Cerebrovascular Diseases



Cerebrovascular Diseases







Questions



1. A 64-year-old man with a history of hypertension, hypercholesterolemia, and distant stroke with residual right-arm weakness presents to your office for evaluation of recurrent episodes of painless left monocular vision loss. He describes the episodes as sudden, painless, and lasting for minutes and brought on by exposure to bright light. He denies headaches and other focal sensory or motor disturbances. Which of the following is the most likely cause?


A. Basilar occlusion with cortical blindness

B. Cardioembolism

C. Large artery atherosclerotic disease

D. Small vessel disease and associated retinopathy

E. Vasculitis of the small and medium cerebral vessels

View Answer

1. Answer C. (MN-37) Amaurosis fugax, or transient central retinal artery occlusion, usually results from cholesterol or thrombotic embolism from ipsilateral carotid atherosclerotic plaque. When the lumen of the carotid artery is nearly occluded, transient attacks can also be due to retinal hypoperfusion, clinically manifesting as vision loss with exposure to bright light. Cardioembolism would be less likely to cause recurrent stereotyped episodes as emboli would have to go to the same artery. Small vessel disease and associated retinopathy is chronic and progressive. Basilar occlusion would be associated with other focal findings and would not follow the chronicity described. Although primary or secondary (giant cell arteritis) can cause vision loss, one would expect painful vision loss in addition to other neurological sequelae such as headaches, jaw claudication, or cognitive disturbance.



2. Which of the following is the patient most likely to develop next?


A. Bilateral occipital lobe infarction

B. Bilateral vision loss

C. Carotid dissection

D. Infarction in the territory of the left middle cerebral artery

E. Intracerebral hemorrhage

View Answer

2. Answer D. (MN-36) High-grade carotid stenosis significantly increases risk of an ipsilateral hemispheric infarct (Table 4.2.1). Pathophysiology of the stroke is either artery-to-artery embolism or typical border-zone territory infarcts related to regional cerebral hypoperfusion. Occipital lobe infarcts, which can cause cortical blindness typically do not result from carotid artery atherosclerotic disease. There are people with an anatomic variant in which the internal carotid artery feeds the ipsilateral posterior cerebral artery via the posterior communicating artery (eg, fetal posterior cerebral artery), but in this case the infarct should be ipsilateral to the atherosclerotic plaque and not bilateral. Carotid dissection and bilateral vision loss are not associated with severe unilateral carotid stenosis.










3. A 34-year-old woman with a history of migraine, who is on oral contraceptives and also smokes one pack of cigarettes per day, develops sudden speech difficulty while at work. On initial examination in the emergency department, she is noted to have slurred speech, thus neurology is called. Which of the following are the next best steps?


A. Give her aspirin

B. Schedule MRI of her brain to better ascertain etiology of her symptoms

C. Send for immediate CT imaging of the head

D. Trial intravenous metoclopramide and ketorolac to see if symptoms resolve with migraine medication

E. Watch her for 30 minutes to see if she develops her typical migraine symptoms

View Answer

3. Answer C. (MN-36) Stroke should be the top consideration whenever encountering a person with acute onset of a focal neurological deficit, including aphasia and/or dysarthria and should prompt immediate activation of a stroke alert and CT imaging of the head to better ascertain the etiology of the patient’s neurological deficits. Any delay in treatment results in worsened prognosis. Complicated migraine, even in someone with a history of migraines, should be considered a diagnosis of exclusion. Aspirin is never advised in this situation because of the possibility of worsening an intracerebral hemorrhage. MRI imaging, although likely useful in this case, should not be performed in the hyperacute setting as it would delay initiation of potential acute stroke treatment such as tPA or mechanical thrombectomy. Imaging must be performed prior to administration of antiplatelet agents.




4. As a neurologist, you are helping to redesign your institution’s protocol for acute stroke management. With regards to the design of the emergency department’s triage of acute stroke alerts, which of the following is most important to keep in mind?


A. An EMS prenotification phone line should be placed in triage

B. The clinical area should be between triage and CT, to ensure that the patient can be quickly evaluated before imaging

C. The CT scan should be easily accessible from the triage area

D. The interventional suite should be easily accessible from the emergency room triage area

E. All of the above

View Answer

4. Answer E. (MN-36) The imaging suite should be close to triage to ensure that imaging can be done quickly. Imaging, usually with CT, is required prior to treatment with intravenous thrombolysis. Access to the imaging and interventional suites can improve the acute stroke process and helps expedite treatment. EMS prenotification is an important component of the acute stroke process.



5. A 44-year-old business executive with no known medical problems is brought to a community hospital emergency room after being found unresponsive. She was last seen normal 1 hour prior to arrival by her husband who says that she suddenly developed vertigo, started to vomit, and had difficulty walking. He called 911 immediately. In the field, her examination was notable for slurred speech, dysconjugate gaze, and weakness of the arms and legs. At the time of ED arrival her blood pressure was 182/90 mm Hg. Respirations were labored, and she had an absent gag reflex. She did not follow any commands other than to look up and had flaccid paralysis in all limbs. Initial noncontrast head CT was unremarkable, and she was intubated for airway protection. This hospital does not have advanced stroke treatment capabilities. Which of the following is the best next step in the emergent care of this patient?


A. Begin IV nicardipine to lower systolic BP to <140 mm Hg

B. Order a stat MRI

C. Order a toxicology screen

D. Perform a lumbar puncture

E. Return to CT and perform a CT angiogram as quickly as possible, while notifying pharmacy that TPA may be needed urgently

View Answer

5. Answer E. (MN-36) The patient has locked-in syndrome concerning for basilar occlusion and presents within the window for IV thrombolysis. CT angiography should be done to visualize the basilar occlusion, which if confirmed should trigger an emergency angiogram either on-site or via emergency transfer. Obtaining a toxicology screen will not address the primary diagnostic consideration at hand. Persons presenting with acute ischemic stroke should be allowed permissive hypertension to levels up to 220 mm Hg as long as there is no evidence of active hypertensive end-organ damage. Lumbar puncture would not be appropriate unless a basilar artery occlusion has been ruled out. While MRI may be helpful in visualizing the ischemic territory, it will delay treatment with thrombolysis and mechanical thrombectomy, leading to a less favorable outcome.



6. She is suspected of having a large vessel occlusion of the basilar artery. Which of the following outcomes is most likely to be positively affected by timely mechanical thrombectomy?


A. Functional disability such as difficulty walking, bathing, or eating at 3 months

B. Hospital mortality

C. Poststroke depression at 3 months

D. Recurrent embolic stroke within 3 months

E. Risk of subsequent cardiac ischemic events

View Answer

6. Answer A. (MN-36) Mechanical thrombectomy improves in-hospital neurological dysfunction and long-term disability and is associated with increased risk of intracranial hemorrhage. Of note, a recent meta-analysis of the BASICS and BEST trials (thrombectomy for basilar artery occlusions) showed improved higher 90-day functional outcome with mechanical thrombectomy (Solla DJF, Stroke Vasc Neuro. 2021). There are no data showing that thrombectomy of basilar artery occlusions improves poststroke depression, recurrent stroke risk, subsequent cardiac ischemic events, or hospital mortality.




7. A 38-year-old right-handed man is brought to his local emergency room after he was witnessed to suddenly develop slurred speech and left-sided weakness. Initial evaluation reveals forced right gaze deviation, profound left neglect, and dense left hemiparesis. Noncontrast CT is unremarkable, and he is treated with intravenous thrombolysis. CT angiography confirms that he has an occlusion of the main trunk of the right middle cerebral artery, and he is transferred by helicopter to the closest thrombectomy capable medical center. Thrombectomy is eventually performed, but the subsequent CT shows a large area of early infarction. Repeat head CT at 24 hours shows progression of infarction with cerebral edema and mass effect, midline shift, and early radiographic evidence of uncal and subfalcine herniation. Which of the following is the next best step in his neurological management?


A. He does not require further treatment because his nondominant hemisphere is affected

B. Initiate corticosteroids to prevent further cerebral edema

C. Request a family meeting to discuss prognosis and treatment options

D. Request neurosurgical consultation for hemicraniectomy evaluation

E. Choices C and D

View Answer

7. Answer E. (MN-36) Despite maximal treatment of his stroke, the patient described has early evidence of malignant MCA infarction resulting in cerebral edema. The definitive treatment to prevent herniation and mortality is prophylactic hemicraniectomy performed within 48 hours of stroke onset. The risks, benefits, and alternatives of surgery as well as the expected neurological prognosis should be discussed with family members prior to surgery. Stroke laterality should not affect the treatment options. While medical therapies can be used as a bridge to decompressive surgery, the use of corticosteroids is not recommended.



8. A 70-year-old man presents to the emergency department after an episode of left-sided hemiplegia that lasted for 10 minutes. He is now asymptomatic. The patient has a history of type 2 diabetes mellitus and hypertension and takes metformin and lisinopril at home. His physical examination is notable for a blood pressure of 160/76 mm Hg, pulse rate of 86/min and regular, and respiration rate of 12/min. No carotid bruits are heard. There is no evidence of any heart murmurs. The remainder of the physical examination is normal. Electrocardiogram shows normal sinus rhythm. CT head shows no signs of an acute infarct.

Which of the following is the most appropriate initial test?


A. EEG

B. Erythrocyte sedimentation rate

C. Hypercoagulability workup

D. Transesophageal echocardiography

E. Vessel imaging with CT angiogram or carotid duplex ultrasonography

View Answer

8. Answer E. (MN-37) The patient had a TIA and is at increased risk of subsequent ischemic stroke. The presence of symptomatic extracranial internal carotid artery stenosis or intracranial vessel stenosis is associated with an increased risk of recurrent ischemia. Given the presence of vascular risk factors and elevated BP, seizure is fairly low on the differential at this point so EEG would not be the most appropriate next step. A transesophageal echocardiography is unlikely to immediately affect management and generally follows performance of a transthoracic echocardiogram. Erythrocyte sedimentation rate is not routinely recommended and should be checked in patients with symptoms concerning for temporal arteritis or infective endocarditis. Similarly, a hypercoagulability workup is unlikely to be needed in an elderly patient with vascular risk factors.



9. A 68-year-old woman is hospitalized after a transient 30-minute episode of right-sided hemiparesis and difficulty speaking. Her physical examination is notable for blood pressure of 132/76 mm Hg, a pulse rate of 76/min and regular, and respiration rate of 12/min. Her neurological examination is completely normal. Her electrocardiogram shows sinus rhythm, head CT shows no acute infarct, CT angiogram of the head and neck shows patent internal carotid arteries and 90% stenosis of the left middle cerebral artery, serum LDL cholesterol level is 120 mg/dL, and her hemoglobin A1c value is 6.2%. The patient is started on an antiplatelet agent.

Which of the following is the most appropriate next step in treatment?


A. Initiate anticoagulation with warfarin

B. Initiate antihypertensive medications, such as ACE inhibitor

C. Initiate high-dose statin

D. Intracranial stenting

E. Perform MRI brain to better clarify diagnosis

View Answer

9. Answer C. (MN-37 and MN-45) The new statin guidelines published by the American Heart Association and the American College of Cardiology in 2013 shifted the focus away from specific low-density lipoprotein cholesterol (LDL-C) targets and onto treatment with high- or moderate-intensity statins. The use of high-intensity atorvastatin for secondary stroke prevention is associated with a reduced long-term risk of ischemic stroke. As a result, statins are recommended as part of the standardized hospital discharge orders after an ischemic stroke or TIA. In the Stenting versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study, patients with symptomatic intracranial atherosclerotic disease who underwent stenting of the stenosis had nearly twofold increased risk of stroke when compared with the best medical therapy. Based on the results of this trial, stenting is not routinely recommended for first-line therapy in patients with intracranial atherosclerosis. In a study comparing warfarin with aspirin for symptomatic intracranial arterial stenosis, warfarin had an increased risk of major hemorrhage and death with no added benefit. Therefore, warfarin has not shown to be beneficial over aspirin for treatment of intracranial atherosclerosis. Current guidelines recommend initiating blood pressure therapy for patients with blood pressure above 140/90 mm Hg several days after stroke onset. Since the patient’s blood pressure is within the goal range of less than 140/90 mm Hg, there is no indication to start a blood pressure medication at this time.




10. A 75-year-old right-handed man presents to the emergency department after a 30-minute episode of difficulty speaking this morning. He also reports experiencing transient loss of vision in his left eye the prior evening. Physical examination is notable for blood pressure of 168/90, a pulse rate of 76/min and regular, and respiration rate of 12/min. His neurological examination is completely normal with no aphasia. Workup reveals 70% to 80% left internal carotid artery stenosis. Electrocardiogram shows normal sinus rhythm.

What is the most appropriate and important next step in management?


A. Anticoagulation

B. Carotid revascularization

C. Initiation of a blood pressure lowering medication for aggressive BP reduction

D. Intravenous thrombolysis

E. Place Holter monitor to evaluate for occult atrial fibrillation

View Answer

10. Answer B. (MN-37 and MN-45) Patient’s presentation of two attacks within 24 hours is consistent with crescendo TIAs, most likely from the symptomatic ipsilateral carotid artery stenosis. Pooled analysis of major randomized trials of medical versus surgical management of symptomatic carotid artery stenosis has shown that carotid revascularization was beneficial over medical therapy for 70% to 99% stenosis. In such cases, data support carotid endarterectomy. Carotid artery stenting can be considered as an alternative in patients with surgically inaccessible lesions or radiation-induced stenosis or in high-surgical-risk patients. Performing carotid endarterectomy within 2 weeks of the last ischemic event is associated with a 30.2% reduction in absolute risk of subsequent stroke. Although the patient would benefit from long-term blood pressure control, excessive blood pressure lowering in the acute setting can sometimes worsen cerebral ischemia. In this case, the patient does not have any comorbidities that require emergent lowering of blood pressure and it is reasonable to maintain blood pressure <220/120 mm Hg for the time being. As discussed earlier, surgical intervention is superior to medical therapy, including anticoagulation, in patients with severe symptomatic carotid artery stenosis. Since the patient has no current neurological deficits, there is no indication for intravenous thrombolysis. The patient already has a likely mechanism for his TIA; thus, further workup for occult atrial fibrillation is not needed.



11. A 65-year-old woman with a history of diabetes is hospitalized after a transient 20-minute episode of left-sided hemiparesis. Her physical examination is notable for blood pressure of 155/95 mm Hg and a pulse rate of 76/min, her electrocardiogram shows sinus rhythm, and CT head shows no acute infarct. What is the patient’s ABCD2 score?


A. Two

B. Three

C. Four

D. Five

E. Six

View Answer

11. Answer E. (MN-37) The patient’s age, history of diabetes, duration of symptoms, presence of motor weakness, and blood pressure on admission earn her points for the ABCD2 score (Table 4.11.1). The ABCD2 score predicts short-term stroke risk after a TIA (Table 4.11.2).

















12. Which of the following statements is correct regarding the diagnostic tests used in evaluating a patient with a recent transient ischemic attack (TIA)?


A. All patients with TIA should undergo evaluation for a patent foramen ovale

B. All patients with TIA should undergo routine screening for antiphospholipid syndrome

C. Digital subtraction angiography is the recommended first step in evaluating for carotid artery stenosis

D. Performing long-term portable cardiac rhythm monitoring is reasonable

E. Choices A and D

View Answer

12. Answer D. (MN-37) Patients with TIAs require urgent evaluation due to the high risk of subsequent ischemic stroke. The initial evaluation includes brain and vascular imaging, identification of vascular risk factors, and cardiac evaluation. A possible cardiac source should be considered in all patients with an embolic event, and cardiac monitoring during the acute hospitalization is essential for diagnosing occult atrial fibrillation. Extended screening for paroxysmal atrial fibrillation using long-term portable cardiac rhythm monitoring is reasonable in patients with no other established cause of stroke or TIA.

Symptomatic large vessel disease, such as carotid artery stenosis, should be evaluated using noninvasive measures prior to considering invasive measures. In such cases, noninvasive testing with carotid duplex ultrasonography, CT angiography, and MR angiography is done before more invasive testing with digital subtraction angiography is considered. All patients with TIA are required to undergo basic laboratory testing to identify any possible stroke etiologies. However, testing for hypercoagulable conditions, such as antiphospholipid syndrome, is not routinely recommended and should only be considered in select patient populations. Similarly, testing for the presence of patent foramen ovale is not routinely done. Patent foramen ovale can cause ischemic stroke through paradoxical embolism and is more commonly associated with strokes in young people with no other established stroke etiology or risk factors. Such cases may warrant testing for the presence of a patent foramen ovale.



13. A 65-year-old woman admitted for urosepsis went into asystole. After two rounds of cardiopulmonary resuscitation and epinephrine there was the return of spontaneous circulation. She is now on two pressors to maintain mean arterial pressure >65 mm Hg. The team would like your opinion on her eligibility for therapeutic hypothermia (TH).


A. Consider cooling to 36 °C instead of 33 °C, due to hemodynamic instability requiring more than two vasopressors

B. She should be cooled to 33 °C, as she does not have either severe and recurrent symptomatic bradycardia requiring pacing or bleeding at a noncompressible site

C. Targeted temperature management is not needed given that the patient had a nonshockable rhythm at onset

D. TH is not recommended in patients with quick return of spontaneous circulation

E. TH is not recommended in this case due to severe systemic infection and/or sepsis

View Answer

13. Answer A. (MN-38) Targeted temperature management, including TH (33°-36 °C), is recommended after cardiac arrest, regardless of initial rhythm, if the patient does not return to neurological baseline. The patient has sepsis, which is considered to be a relative contraindication for TH to 33 °C. Severe and recurrent symptomatic bradycardia requiring pacing or bleeding at a noncompressible site are the only two absolute contraindications for TH to 33 °C. The high vasopressor requirement makes her a better candidate for TH to 36 °C as hypothermia may worsen hemodynamic instability.




14. A 66-year-old man is brought into emergency medicine after a witnessed cardiac arrest at home, preceding which he had complained of chest pain and shortness of breath. He received four rounds of CPR, resuscitation meds, and three rounds of shocks administered by the paramedics following which there was return of spontaneous circulation. Approximately 6 hours after the initiation of therapeutic hypothermia, the patient started to exhibit continuous multifocal myoclonus and an urgent EEG performed showed epileptiform activity. What would be the next best step?


A. Better characterization of the seizures by using paralytics to suppress muscle artifact is necessary before initiating an antiepileptic regimen

B. Discontinue targeted temperature management as this could worsen the myoclonus

C. Discuss with the family about withdrawing all life-sustaining treatment as guidelines are clear that patients with myoclonic status epilepticus within the first day after a primary circulatory arrest have a poor prognosis

D. Make no changes to the overall treatment plan as myoclonus is common after cardiac arrest and does not require treatment other than a muscle relaxant such as baclofen

E. Myoclonic status epilepticus does not always portend a poor outcome; initiate institutional status epilepticus protocol and treat aggressively

View Answer

14. Answer E. (MN-38) Although postarrest myoclonus has traditionally been thought to signal no hope of neurological recovery, more recent data in patients treated with targeted temperature management indicate that up to 10% may recover consciousness and have a good functional outcome. In this case, the patient should be receiving aggressive management of his seizures and myoclonus. In no circumstances is withdrawal of life-sustaining treatment while the patient is receiving targeted temperature management prudent. Moreover, the advent of postarrest myoclonus should not delay initiation of targeted temperature management. Temporary use of paralytics can be done to eliminate muscle artifact on EEG, but care should be taken that the patient remains sedated throughout.



15. A 58-year-old man had a witnessed out-of-hospital cardiac arrest, with the return of spontaneous circulation achieved after 22 minutes of ACLS. Therapeutic hypothermia (TH) was initiated. The neurological examination was significant for absent brain stem reflexes, and hemodynamics were stable. The primary team would like you to do an initial consult on neuroprognostication.


A. Diffusion-weighted imaging sequence of the MRI obtained within 24 hours is the most sensitive and specific modality for prognostication and should be recommended in this case

B. Lack of brain stem reflexes is a definite sign of poor prognosis, and the family should be updated tonight about the withdrawal of life-sustaining treatment as a final recommendation

C. Neuroprognostication should be delayed for at least 5 to 7 days after the cardiac arrest event, as the standard modalities for assessing prognosis might be influenced by the use of TH and examination off sedation is of paramount importance

D. Somatosensory evoked potentials are not affected by TH or sedation, so that should be scheduled the next day and be utilized for accurate neuroprognostication

View Answer

15. Answer C. (MN-38) TH can influence the metabolism of sedatives and paralytics and also make the modalities of neuroprognostication (neurological examination, EEG background, and reactivity, somatosensory evoked potentials) less sensitive. Guidelines have recommended delaying assessment for prognostication until at least 72 hours after normothermia achieved and until all sedation has been appropriately metabolized. DWI lesion burden on MRI performed after day 5 has shown to be specific but not sensitive for poor outcomes. Clinicians should use a multimodal approach to prognosticate for individual patients.



16. The following pathological abnormality in adults is associated with lobar ICH:


A. β-Amyloid protein deposition

B. Fasting hypoglycemia <80 mg/dL

C. Fever >38.3 °C

D. High LDL-cholesterol

E. Neutropenia (absolute neutrophil count <1,500)

View Answer

16. Answer A. (MN-39) Cerebral amyloid angiopathy (CAA) is characterized by the deposition of β-amyloid protein in small- to medium-sized blood vessels of the brain and leptomeninges, which may undergo fibrinoid necrosis. It can occur as a sporadic disorder, in association with Alzheimer disease, or with certain familial syndromes. Neutropenia is not considered a risk factor for lobar ICH. Hypercholesterolemia is a known risk factor for stroke and may be a contributing factor for the development of lipohyalinosis and small vessel disease (SVD). Hypoglycemia is not a risk factor for lobar ICH; however, uncontrolled diabetes mellitus and hyperglycemia can increase the risk of thrombolysis-associated ICH. Fever is not considered a risk factor for lobar ICH.




17. Which of the following is the most treatable modifiable risk factor for ICH?


A. Chronic hypertension

B. Chronic obstructive pulmonary disease (COPD)

C. Diabetes mellitus

D. Dyslipidemia

E. Male gender

View Answer

17. Answer A. (MN-39) Hypertension is the strongest modifiable risk factor of incident ICH (Table 4.17.1). Studies have shown that noncompliance with antihypertensive medications increases the risk of ICH, and control of blood pressure has been shown to reduce this risk. Chronic hypertension causes a small vessel vasculopathy termed lipohyalinosis. Diabetes mellitus and dyslipidemia are modifiable risk factors for stroke in general and could potentially lead to the development of small vessel disease. Gender is not a modifiable risk factor for stroke.










18. Which of the following is one of the most significant risk factors for early neurological deterioration due to hematoma expansion?


A. A brief interval from symptom onset to initial CT scanning

B. Fever >38.3 °C

C. Glasgow coma scale score <8 at onset

D. Hyperglycemia

E. Presence of cerebral microbleeds on MRI

View Answer

18. Answer A. (MN-39) The most significant risk factor for hematoma expansion and neurological deterioration is the timing from ictus to initial CT imaging. Fever and hyperglycemia are physiological derangements that can produce neurological deterioration after ICH. Cerebral microbleeds are not considered risk factors for early clinical deterioration after ICH. However, the presence of cerebral microbleeds may increase the risk of thrombolysis-associated ICH.



19. Which of the following is the most widely accepted indication for surgical evacuation of ICH?


A. Cerebellar hematoma >3 cm in diameter

B. Lobar hematoma <3 cm in diameter

C. Lobar hematoma >60 mL in volume with herniation

D. Pontine hematoma in the comatose patient

E. Thalamic hematoma in the stuporous patient

View Answer

19. Answer A. (MN-39) Prior clinical trials have failed to show a superiority of hematoma evacuation over medical therapy for supratentorial ICH in both patients with hematoma >2 cm in diameter and GCS ≥ 5 (STICH-I) or in conscious patients with superficial lobar ICH 10 to 100 mL without IVH (STICH-II). The only widely accepted indication, for which there is no clinical trial data, is a cerebellar hematoma >3 cm in diameter. The recent ENRICH trial suggests that minimally-invasive surgical evacuation of lobar hemorrhages between 30 and 80 mL is beneficial.



20. In a patient with coagulopathic lobar ICH from apixaban, which intervention would be most suitable?


A. Careful control of systolic blood pressure to a level ≤180 mm Hg

B. Platelet transfusion

C. Reversal with Andexanet alfa

D. Targeted temperature management

E. Tranexamic acid

View Answer

20. Answer C. (MN-39) The newer direct oral anticoagulant (DOAC) agents that inhibit thrombin or factor Xa, such as dabigatran, rivaroxaban, and apixaban, are increasingly being offered on the basis of superior safety data. The ANNEXA-4 clinical trial led to the FDA approval of Andexanet alfa as the only specific reversal option for apixaban, rivaroxaban, and edoxaban (Table 4.20.1). Andexanet alfa is a decoy protein that binds to circulating factor Xa inhibitors, thus freeing native active factor Xa to stimulate thrombosis and fibrin clot formation at the site of bleeding. Targeted temperature management (TTM), platelet transfusion, blood pressure control, or antifibrinolytic such as tranexamic acid would not have any biological impact on the mechanism of action of factor Xa inhibitors.










21. A 65-year-old woman presents with a 40 mL putaminal ICH. She is intubated, and an arterial line is inserted. Blood pressure is 220/125 mm Hg. Which IV agent would be least appropriate to lower the blood pressure?


A. Clevidipine

B. Labetalol

C. Nicardipine

D. Sodium nitroprusside

E. Choices A and C

View Answer

21. Answer D. (MN-39) Given the need to precisely control BP levels in the setting of impaired autoregulation, use of fast-acting continuous infusion agents with intra-arterial monitoring is recommended. Preferred agents are β-blockers (intravenous [IV] labetalol) and calcium channel blockers (nicardipine and clevidipine) (Table 4.21.1). Use of nitroprusside has drawbacks because this agent is associated with an unreliable dose-response relationship and may exacerbate cerebral edema and increased intracranial pressure.










22. For the patient above, which systolic BP target would be least suitable based on randomized controlled trials?


A. SBP <120 mm Hg

B. SBP <140 mm Hg

C. SBP <160 mm Hg

D. SBP <180 mm Hg

E. All of the above targets are safe and acceptable

View Answer

22. Answer A. (MN-39) The ATACH-2 clinical trial, which compared a systolic BP target of <180 with <140 mm Hg, demonstrated that lowering of SBP < 140 mm Hg was associated with a higher proportion of serious adverse events, especially renal complications, particularly if SBP fell below 120 mm Hg.




23. A 34-year-old woman presents to the emergency department complaining of “the worst headache of my life.” She has a history of polycystic kidney disease. At home after calling 911 she temporarily lost consciousness. Her neurological examination is notable for nuchal rigidity, disorientation to time of day, and inattention as evidenced by poor performance on counting backward from 20 to 1. GCS is Eyes 3 (open to voice), Motor 6 (follows commands), and Verbal 4 (conversant but not fully oriented). CT shows SAH with bilateral ventricular hemorrhage. What is her Hunt-Hess grade?


A. I

B. II

C. III

D. IV

E. V

View Answer

23. Answer C. (MN-40) Hunt-Hess grade III, which describes a state of lethargy or confusion. Grade I is mild to moderate headache, grade II is severe headache or the presence of an isolated cranial nerve deficit (ie, CN 3 palsy), and in both cases mental status is completely normal (Table 4.23.1). Grade IV is stupor (best motor or verbal response requires painful stimulation), and grade V is coma GCS not in HH scale.










24. Head CT scan shows a small amount of thin SAH in the basal cisterns and a moderate amount of intraventricular hemorrhage (IVH) in the lateral and third ventricles, with moderate hydrocephalus. What is her modified Fisher score?


A. 0

B. I

C. II

D. III

E. IV

View Answer

24. Answer C. (MN-40) The modified Fisher scale evaluates the extent of hemorrhage on CT and predicts the risk of developing delayed cerebral ischemia (DCI) from vasospasm (Table 4.24.1). Grade II corresponds to thin cisternal SAH with bilateral IVH and a 20% risk of developing DCI. Grade 0 is no SAH or IVH and implies no risk of DCI. Grade I describes only thin cisternal blood without bilateral IVH and corresponds to a 10% risk of developing DCI. Grade III is cisternal SAH in at least one cistern or fissure without bilateral IVH and implies a 20% risk of DCI. Grade IV describes thick cisternal SAH and bilateral IVH and is associated with a 40% risk of DCI (Claassen et al. Stroke. 2001;32:2012-2020).