MCQ Quiz: Stroke

Stroke is a medical emergency that occurs when blood flow to the brain is interrupted, either by a blockage (ischemic stroke) or a rupture of a blood vessel (hemorrhagic stroke). Time is critical in stroke management, as rapid intervention can significantly improve outcomes and reduce long-term disability. For PharmD students, understanding the complex pharmacotherapy involved in stroke care is essential. This includes mastering the use of fibrinolytics like alteplase in acute ischemic stroke, managing blood pressure in both ischemic and hemorrhagic events, and implementing effective strategies for primary and secondary prevention. This quiz will test your knowledge on the diagnosis, acute management, and preventative pharmacotherapy for various types of stroke.

1. Which of the following is the most common type of stroke?

• a) Hemorrhagic Stroke
• b) Ischemic Stroke
• c) Transient Ischemic Attack (TIA)
• d) Subarachnoid Hemorrhage

Answer: b) Ischemic Stroke

2. The acronym FAST is used to help recognize the signs of a stroke. What does the “A” stand for?

• a) Agitation
• b) Arm weakness
• c) Alertness
• d) Aphasia

Answer: b) Arm weakness

3. What is the primary purpose of obtaining a non-contrast computed tomography (CT) scan of the head in a patient with acute stroke symptoms?

• a) To determine the size of the ischemic core.
• b) To rule out a hemorrhagic stroke before considering fibrinolytic therapy.
• c) To visualize the blood vessels in the brain.
• d) To measure the patient’s intracranial pressure.

Answer: b) To rule out a hemorrhagic stroke before considering fibrinolytic therapy.

4. Alteplase (tPA) is a fibrinolytic agent used in acute ischemic stroke. What is its mechanism of action?

• a) It inhibits platelet aggregation.
• b) It directly dissolves the fibrin clot.
• c) It converts plasminogen to plasmin, which then degrades the fibrin clot.
• d) It inactivates thrombin.

Answer: c) It converts plasminogen to plasmin, which then degrades the fibrin clot.

5. According to AHA/ASA guidelines, what is the standard time window from symptom onset for administering intravenous alteplase in most eligible patients?

• a) Within 1 hour
• b) Within 3 to 4.5 hours
• c) Within 6 hours
• d) Within 24 hours

Answer: b) Within 3 to 4.5 hours

6. A patient presents with acute ischemic stroke symptoms that began 2 hours ago. Which of the following is an absolute contraindication to receiving alteplase?

• a) Age 75 years
• b) Blood pressure of 170/100 mmHg
• c) Evidence of intracranial hemorrhage on head CT.
• d) History of a previous TIA.

Answer: c) Evidence of intracranial hemorrhage on head CT.

7. Before administering alteplase, the patient’s blood pressure must be lowered to what level?

• a) < 220/120 mmHg
• b) < 200/110 mmHg
• c) < 185/110 mmHg
• d) < 160/90 mmHg

Answer: c) < 185/110 mmHg

8. The total dose of alteplase for acute ischemic stroke is 0.9 mg/kg. How is this dose administered?

• a) As a single IV push over 2 minutes.
• b) 10% as a bolus over 1 minute, followed by the remaining 90% as an infusion over 60 minutes.
• c) As a continuous infusion over 24 hours.
• d) 50% as a bolus, and 50% as an infusion over 30 minutes.

Answer: b) 10% as a bolus, followed by the remaining 90% as an infusion over 60 minutes.

9. What is the most serious and feared complication of alteplase therapy?

• a) Hypotension
• b) Symptomatic intracranial hemorrhage
• c) Allergic reaction
• d) Nausea and vomiting

Answer: b) Symptomatic intracranial hemorrhage

10. For a patient with an acute ischemic stroke who is NOT a candidate for alteplase, what is the generally accepted blood pressure goal for the first 24 hours (permissive hypertension)?

• a) Do not lower the BP unless it is > 220/120 mmHg.
• b) Lower the BP to < 185/110 mmHg.
• c) Lower the BP to < 140/90 mmHg.
• d) Lower the BP to < 120/80 mmHg.

Answer: a) Do not lower the BP unless it is > 220/120 mmHg.

11. When should aspirin therapy be initiated in a patient who has received alteplase for an acute ischemic stroke?

• a) Immediately before alteplase administration.
• b) Concurrently with the alteplase infusion.
• c) Generally delayed until 24 hours after alteplase administration, following a repeat head CT.
• d) Aspirin should be avoided for 7 days.

Answer: c) Generally delayed until 24 hours after alteplase administration, following a repeat head CT.

12. Mechanical thrombectomy is a treatment option for acute ischemic stroke caused by:

• a) A small vessel lacunar infarct.
• b) A large vessel occlusion in the anterior circulation.
• c) A hemorrhagic conversion.
• d) Any type of ischemic stroke, regardless of location.

Answer: b) A large vessel occlusion in the anterior circulation.

13. For secondary prevention after a non-cardioembolic ischemic stroke or TIA, which of the following is a recommended first-line antiplatelet therapy?

• a) Warfarin
• b) Aspirin, clopidogrel, or aspirin/extended-release dipyridamole.
• c) Ticagrelor
• d) No antiplatelet therapy is needed.

Answer: b) Aspirin, clopidogrel, or aspirin/extended-release dipyridamole.

14. Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for secondary stroke prevention is recommended for:

• a) All stroke patients for at least one year.
• b) A short duration (21-90 days) following a minor stroke or high-risk TIA.
• c) Only patients who have had a hemorrhagic stroke.
• d) Indefinite use in all patients.

Answer: b) A short duration (21-90 days) following a minor stroke or high-risk TIA.

15. High-intensity statin therapy is recommended for secondary prevention in patients with ischemic stroke of atherosclerotic origin, regardless of their baseline LDL cholesterol. Which of the following is a high-intensity statin regimen?

• a) Simvastatin 20 mg daily
• b) Pravastatin 40 mg daily
• c) Atorvastatin 80 mg daily
• d) Lovastatin 40 mg daily

Answer: c) Atorvastatin 80 mg daily

16. The most common cause of cardioembolic stroke is:

• a) Atrial fibrillation
• b) Deep vein thrombosis
• c) Carotid artery stenosis
• d) Hypertension

Answer: a) Atrial fibrillation

17. For secondary prevention of stroke in a patient with non-valvular atrial fibrillation, which class of medication is preferred?

• a) Antiplatelet agents like aspirin.
• b) Direct oral anticoagulants (DOACs).
• c) Beta-blockers.
• d) Statins.

Answer: b) Direct oral anticoagulants (DOACs).

18. A major cause of intracerebral hemorrhage (ICH) is:

• a) Atrial fibrillation
• b) Carotid artery plaque
• c) Uncontrolled hypertension
• d) Anemia

Answer: c) Uncontrolled hypertension

19. A patient on warfarin presents with an acute ICH and an INR of 4.5. Which of the following is the most appropriate agent for rapid reversal of anticoagulation?

• a) Vitamin K alone
• b) Protamine sulfate
• c) Four-factor prothrombin complex concentrate (4F-PCC, Kcentra®) + Vitamin K
• d) Fresh frozen plasma (FFP) as a first-line agent.

Answer: c) Four-factor prothrombin complex concentrate (4F-PCC, Kcentra®) + Vitamin K

20. A patient taking dabigatran presents with a life-threatening bleed. Which reversal agent is specific for dabigatran?

• a) Andexanet alfa
• b) Protamine
• c) Idarucizumab (Praxbind®)
• d) Vitamin K

Answer: c) Idarucizumab (Praxbind®)

21. A subarachnoid hemorrhage (SAH) is most commonly caused by:

• a) Uncontrolled hypertension
• b) The rupture of a cerebral aneurysm
• c) Head trauma
• d) An ischemic stroke conversion

Answer: b) The rupture of a cerebral aneurysm

22. Nimodipine is administered to patients following an aneurysmal SAH for what purpose?

• a) To lower blood pressure aggressively.
• b) To prevent cerebral vasospasm and delayed cerebral ischemia.
• c) To dissolve the blood clot.
• d) To prevent seizures.

Answer: b) To prevent cerebral vasospasm and delayed cerebral ischemia.

23. What is the CHA₂DS₂-VASc score used for?

• a) To assess the severity of an acute ischemic stroke.
• b) To estimate the risk of stroke in patients with atrial fibrillation.
• c) To determine a patient’s eligibility for alteplase.
• d) To grade the severity of a subarachnoid hemorrhage.

Answer: b) To estimate the risk of stroke in patients with atrial fibrillation.

24. A transient ischemic attack (TIA) is best described as:

• a) A completed stroke with permanent damage.
• b) A “mini-stroke” where symptoms resolve completely, typically within an hour, without evidence of acute infarction.
• c) A type of seizure.
• d) A severe migraine headache.

Answer: b) A “mini-stroke” where symptoms resolve completely, typically within an hour, without evidence of acute infarction.

25. For secondary stroke prevention, what is the recommended blood pressure goal according to the AHA/ASA guidelines?

• a) < 160/100 mmHg
• b) < 150/90 mmHg
• c) < 140/90 mmHg, and <130/80 mmHg may be reasonable.
• d) < 120/80 mmHg is mandatory for all patients.

Answer: c) < 140/90 mmHg, and <130/80 mmHg may be reasonable.

26. Which of the following is a primary prevention strategy for stroke?

• a) Administering alteplase.
• b) Performing a mechanical thrombectomy.
• c) Managing risk factors like hypertension, diabetes, and dyslipidemia.
• d) Initiating DAPT after a stroke.

Answer: c) Managing risk factors like hypertension, diabetes, and dyslipidemia.

27. A patient with a minor ischemic stroke (NIHSS score ≤ 3) is a poor CYP2C19 metabolizer. Which antiplatelet agent would be a less effective choice?

• a) Aspirin
• b) Clopidogrel
• c) Dipyridamole
• d) Ticagrelor

Answer: b) Clopidogrel

28. The maximum total dose of alteplase for ischemic stroke is capped at:

• a) 50 mg
• b) 75 mg
• c) 90 mg
• d) 100 mg

Answer: c) 90 mg

29. What is the role of deep vein thrombosis (DVT) prophylaxis in a patient with an acute stroke who has restricted mobility?

• a) It is not necessary.
• b) To prevent the formation of blood clots in the legs.
• c) To treat the stroke itself.
• d) To lower blood pressure.

Answer: b) To prevent the formation of blood clots in the legs.

30. Which of the following is a direct oral anticoagulant (DOAC)?

• a) Warfarin
• b) Enoxaparin
• c) Apixaban
• d) Heparin

Answer: c) Apixaban

31. A “lacunar stroke” is a type of ischemic stroke caused by the occlusion of:

• a) A large cerebral artery like the MCA.
• b) The carotid artery.
• c) A small, perforating artery deep within the brain.
• d) A major vein.

Answer: c) A small, perforating artery deep within the brain.

32. A patient with a history of GI bleeding has a stroke and requires antiplatelet therapy for secondary prevention. Which of the following strategies might reduce their risk of future GI bleeds?

• a) Adding a proton pump inhibitor (PPI) to their antiplatelet regimen.
• b) Using aspirin alone at a high dose.
• c) Switching to warfarin.
• d) No strategy can reduce this risk.

Answer: a) Adding a proton pump inhibitor (PPI) to their antiplatelet regimen.

33. An arteriovenous malformation (AVM) is a risk factor for which type of stroke?

• a) Cardioembolic ischemic stroke
• b) Lacunar stroke
• c) Intracerebral hemorrhage
• d) Atherothrombotic stroke

Answer: c) Intracerebral hemorrhage

34. What is the primary route of administration for nimodipine in SAH?

• a) Intravenous
• b) Intramuscular
• c) Oral or via nasogastric tube
• d) Transdermal

Answer: c) Oral or via nasogastric tube

35. A patient experiences a sudden, severe headache often described as the “worst headache of my life.” This is a classic symptom of:

• a) A transient ischemic attack (TIA).
• b) A subarachnoid hemorrhage (SAH).
• c) A sinus infection.
• d) A migraine.

Answer: b) A subarachnoid hemorrhage (SAH).

36. A pharmacist’s role on a hospital’s stroke team includes:

• a) Performing the initial neurological exam.
• b) Preparing the alteplase infusion and verifying the dose.
• c) Interpreting the head CT scan.
• d) Deciding if the patient needs surgery.

Answer: b) Preparing the alteplase infusion and verifying the dose.

37. Which lifestyle modification is most impactful for the primary prevention of stroke?

• a) Increasing caffeine intake.
• b) Smoking cessation and blood pressure control.
• c) Reducing dietary fiber.
• d) Avoiding exercise.

Answer: b) Smoking cessation and blood pressure control.

38. Tenecteplase is being used more frequently off-label for acute ischemic stroke because it offers what potential advantage over alteplase?

• a) It is less effective.
• b) It can be administered as a single, weight-based IV bolus.
• c) It has a higher risk of bleeding.
• d) It is only approved for hemorrhagic stroke.

Answer: b) It can be administered as a single, weight-based IV bolus.

39. A patient is being discharged after a stroke. An important role for the pharmacist is:

• a) Recommending a new diet plan.
• b) Scheduling physical therapy appointments.
• c) Providing medication counseling on their new secondary prevention regimen.
• d) Driving the patient home.

Answer: c) Providing medication counseling on their new secondary prevention regimen.

40. The NIH Stroke Scale (NIHSS) is a tool used to:

• a) Predict the long-term outcome of a stroke.
• b) Quantify the severity of stroke-related neurologic deficits.
• c) Diagnose the cause of the stroke.
• d) Determine the patient’s blood pressure goal.

Answer: b) Quantify the severity of stroke-related neurologic deficits.

41. The underlying pathophysiology of an ischemic stroke is:

• a) The rupture of a blood vessel.
• b) A seizure.
• c) The occlusion of a cerebral artery by a thrombus or embolus.
• d) An infection in the brain.

Answer: c) The occlusion of a cerebral artery by a thrombus or embolus.

42. Which of the following is NOT a component of the FAST acronym for stroke?

• a) Face drooping
• b) Arm weakness
• c) Speech difficulty
• d) Temperature (fever)

Answer: d) Temperature (fever)

43. A patient taking apixaban presents with an acute ICH. Which agent can be used for reversal?

• a) Idarucizumab
• b) Vitamin K
• c) Andexanet alfa
• d) Protamine sulfate

Answer: c) Andexanet alfa

44. What is a “penumbra” in the context of an ischemic stroke?

• a) The area of irreversibly damaged brain tissue (infarct core).
• b) The area of brain tissue surrounding the core that is at risk but still potentially salvageable.
• c) The blood clot itself.
• d) A swelling in the brain.

Answer: b) The area of brain tissue surrounding the core that is at risk but still potentially salvageable.

45. Which of the following is a non-modifiable risk factor for stroke?

• a) Hypertension
• b) Smoking
• c) Age
• d) Diabetes

Answer: c) Age

46. After an ICH, why is it important to manage blood pressure carefully?

• a) To increase the size of the hematoma.
• b) To prevent hematoma expansion while maintaining adequate cerebral perfusion.
• c) To dissolve the blood clot.
• d) Blood pressure management is not important in ICH.

Answer: b) To prevent hematoma expansion while maintaining adequate cerebral perfusion.

47. A patient with a history of ischemic stroke and non-valvular atrial fibrillation is managed with dabigatran. This medication works by:

• a) Inhibiting Vitamin K epoxide reductase.
• b) Directly inhibiting thrombin (Factor IIa).
• c) Directly inhibiting Factor Xa.
• d) Inhibiting platelet aggregation.

Answer: b) Directly inhibiting thrombin (Factor IIa).

48. Why must alteplase be administered within a specific time window?

• a) The medication expires quickly.
• b) The risk of bleeding increases significantly while the potential for benefit decreases as time from symptom onset passes.
• c) Hospital policy dictates the time window.
• d) It is only effective if given within the first 60 minutes.

Answer: b) The risk of bleeding increases significantly while the potential for benefit decreases as time from symptom onset passes.

49. For a patient with a TIA and an ABCD² score of 5, what is the recommended management?

• a) Reassurance and follow-up in one year.
• b) Urgent evaluation and initiation of secondary prevention therapy.
• c) Admission to the hospital for observation is often recommended.
• d) Both B and C are correct.

Answer: d) Both B and C are correct.

50. An important patient education point for preventing stroke is:

• a) Recognizing the symptoms of a stroke and calling 9-1-1 immediately.
• b) Taking aspirin daily without consulting a doctor.
• c) Avoiding all physical activity.
• d) Increasing salt intake to raise blood pressure.

Answer: a) Recognizing the symptoms of a stroke and calling 9-1-1 immediately.