Stroke High Yield self assessment-SAQS

🧠 Comprehensive Stroke – ACEM Specialist Self-Assessment (25 SAQs)

Ischaemic, haemorrhagic, unknown onset, ESUS, CHA2DS2-VASc, lysis/EVT selection, CT perfusion, BP targets, reversal & sICH management.

Q1. List key clinical features and the initial approach for suspected acute stroke.

Reveal Answer
  • Abrupt focal deficit (face/arm weakness, aphasia/neglect, visual field loss, ataxia, dysarthria, diplopia)
  • ABC stabilisation, glucose, IV access, ECG/monitor, focussed NIHSS
  • Immediate imaging pathway: NCCT → CTA (± CTP by protocol)
  • Parallel eligibility screen for IVT/EVT; avoid hypoxia/hypotension; targeted BP control

Q2. What are the Dominant-hemisphere MCA syndrome hallmarks.

Reveal Answer
  • Contralateral face/arm > leg weakness ± sensory loss
  • Aphasia (Broca/Wernicke/global), apraxia
  • Gaze preference to lesion; contralateral homonymous field deficit

Q3. What is non-dominant (right) MCA syndrome

Reveal Answer
  • Contralateral face/arm > leg weakness ± sensory loss
  • Hemispatial neglect, anosognosia, constructional apraxia
  • Gaze preference to lesion; visual field deficit

Q4. Summarise cardinal features of PICA (lateral medullary/Wallenberg) syndrome.

Reveal Answer
  • Vertigo, nystagmus, ipsilateral limb/gait ataxia
  • Dysphagia/hoarseness (nucleus ambiguus), ipsilateral Horner
  • Loss of pain/temp: ipsilateral face + contralateral body (“crossed signs”)

Q5. What clinical signs Differentiate ACA versus PCA stroke

Reveal Answer
  • ACA: leg-predominant weakness/apraxia, abulia, grasp reflex
  • PCA: homonymous hemianopia, alexia without agraphia, thalamic sensory syndromes

Q6. for Acute Stroke in the ED? .

Reveal Answer
  • Non-Con CT to exclude haemorrhage/assess early ischaemic change
  • CTA head/neck for LVO detection and EVT planning
  • CTPerfusion when time-indeterminate or beyond early window to define core/penumbra

Q7. Define CT perfusion “core” and “penumbra” with commonly used thresholds and clinical utility.

Reveal Answer
  • Core: irreversibly injured tissue (e.g., rCBF < ~30% of contralateral)
  • Penumbra: hypoperfused salvageable tissue (e.g., Tmax > ~6 s minus core)
  • Guides IVT/EVT beyond time criteria; balances benefit vs haemorrhagic risk

Q8. List eligibility for IV thrombolysis

Reveal Answer
  • Disabling focal deficit; age ≥18; LKW/onset ≤4.5 h
  • NCCT: no haemorrhage/large established infarct
  • BP reducible to ≤185/110 mmHg before bolus

Q9. List major absolute exclusion criteria for IV thrombolysis in the ED context.

Reveal Answer
  • Intracranial haemorrhage; recent major head trauma/IC surgery
  • Active bleeding/severe coagulopathy; recent DOAC without reversal/levels
  • Refractory severe hypertension despite therapy

Q10. Outline imaging-based selection for unknown-onset/wake-up stroke and late IVT.

Reveal Answer
  • MRI DWI–FLAIR mismatch → IVT candidate
  • CTP/MRP core–penumbra mismatch → extended IVT window per protocol

Q11. State BP targets around thrombolysis and early post-lysis care.

Reveal Answer
  • Pre-lysis: ≤185/110 mmHg
  • Post-lysis (0–24 h): ≤180/105 mmHg; frequent neuro/BP checks; defer antithrombotics until post-lysis scan

Q12. Summarise early-window Endovascular Thrombectomy(EVT) (0–6 h) selection for anterior-circulation LVO.

Reveal Answer
  • LVO on CTA (ICA/M1 ± proximal M2)
  • Disabling deficit (e.g., NIHSS ≥ ~6)
  • No very large established core (ASPECTS reasonably preserved)

Q13. Summarise late-window EVT (6–24 h) selection and contemporary evidence for Large core infarcts.

Reveal Answer
  • Clinical-core mismatch (severe deficit, small core) and/or perfusion-core mismatch
  • Trials support EVT benefit even with “large core” (low ASPECTS/high rCBF-defined core) in selected patients

Q14. Interpret ASPECTS scoring and its role in stroke assessment and management.

Reveal Answer
  • 10-point MCA CT score of early ischaemic change (higher = smaller core)
  • Complements CTA and CT Perfusion for IV Lysis and Thrombectomy decisions; very low scores suggest extensive core

Q15. Outline the recognition and reperfusion strategies for suspected basilar-artery occlusion.

Reveal Answer
  • Coma/fluctuating consciousness, quadriparesis, cranial neuropathies, severe ataxia
  • NCCT → CTA head/neck; consider CTP/MRP where available
  • IVT if eligible; expedite EVT if LVO confirmed

Q16. Specify the BP strategy when no immediate reperfusion is planned (ischaemic stroke).

Reveal Answer
  • Permissive hypertension (often up to ~220/120 mmHg for 24–48 h)
  • Avoid rapid reductions unless compelling indications (e.g., aortic dissection, hypertensive emergency)

Q17. What is the nitial management of Intracranial Haemorrhage?(ICH).

Reveal Answer
  • Airway protection as required; reverse coagulopathy immediately
  • Early BP control to limit expansion; analgesia/sedation; head up 30°
  • NCCT ± CTA “spot sign”; neurocritical care and neurosurgical involvement

Q18. State BP targets and monitoring priorities in spontaneous ICH.

Reveal Answer
  • Prompt SBP lowering (commonly to ~140–160 mmHg if presenting SBP very high)
  • Continuous BP/neurological observation; avoid hypotension

Q19. Outline anticoagulant reversal approaches in ICH, with resoect to the following: (warfarin, dabigatran, factor-Xa inhibitors).

Reveal Answer
  • Warfarin: 4-factor PCC + IV vitamin K
  • Dabigatran: idarucizumab; consider dialysis if needed
  • Apixaban/rivaroxaban: andexanet alfa (if available) or PCC per protocol

Q20. Define ESUS(Embolic Stroke of Unknown source) and outline your diagnostic work-up .

Reveal Answer
  • Non-lacunar Acute Ischaemic Stroke with no major-artery stenosis or clear cardioembolic source
  • Imaging: CTA head/neck; telemetry ± prolonged rhythm monitoring; TTE/TEE as indicated

Q21. List CHA2DS2-VASc components and the relevance to secondary prevention.

Reveal Answer
  • CHF (1), HTN (1), Age ≥75 (2), DM (1), Stroke/TIA/TE (2), Vascular dz (1), Age 65–74 (1), Sex female (1)
  • Guides anticoagulation decisions in AF-related secondary prevention

Q22. What is the Recommended anticoagulation timing after AF-related Acute Ischaemic Stroke?.

Reveal Answer
  • Minor infarct: restart within a few days (post-imaging)
  • Moderate: ~6–7 days
  • Large: ~12–14 days; individualise per imaging/haemorrhagic risk

Q23. What is the Indication for DAPT after minor non-cardioembolic stroke/TIA and typical duration of treatment?.

Reveal Answer
  • Minor stroke/high-risk TIA when IVT not given
  • Short course (≈21 days), then single antiplatelet therapy

Q24. Describe your management of symptomatic intracranial haemorrhage (sICH) after IV thrombolysis.

Reveal Answer
  • Recognise deterioration → stop lytic immediately
  • Urgent NCCT; labs (CBC, PT/INR, aPTT, fibrinogen)
  • Reversal/support: cryoprecipitate to fibrinogen >150–200 mg/dL; consider antifibrinolytic (per local protocol)
  • BP control, ICP measures, neurocritical-care/neurosurgical consult
  • Avoid routine platelet transfusion post-lysis unless specific indication

Q25. List CT perfusion pitfalls that can misclassify core/penumbra and strategies to mitigate.

Reveal Answer
  • Motion/contrast timing artefacts → repeat/run QA, stabilise IV access
  • Contralateral carotid disease skewing reference → correlate with CTA/clinical
  • Ultra-early presentations overestimate core → integrate ASPECTS, serial imaging
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