BARKLEY SCRN STROKE CERTIFICATION
PRACTICE EXAM EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
EXAM COVERAGE
1. Stroke Anatomy, Physiology, and Pathophysiology
2. Acute Stroke Assessment, Diagnostics, and Neuroimaging
3. Acute Reperfusion Therapies and Interventional Management
4. Post-Acute Stroke Care, Complications, and Secondary Prevention
5. Professional Practice, Quality Improvement, and Special Populations
1. A 68-year-old male presents to the emergency department with sudden-onset right-sided
hemiparesis, global aphasia, and a gaze preference to the left, starting 90 minutes ago. His
NIHSS score is 18. Non-contrast head CT shows no acute intracranial hemorrhage. CT
angiography reveals a proximal left middle cerebral artery (MCA M1) occlusion. Blood pressure
is 165/95 mmHg. What is the most appropriate initial evidence-based management strategy?
A. Immediate administration of intravenous antihypertensives until blood pressure is below
120/80 mmHg prior to any other intervention
B. Immediate administration of intravenous alteplase or tenecteplase followed by emergent
endovascular thrombectomy (EVT) evaluation
C. Deferral of all reperfusion therapies for 24 hours to monitor spontaneous neurological
recovery
D. Immediate administration of therapeutic intravenous heparin infusion without thrombolytics
CORRECT ANSWER : B
Rationale: For patients presenting within the acute window with an acute ischemic stroke due to
a large vessel occlusion (LVO), standard guidelines recommend bridging therapy—intravenous
thrombolysis followed by urgent endovascular thrombectomy (EVT). Lowering BP below
, 180/105 is not required prior to alteplase unless it exceeds that threshold or other organ damage
exists. Options A, C, and D delay critical life-saving revascularization.
2. A 72-year-old female is evaluated 3 hours after the onset of acute left facial droop and left arm
weakness. Her NIHSS score is 6. Non-contrast head CT is negative for hemorrhage. Her past
medical history includes type 2 diabetes and a remote ischemic stroke 3 years ago. She takes
aspirin 81 mg daily. What is the most accurate statement regarding intravenous thrombolysis
eligibility under current guidelines?
A. A history of remote ischemic stroke combined with diabetes constitutes an absolute
contraindication to intravenous alteplase
B. A remote history of ischemic stroke more than 3 months ago combined with diabetes is
not an exclusion criterion, making her a candidate for IV thrombolysis
C. Antiplatelet monotherapy prevents the safe administration of intravenous thrombolytics
D. Age over 70 automatically disqualifies a patient from receiving intravenous tenecteplase
CORRECT ANSWER : B
Rationale: While a prior stroke within the past 3 months combined with diabetes is a
relative/absolute contraindication for alteplase, a remote stroke (> 3 months ago) is not an
exclusion criterion. Antiplatelet use alone does not preclude thrombolysis. Options A, C, and D
reflect outdated or incorrect clinical criteria.
3. A 55-year-old female is admitted to the stroke unit following a right hemispheric ischemic
stroke. Over the last 4 hours, she becomes increasingly somnolent, develops a new left-sided
pupillary dilation, and her blood pressure rises while her heart rate drops. What acute
neurosurgical complication is most likely occurring?
A. Acute subarachnoid hemorrhage expansion
B. Malignant MCA infarction resulting in uncal herniation and elevated intracranial
pressure
C. Central cord syndrome
D. Hypoglycemic encephalopathy
CORRECT ANSWER : B
Rationale: Large middle cerebral artery (MCA) infarctions can develop massive edema
(malignant MCA infarction), leading to severe intracranial pressure elevation, brain shift, and
uncal herniation (manifested by pupillary dilation and Cushing's triad). This often requires
emergent decompressive hemicraniectomy.
, 4. A stroke nurse is managing a patient receiving intravenous alteplase infusion. Thirty minutes into
the infusion, the patient acutely complains of tongue swelling, difficulty swallowing, and mild
hoarseness, accompanied by a drop in blood pressure to 90/60 mmHg. What is the immediate
priority action?
A. Increase the alteplase infusion rate to complete the dose faster
B. Immediately stop the alteplase infusion and administer emergency medications for
angioedema (e.g., IV methylprednisolone, diphenhydramine, and epinephrine if necessary)
C. Administer sublingual nitroglycerin for suspected myocardial infarction
D. Obtain a stat repeat non-contrast head CT scan
CORRECT ANSWER : B
Rationale: Oromilingual angioedema is a known, potentially life-threatening adverse reaction to
alteplase (especially in patients taking ACE inhibitors). The infusion must be stopped
immediately, and treatment for acute angioedema and airway protection must be initiated.
5. A 60-year-old male with an acute left MCA stroke is being evaluated for endovascular
thrombectomy (EVT). Perfusion imaging demonstrates a small core infarct volume of 15 mL
with a large penumbra (mismatch ratio > 1.8), and the time from last known well is 14 hours.
What is the clinical implication of these advanced imaging findings?
A. The patient is outside the treatment window and should receive comfort care only
B. The patient is a strong candidate for endovascular thrombectomy based on extended-
window trial criteria showing salvageable tissue
C. The presence of a penumbra means intravenous alteplase must be given regardless of the 4.5-
hour limit
D. Advanced imaging findings have no bearing on mechanical thrombectomy decisions
CORRECT ANSWER : B
Rationale: Advanced neuroimaging (CT perfusion or MRI) in the extended time window (6 to 24
hours) identifies patients with favorable mismatch profiles (small core, large penumbra) who
benefit significantly from mechanical thrombectomy despite the delayed presentation.
6. A 79-year-old male is admitted with an acute cardioembolic stroke due to newly diagnosed
persistent atrial fibrillation. His CHA2DS2-VASc score is 5. He has a small subcortical infarct
without hemorrhage on head CT. According to current guidelines, when is the optimal time to
initiate oral anticoagulation to balance stroke recurrence risk against hemorrhagic
transformation?
PRACTICE EXAM EXAM with Questions and
Answers/Plus a Rationale Updated 2026 A+/Instant
Download PDF
EXAM COVERAGE
1. Stroke Anatomy, Physiology, and Pathophysiology
2. Acute Stroke Assessment, Diagnostics, and Neuroimaging
3. Acute Reperfusion Therapies and Interventional Management
4. Post-Acute Stroke Care, Complications, and Secondary Prevention
5. Professional Practice, Quality Improvement, and Special Populations
1. A 68-year-old male presents to the emergency department with sudden-onset right-sided
hemiparesis, global aphasia, and a gaze preference to the left, starting 90 minutes ago. His
NIHSS score is 18. Non-contrast head CT shows no acute intracranial hemorrhage. CT
angiography reveals a proximal left middle cerebral artery (MCA M1) occlusion. Blood pressure
is 165/95 mmHg. What is the most appropriate initial evidence-based management strategy?
A. Immediate administration of intravenous antihypertensives until blood pressure is below
120/80 mmHg prior to any other intervention
B. Immediate administration of intravenous alteplase or tenecteplase followed by emergent
endovascular thrombectomy (EVT) evaluation
C. Deferral of all reperfusion therapies for 24 hours to monitor spontaneous neurological
recovery
D. Immediate administration of therapeutic intravenous heparin infusion without thrombolytics
CORRECT ANSWER : B
Rationale: For patients presenting within the acute window with an acute ischemic stroke due to
a large vessel occlusion (LVO), standard guidelines recommend bridging therapy—intravenous
thrombolysis followed by urgent endovascular thrombectomy (EVT). Lowering BP below
, 180/105 is not required prior to alteplase unless it exceeds that threshold or other organ damage
exists. Options A, C, and D delay critical life-saving revascularization.
2. A 72-year-old female is evaluated 3 hours after the onset of acute left facial droop and left arm
weakness. Her NIHSS score is 6. Non-contrast head CT is negative for hemorrhage. Her past
medical history includes type 2 diabetes and a remote ischemic stroke 3 years ago. She takes
aspirin 81 mg daily. What is the most accurate statement regarding intravenous thrombolysis
eligibility under current guidelines?
A. A history of remote ischemic stroke combined with diabetes constitutes an absolute
contraindication to intravenous alteplase
B. A remote history of ischemic stroke more than 3 months ago combined with diabetes is
not an exclusion criterion, making her a candidate for IV thrombolysis
C. Antiplatelet monotherapy prevents the safe administration of intravenous thrombolytics
D. Age over 70 automatically disqualifies a patient from receiving intravenous tenecteplase
CORRECT ANSWER : B
Rationale: While a prior stroke within the past 3 months combined with diabetes is a
relative/absolute contraindication for alteplase, a remote stroke (> 3 months ago) is not an
exclusion criterion. Antiplatelet use alone does not preclude thrombolysis. Options A, C, and D
reflect outdated or incorrect clinical criteria.
3. A 55-year-old female is admitted to the stroke unit following a right hemispheric ischemic
stroke. Over the last 4 hours, she becomes increasingly somnolent, develops a new left-sided
pupillary dilation, and her blood pressure rises while her heart rate drops. What acute
neurosurgical complication is most likely occurring?
A. Acute subarachnoid hemorrhage expansion
B. Malignant MCA infarction resulting in uncal herniation and elevated intracranial
pressure
C. Central cord syndrome
D. Hypoglycemic encephalopathy
CORRECT ANSWER : B
Rationale: Large middle cerebral artery (MCA) infarctions can develop massive edema
(malignant MCA infarction), leading to severe intracranial pressure elevation, brain shift, and
uncal herniation (manifested by pupillary dilation and Cushing's triad). This often requires
emergent decompressive hemicraniectomy.
, 4. A stroke nurse is managing a patient receiving intravenous alteplase infusion. Thirty minutes into
the infusion, the patient acutely complains of tongue swelling, difficulty swallowing, and mild
hoarseness, accompanied by a drop in blood pressure to 90/60 mmHg. What is the immediate
priority action?
A. Increase the alteplase infusion rate to complete the dose faster
B. Immediately stop the alteplase infusion and administer emergency medications for
angioedema (e.g., IV methylprednisolone, diphenhydramine, and epinephrine if necessary)
C. Administer sublingual nitroglycerin for suspected myocardial infarction
D. Obtain a stat repeat non-contrast head CT scan
CORRECT ANSWER : B
Rationale: Oromilingual angioedema is a known, potentially life-threatening adverse reaction to
alteplase (especially in patients taking ACE inhibitors). The infusion must be stopped
immediately, and treatment for acute angioedema and airway protection must be initiated.
5. A 60-year-old male with an acute left MCA stroke is being evaluated for endovascular
thrombectomy (EVT). Perfusion imaging demonstrates a small core infarct volume of 15 mL
with a large penumbra (mismatch ratio > 1.8), and the time from last known well is 14 hours.
What is the clinical implication of these advanced imaging findings?
A. The patient is outside the treatment window and should receive comfort care only
B. The patient is a strong candidate for endovascular thrombectomy based on extended-
window trial criteria showing salvageable tissue
C. The presence of a penumbra means intravenous alteplase must be given regardless of the 4.5-
hour limit
D. Advanced imaging findings have no bearing on mechanical thrombectomy decisions
CORRECT ANSWER : B
Rationale: Advanced neuroimaging (CT perfusion or MRI) in the extended time window (6 to 24
hours) identifies patients with favorable mismatch profiles (small core, large penumbra) who
benefit significantly from mechanical thrombectomy despite the delayed presentation.
6. A 79-year-old male is admitted with an acute cardioembolic stroke due to newly diagnosed
persistent atrial fibrillation. His CHA2DS2-VASc score is 5. He has a small subcortical infarct
without hemorrhage on head CT. According to current guidelines, when is the optimal time to
initiate oral anticoagulation to balance stroke recurrence risk against hemorrhagic
transformation?
