1
SCRN Stroke Certification Final Exam Questions and Answers with
Detailed Rationales for All Answer Choices
Question 1: A patient arrives in the emergency department with sudden onset of right-sided
weakness, facial droop, and aphasia that began 45 minutes ago. Which of the following is the highest
priority initial action according to current stroke guidelines?
A. Obtain a complete medical history from family members
B. Establish IV access and draw baseline laboratory studies including coagulation profile
C. Perform a non-contrast CT of the head to rule out hemorrhage
D. Administer aspirin 325 mg orally
CORRECT ANSWER: C. Perform a non-contrast CT of the head to rule out hemorrhage
Rationale: Rapid neuroimaging with non-contrast CT is required to exclude intracranial hemorrhage
before any reperfusion therapy can be considered. Time-critical decisions regarding thrombolysis or
endovascular therapy depend on confirming the absence of hemorrhage and assessing for large vessel
occlusion.
Question 2: Which of the following NIH Stroke Scale (NIHSS) findings is most consistent with a left
middle cerebral artery (MCA) territory ischemic stroke?
A. Left hemiparesis, left neglect, and anosognosia
B. Right hemiparesis, aphasia, and right visual field deficit
C. Bilateral lower extremity weakness and urinary incontinence
D. Crossed findings of ipsilateral facial weakness and contralateral body weakness
CORRECT ANSWER: B. Right hemiparesis, aphasia, and right visual field deficit
Rationale: The left MCA supplies language areas in the dominant hemisphere as well as motor and
sensory pathways for the right side of the body. Classic findings include aphasia (expressive, receptive, or
global), right hemiparesis, and right homonymous hemianopia.
Question 3: A patient is eligible for intravenous alteplase. According to current AHA/ASA guidelines,
what is the recommended maximum time window from last known well for administration of IV
thrombolysis in most patients?
A. 3 hours
B. 4.5 hours
C. 6 hours
D. 24 hours
CORRECT ANSWER: B. 4.5 hours
,2
Rationale: Intravenous alteplase is recommended for selected patients within 4.5 hours of last known
well when the benefit is judged to outweigh the risk. The original 3-hour window has been extended to
4.5 hours for carefully selected patients based on evidence from ECASS III and subsequent analyses.
Question 4: Which of the following laboratory values is an absolute contraindication to intravenous
thrombolysis with alteplase?
A. Platelet count of 120,000/µL
B. International normalized ratio (INR) of 1.8
C. Blood glucose of 55 mg/dL that corrects promptly with treatment
D. Serum creatinine of 1.8 mg/dL
CORRECT ANSWER: B. International normalized ratio (INR) of 1.8
Rationale: An INR greater than 1.7 is an absolute contraindication to IV alteplase because of significantly
elevated risk of symptomatic intracranial hemorrhage. Mild thrombocytopenia, corrected hypoglycemia,
and moderate renal impairment are relative considerations but not absolute exclusions in current
guidelines.
Question 5: A patient with acute ischemic stroke has a large vessel occlusion of the proximal MCA and
last known well time of 8 hours. Which advanced imaging finding supports consideration of
endovascular thrombectomy beyond 6 hours?
A. Large core infarct volume exceeding 70 mL on CT perfusion
B. Mismatch between ischemic core and penumbra on CT perfusion or MR diffusion-perfusion imaging
C. Complete absence of collateral circulation on multiphase CTA
D. Hyperdense MCA sign alone
CORRECT ANSWER: B. Mismatch between ischemic core and penumbra on CT perfusion or MR
diffusion-perfusion imaging
Rationale: Late-window thrombectomy trials (DAWN and DEFUSE 3) demonstrated benefit in selected
patients up to 16–24 hours when advanced imaging shows a significant mismatch between a relatively
small ischemic core and a larger area of potentially salvageable penumbra.
Question 6: Which of the following is the most appropriate blood pressure target for a patient with
acute ischemic stroke who is not a candidate for thrombolysis or thrombectomy and has no other
compelling indication for acute BP reduction?
A. Reduce systolic BP to less than 140 mm Hg within the first hour
B. Allow permissive hypertension up to 220/120 mm Hg unless other indications exist
C. Lower BP only if diastolic exceeds 110 mm Hg
D. Maintain mean arterial pressure between 70 and 80 mm Hg
,3
CORRECT ANSWER: B. Allow permissive hypertension up to 220/120 mm Hg unless other indications
exist
Rationale: In patients with ischemic stroke who are not receiving reperfusion therapy, blood pressure is
generally allowed to remain elevated (permissive hypertension) to support collateral flow to the ischemic
penumbra, unless BP exceeds 220/120 mm Hg or there is a concurrent hypertensive emergency.
Question 7: A patient develops sudden severe headache, nausea, and declining level of consciousness
6 hours after receiving intravenous alteplase. What is the most appropriate immediate action?
A. Administer an additional dose of alteplase
B. Obtain emergent non-contrast head CT and prepare for possible reversal of thrombolysis
C. Begin continuous EEG monitoring
D. Administer intravenous labetalol to lower blood pressure aggressively
CORRECT ANSWER: B. Obtain emergent non-contrast head CT and prepare for possible reversal of
thrombolysis
Rationale: Neurologic deterioration after thrombolysis raises concern for symptomatic intracranial
hemorrhage. Immediate imaging is required, and if hemorrhage is confirmed, protocols for blood
pressure control and consideration of cryoprecipitate, antifibrinolytics, or other reversal strategies are
initiated.
Question 8: Which of the following statements best describes the role of the NIH Stroke Scale in acute
stroke care?
A. It is used solely to determine eligibility for endovascular therapy
B. It provides a standardized, quantifiable measure of neurologic deficit that guides treatment decisions
and monitors for deterioration
C. It replaces the need for a detailed neurologic examination
D. A score of zero excludes the possibility of stroke
CORRECT ANSWER: B. It provides a standardized, quantifiable measure of neurologic deficit that
guides treatment decisions and monitors for deterioration
Rationale: The NIHSS is a validated tool that quantifies stroke severity, helps determine eligibility for
reperfusion therapies, facilitates communication among providers, and allows serial assessment for
neurologic change.
Question 9: A patient with atrial fibrillation and acute ischemic stroke is being evaluated for
anticoagulation. When is the earliest that oral anticoagulation is generally considered after a large
infarct with significant mass effect?
, 4
A. Immediately upon diagnosis
B. Within 24 hours
C. After 1–2 weeks, once the risk of hemorrhagic transformation has decreased
D. Only after 30 days
CORRECT ANSWER: C. After 1–2 weeks, once the risk of hemorrhagic transformation has decreased
Rationale: In patients with large ischemic strokes and substantial mass effect or hemorrhagic risk,
initiation of anticoagulation is typically delayed for 1–2 weeks to reduce the risk of symptomatic
hemorrhagic transformation, guided by clinical stability and follow-up imaging.
Question 10: Which of the following is the most common mechanism of ischemic stroke in patients
with significant carotid artery stenosis?
A. Lacunar infarction from lipohyalinosis
B. Artery-to-artery embolism or hypoperfusion distal to the stenosis
C. Paradoxical embolism through a patent foramen ovale
D. Cardioembolism from left atrial appendage thrombus
CORRECT ANSWER: B. Artery-to-artery embolism or hypoperfusion distal to the stenosis
Rationale: High-grade carotid stenosis can produce ischemic stroke either by artery-to-artery embolism
of plaque material or by hemodynamic compromise distal to the lesion, particularly in the setting of
reduced collateral flow.
Question 11: A patient presents with pure motor hemiparesis affecting the face, arm, and leg equally,
without cortical signs. Which stroke subtype is most likely?
A. Large-vessel atherosclerosis of the MCA
B. Cardioembolic stroke
C. Lacunar infarction in the internal capsule or basis pontis
D. Watershed infarction
CORRECT ANSWER: C. Lacunar infarction in the internal capsule or basis pontis
Rationale: Classic lacunar syndromes, including pure motor hemiparesis, result from small-vessel
lipohyalinosis affecting deep penetrating arteries supplying the internal capsule, basis pontis, or corona
radiata, and typically lack cortical findings.
Question 12: Which of the following medications is recommended as first-line secondary prevention in
a patient with non-cardioembolic ischemic stroke who has no contraindication to antiplatelet therapy?
A. Warfarin with target INR 2–3
B. Aspirin 81–325 mg daily or dual antiplatelet therapy for a short period in selected patients
SCRN Stroke Certification Final Exam Questions and Answers with
Detailed Rationales for All Answer Choices
Question 1: A patient arrives in the emergency department with sudden onset of right-sided
weakness, facial droop, and aphasia that began 45 minutes ago. Which of the following is the highest
priority initial action according to current stroke guidelines?
A. Obtain a complete medical history from family members
B. Establish IV access and draw baseline laboratory studies including coagulation profile
C. Perform a non-contrast CT of the head to rule out hemorrhage
D. Administer aspirin 325 mg orally
CORRECT ANSWER: C. Perform a non-contrast CT of the head to rule out hemorrhage
Rationale: Rapid neuroimaging with non-contrast CT is required to exclude intracranial hemorrhage
before any reperfusion therapy can be considered. Time-critical decisions regarding thrombolysis or
endovascular therapy depend on confirming the absence of hemorrhage and assessing for large vessel
occlusion.
Question 2: Which of the following NIH Stroke Scale (NIHSS) findings is most consistent with a left
middle cerebral artery (MCA) territory ischemic stroke?
A. Left hemiparesis, left neglect, and anosognosia
B. Right hemiparesis, aphasia, and right visual field deficit
C. Bilateral lower extremity weakness and urinary incontinence
D. Crossed findings of ipsilateral facial weakness and contralateral body weakness
CORRECT ANSWER: B. Right hemiparesis, aphasia, and right visual field deficit
Rationale: The left MCA supplies language areas in the dominant hemisphere as well as motor and
sensory pathways for the right side of the body. Classic findings include aphasia (expressive, receptive, or
global), right hemiparesis, and right homonymous hemianopia.
Question 3: A patient is eligible for intravenous alteplase. According to current AHA/ASA guidelines,
what is the recommended maximum time window from last known well for administration of IV
thrombolysis in most patients?
A. 3 hours
B. 4.5 hours
C. 6 hours
D. 24 hours
CORRECT ANSWER: B. 4.5 hours
,2
Rationale: Intravenous alteplase is recommended for selected patients within 4.5 hours of last known
well when the benefit is judged to outweigh the risk. The original 3-hour window has been extended to
4.5 hours for carefully selected patients based on evidence from ECASS III and subsequent analyses.
Question 4: Which of the following laboratory values is an absolute contraindication to intravenous
thrombolysis with alteplase?
A. Platelet count of 120,000/µL
B. International normalized ratio (INR) of 1.8
C. Blood glucose of 55 mg/dL that corrects promptly with treatment
D. Serum creatinine of 1.8 mg/dL
CORRECT ANSWER: B. International normalized ratio (INR) of 1.8
Rationale: An INR greater than 1.7 is an absolute contraindication to IV alteplase because of significantly
elevated risk of symptomatic intracranial hemorrhage. Mild thrombocytopenia, corrected hypoglycemia,
and moderate renal impairment are relative considerations but not absolute exclusions in current
guidelines.
Question 5: A patient with acute ischemic stroke has a large vessel occlusion of the proximal MCA and
last known well time of 8 hours. Which advanced imaging finding supports consideration of
endovascular thrombectomy beyond 6 hours?
A. Large core infarct volume exceeding 70 mL on CT perfusion
B. Mismatch between ischemic core and penumbra on CT perfusion or MR diffusion-perfusion imaging
C. Complete absence of collateral circulation on multiphase CTA
D. Hyperdense MCA sign alone
CORRECT ANSWER: B. Mismatch between ischemic core and penumbra on CT perfusion or MR
diffusion-perfusion imaging
Rationale: Late-window thrombectomy trials (DAWN and DEFUSE 3) demonstrated benefit in selected
patients up to 16–24 hours when advanced imaging shows a significant mismatch between a relatively
small ischemic core and a larger area of potentially salvageable penumbra.
Question 6: Which of the following is the most appropriate blood pressure target for a patient with
acute ischemic stroke who is not a candidate for thrombolysis or thrombectomy and has no other
compelling indication for acute BP reduction?
A. Reduce systolic BP to less than 140 mm Hg within the first hour
B. Allow permissive hypertension up to 220/120 mm Hg unless other indications exist
C. Lower BP only if diastolic exceeds 110 mm Hg
D. Maintain mean arterial pressure between 70 and 80 mm Hg
,3
CORRECT ANSWER: B. Allow permissive hypertension up to 220/120 mm Hg unless other indications
exist
Rationale: In patients with ischemic stroke who are not receiving reperfusion therapy, blood pressure is
generally allowed to remain elevated (permissive hypertension) to support collateral flow to the ischemic
penumbra, unless BP exceeds 220/120 mm Hg or there is a concurrent hypertensive emergency.
Question 7: A patient develops sudden severe headache, nausea, and declining level of consciousness
6 hours after receiving intravenous alteplase. What is the most appropriate immediate action?
A. Administer an additional dose of alteplase
B. Obtain emergent non-contrast head CT and prepare for possible reversal of thrombolysis
C. Begin continuous EEG monitoring
D. Administer intravenous labetalol to lower blood pressure aggressively
CORRECT ANSWER: B. Obtain emergent non-contrast head CT and prepare for possible reversal of
thrombolysis
Rationale: Neurologic deterioration after thrombolysis raises concern for symptomatic intracranial
hemorrhage. Immediate imaging is required, and if hemorrhage is confirmed, protocols for blood
pressure control and consideration of cryoprecipitate, antifibrinolytics, or other reversal strategies are
initiated.
Question 8: Which of the following statements best describes the role of the NIH Stroke Scale in acute
stroke care?
A. It is used solely to determine eligibility for endovascular therapy
B. It provides a standardized, quantifiable measure of neurologic deficit that guides treatment decisions
and monitors for deterioration
C. It replaces the need for a detailed neurologic examination
D. A score of zero excludes the possibility of stroke
CORRECT ANSWER: B. It provides a standardized, quantifiable measure of neurologic deficit that
guides treatment decisions and monitors for deterioration
Rationale: The NIHSS is a validated tool that quantifies stroke severity, helps determine eligibility for
reperfusion therapies, facilitates communication among providers, and allows serial assessment for
neurologic change.
Question 9: A patient with atrial fibrillation and acute ischemic stroke is being evaluated for
anticoagulation. When is the earliest that oral anticoagulation is generally considered after a large
infarct with significant mass effect?
, 4
A. Immediately upon diagnosis
B. Within 24 hours
C. After 1–2 weeks, once the risk of hemorrhagic transformation has decreased
D. Only after 30 days
CORRECT ANSWER: C. After 1–2 weeks, once the risk of hemorrhagic transformation has decreased
Rationale: In patients with large ischemic strokes and substantial mass effect or hemorrhagic risk,
initiation of anticoagulation is typically delayed for 1–2 weeks to reduce the risk of symptomatic
hemorrhagic transformation, guided by clinical stability and follow-up imaging.
Question 10: Which of the following is the most common mechanism of ischemic stroke in patients
with significant carotid artery stenosis?
A. Lacunar infarction from lipohyalinosis
B. Artery-to-artery embolism or hypoperfusion distal to the stenosis
C. Paradoxical embolism through a patent foramen ovale
D. Cardioembolism from left atrial appendage thrombus
CORRECT ANSWER: B. Artery-to-artery embolism or hypoperfusion distal to the stenosis
Rationale: High-grade carotid stenosis can produce ischemic stroke either by artery-to-artery embolism
of plaque material or by hemodynamic compromise distal to the lesion, particularly in the setting of
reduced collateral flow.
Question 11: A patient presents with pure motor hemiparesis affecting the face, arm, and leg equally,
without cortical signs. Which stroke subtype is most likely?
A. Large-vessel atherosclerosis of the MCA
B. Cardioembolic stroke
C. Lacunar infarction in the internal capsule or basis pontis
D. Watershed infarction
CORRECT ANSWER: C. Lacunar infarction in the internal capsule or basis pontis
Rationale: Classic lacunar syndromes, including pure motor hemiparesis, result from small-vessel
lipohyalinosis affecting deep penetrating arteries supplying the internal capsule, basis pontis, or corona
radiata, and typically lack cortical findings.
Question 12: Which of the following medications is recommended as first-line secondary prevention in
a patient with non-cardioembolic ischemic stroke who has no contraindication to antiplatelet therapy?
A. Warfarin with target INR 2–3
B. Aspirin 81–325 mg daily or dual antiplatelet therapy for a short period in selected patients
