalus. Glasgow Coma Scale score is 4 on presentation.
Which easy-to-use score system may help you predict a 30-day
mortality rate?
a. Hunt-Hess Score
b. Intraparenchymal cerebral hemorrhage (ICH) score
c. World Federation of Neurosurgeons Grading System (WFNS)
d. National Institutes of Health Stroke Scale
e. Glasgow outcome score
III.19. Answer b.
The ICH score is a simple, easy clinical grading scale for
predicting a 30-day mortality rate. Hunt-Hess and the WFNS
grading systems are used for subarachnoid hemorrhage.
III.20. Approximately what percentage of the US population has an
unruptured intracranial aneurysm?
a. 0.01%
b. 2%
c. 10%
d. 20%
e. 33%
III.20. Answer b.
About 0.5% to 2% of the population has an unruptured
intracranial saccular aneurysm.
III.21. Which of the following factors increases the risk of rupture in
an incidentally found cerebral aneurysm?
a. Diabetes mellitus
b. Polycystic kidney disease
c. Increasing size of aneurysm
d. Location at the middle cerebral artery
e. Fibromuscular dysplasia
III.21. Answer c.
The most important factors are increasing size and poste-
rior circulation or posterior communicating artery segment
location. Polycystic kidney disease and fibromuscular dys-
plasia increase the likelihood of an aneurysm developing
but not necessarily the risk of rupture. Age, hypertension,
Finnish or Japanese heritage, and prior subarachnoid hem-
orrhage increase this risk.
III.22. Which of the following types of vascular malformation most
commonly has a genetic and a sporadic form?
a. Arteriovenous malformation
b. Dural arteriovenous fistula
d. Developmental venous anomaly
e. Capillary telangiectasia
III.22. Answer c.
Cavernous malformations of the brain may be sporadic or
familial. The KRIT1 mutation, or CCM1, is the most com-
mon type of the familial form. Cases of familial arteriove-
nous malformation occur, but these are rare.
III.23. This magnetic resonance imaging (MRI) scan shows which type
of vascular malformation?
III.23. Answer d.
This axial T1 MRI with contrast medium shows a large
developmental venous anomaly in the right cerebellum.
III.24. Which of the following medications is not approved by the US
Food and Drug Administration for treatment of centrally medi-
ated spasticity?
a. Dantrolene
b. Gabapentin
c. Diazepam
d. Baclofen
e. Tizanidine
III.24. Answer b.
The spasticity associated with ischemic stroke is often
treated with baclofen, tizanidine, diazepam, and dantrolene.
III.25. Which of the following conditions is a symptom of autonomic
dysreflexia after spinal cord injury?
a. Bradycardia
b. Hypotension
c. Hypothermia
d. Sweating below the level of the spinal cord injury
e. Diarrhea
III.25. Answer a.
Autonomic dysreflexia affects patients who have an injury
at T6 or above. This results in an uninhibited sympathetic
response to noxious stimuli. Symptoms typically include
headache, blood pressure higher than baseline, diaphore-
sis, facial flushing, pupillary dilatation, and bradycardia.
III.26. Which of the following statements best describes constraint-
induced movement therapy used for patients with ischemic
stroke?
a. Tactile stimulation is used to facilitate muscle movements
b. The unaffected limb is restrained, forcing the patient to use the
affected limb
c. Resistance provided by stronger muscles is used to facilitate the
weaker components of the same motion pattern
d. Patient is initially constrained to bed for 2 weeks to allow the
brain to rest before initiation of intense therapy
e. Transcranial magnetic stimulation is used in combination with
constraining movement for intermittent periods
III.26. Answer b.
Constraint-induced movement therapy involves restraint of
the unaffected limb, effectively forcing the use of the
affected limb in intensive motor shaping and repetitive task
practice directed by a clinician.
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