Stroke: acute management and secondary prevention MCQs With Answer

Stroke: acute management and secondary prevention MCQs With Answer

This question set is designed for M.Pharm students preparing for Pharmacotherapeutics II (MPP 202T). It focuses on acute ischemic and hemorrhagic stroke management and evidence-based secondary prevention strategies emphasizing pharmacology: thrombolytics (dosing, contraindications), endovascular therapy selection, blood pressure and glucose targets, antiplatelet and anticoagulant choices and timing, statin use, carotid intervention indications, and practical considerations when patients are on DOACs or antiplatelets. Questions are clinically oriented and reference major trial-based recommendations to deepen understanding of drug selection, dosing, contraindications and the rationale behind guideline-directed therapy used in acute care and long-term prevention of recurrent stroke.

Q1. Which is the recommended intravenous alteplase dosing regimen for eligible acute ischemic stroke patients?

• Alteplase 0.6 mg/kg (max 60 mg) as a 10% bolus then remainder over 60 minutes
• Alteplase 0.9 mg/kg (max 90 mg) with 10% given as bolus and the remainder infused over 60 minutes
• Alteplase 1.0 mg/kg (no maximum) as a single bolus
• Alteplase 0.25 mg/kg as a single bolus

Correct Answer: Alteplase 0.9 mg/kg (max 90 mg) with 10% given as bolus and the remainder infused over 60 minutes

Q2. Which laboratory parameter is considered a contraindication to IV alteplase in acute ischemic stroke?

• Platelet count of 150,000/mm3
• INR 1.2
• INR >1.7
• Normal PT and aPTT

Correct Answer: INR >1.7

Q3. What is the generally accepted time window from symptom onset for IV alteplase administration in eligible patients?

• Within 90 minutes
• Within 3 hours
• Within 4.5 hours
• Within 12 hours

Correct Answer: Within 4.5 hours

Q4. For selected patients with large vessel occlusion and favorable perfusion imaging, up to how many hours after last-known-well can endovascular thrombectomy be considered?

• 6 hours only
• 12 hours irrespective of imaging
• Up to 24 hours with appropriate imaging selection
• 48 hours for all patients

Correct Answer: Up to 24 hours with appropriate imaging selection

Q5. Prior to administering IV thrombolysis, blood pressure should be lowered to which target?

• Systolic <160 mmHg and diastolic <100 mmHg
• Systolic <185 mmHg and diastolic <110 mmHg
• Systolic <220 mmHg and diastolic <120 mmHg
• Any blood pressure is acceptable if treated immediately with alteplase

Correct Answer: Systolic <185 mmHg and diastolic <110 mmHg

Q6. After IV alteplase administration for ischemic stroke, when should antiplatelet therapy (e.g., aspirin) generally be initiated?

• Immediately during alteplase infusion
• Within 6 hours after alteplase completion
• Not earlier than 24 hours after alteplase and only after follow-up imaging excludes hemorrhage
• After 7 days irrespective of imaging

Correct Answer: Not earlier than 24 hours after alteplase and only after follow-up imaging excludes hemorrhage

Q7. For acute minor ischemic stroke or high‑risk TIA, what is the recommended duration of dual antiplatelet therapy (aspirin plus clopidogrel) based on CHANCE/POINT evidence?

• Indefinitely
• 3 months
• 21 days (approximately 3 weeks)
• 1 year

Correct Answer: 21 days (approximately 3 weeks)

Q8. Which lipid management strategy is recommended for most patients after ischemic stroke of atherosclerotic origin?

• No statin if LDL is normal
• Moderate-intensity statin only if LDL >130 mg/dL
• High-intensity statin therapy started early irrespective of baseline LDL
• PCSK9 inhibitor as first-line therapy

Correct Answer: High-intensity statin therapy started early irrespective of baseline LDL

Q9. Which patient is most likely to be a candidate for urgent carotid endarterectomy for secondary stroke prevention?

• Asymptomatic carotid stenosis 40% discovered incidentally
• Symptomatic carotid stenosis 75% within 2 weeks of a hemispheric TIA or minor stroke
• Complete carotid occlusion with no residual lumen
• Symptomatic carotid stenosis 30% with recurrent symptoms

Correct Answer: Symptomatic carotid stenosis 75% within 2 weeks of a hemispheric TIA or minor stroke

Q10. For long-term secondary prevention in non‑valvular atrial fibrillation after ischemic stroke, which option is generally preferred?

• Aspirin monotherapy
• Dual antiplatelet therapy indefinitely
• Direct oral anticoagulant (DOAC) rather than warfarin for most patients
• No antithrombotic therapy if stroke was small

Correct Answer: Direct oral anticoagulant (DOAC) rather than warfarin for most patients

Q11. Which CHADS2-VASc score threshold typically prompts consideration of anticoagulation for stroke prevention in atrial fibrillation?

• Score of 0
• Score of 1 in all patients
• Score ≥2
• Score ≥6 only

Correct Answer: Score ≥2

Q12. What is the usual therapeutic INR target range for warfarin when used for stroke prevention in atrial fibrillation?

• INR 1.0–1.5
• INR 1.5–2.0
• INR 2.0–3.0
• INR 3.5–4.5

Correct Answer: INR 2.0–3.0

Q13. What is a commonly recommended outpatient blood pressure target for secondary prevention after ischemic stroke in most patients?

• Maintain systolic BP ≥160 mmHg
• Target systolic BP <140 mmHg (or individualized lower target in some patients)
• Do not treat hypertension for at least 3 months after stroke
• Target diastolic only, keeping it >90 mmHg

Correct Answer: Target systolic BP <140 mmHg (or individualized lower target in some patients)

Q14. In a patient who took a direct oral anticoagulant (DOAC) within the past 24–48 hours, what is the usual recommendation regarding IV alteplase for acute ischemic stroke?

• Proceed with IV alteplase regardless of DOAC timing
• IV alteplase is contraindicated unless sensitive coagulation assays are normal or reversal agent given
• Give double-dose alteplase to overcome DOAC effect
• Switch to antiplatelet therapy immediately instead of thrombolysis

Correct Answer: IV alteplase is contraindicated unless sensitive coagulation assays are normal or reversal agent given

Q15. For patients with spontaneous intracerebral hemorrhage who were on antiplatelet therapy prior to bleed, what does current trial evidence (e.g., PATCH) suggest about routine platelet transfusion?

• Routine platelet transfusion improves outcomes and is recommended
• Platelet transfusion is harmful or offers no benefit and is not routinely recommended
• Platelet transfusion is mandatory for all ICH patients
• Platelet transfusion should be given only if the platelet count is >400,000/mm3

Correct Answer: Platelet transfusion is harmful or offers no benefit and is not routinely recommended

Q16. In acute intracerebral hemorrhage, intensive blood pressure lowering to which systolic target has been shown to be reasonable to reduce hematoma expansion?

• Systolic BP <120 mmHg for all patients
• Systolic BP <140 mmHg (acute lowering in the first 24 hours for many patients)
• Systolic BP <180 mmHg only
• No BP lowering is recommended in ICH

Correct Answer: Systolic BP <140 mmHg (acute lowering in the first 24 hours for many patients)

Q17. Patients with wake‑up stroke who show a DWI-FLAIR mismatch on MRI are considered:

• Ineligible for any reperfusion therapy
• Potential candidates for IV thrombolysis within a tissue‑based (not time‑based) window
• Automatically eligible for thrombectomy without imaging
• Only eligible for antiplatelet therapy

Correct Answer: Potential candidates for IV thrombolysis within a tissue‑based (not time‑based) window

Q18. Which tenecteplase dosing has been supported in recent trials as an alternative to alteplase for some patients with large vessel occlusion prior to thrombectomy?

• Tenecteplase 0.1 mg/kg single bolus
• Tenecteplase 0.25 mg/kg single bolus
• Tenecteplase 0.9 mg/kg with 10% bolus then infusion
• Tenecteplase 1.0 mg/kg single bolus

Correct Answer: Tenecteplase 0.25 mg/kg single bolus

Q19. What blood glucose range is generally recommended to avoid extremes during the acute phase of stroke?

• Keep glucose <70 mg/dL to reduce metabolic demand
• Maintain glucose between 140–180 mg/dL
• Allow glucose >300 mg/dL to ensure energy supply
• No monitoring or control of glucose is necessary in acute stroke

Correct Answer: Maintain glucose between 140–180 mg/dL

Q20. For secondary prevention in non‑cardioembolic ischemic stroke, which single antiplatelet agent is commonly used and supported by CAPRIE evidence as an effective option?

• Aspirin 325 mg daily indefinitely for all patients
• Clopidogrel 75 mg daily as monotherapy
• Ticagrelor plus aspirin indefinitely
• Warfarin INR 2–3 as antiplatelet substitute

Correct Answer: Clopidogrel 75 mg daily as monotherapy

Download