SCRN Chapter 6 Stroke Diagnostics Exam

1. What is the only blood test you must have results of in order to safely administer IV tissue plasminogen activator (tPA)—besides international normalized ratio (INR), which is required for patients on Coumadin? A. Liver enzymes B. Cardiac enzymes C. Creatinine to know if CT angiography is safe D. Blood sugar - Answer- 1. D The American Heart Association guidelines state that "only blood glucose must precede the initiation of IV EPA" (Class I, Level of Evidence B recommendation). They also state that except for patients without suspicion of bleeding abnormality or thrombocytopenia, not on heparin or Coumadin, and not on other anticoagulants, IV EPA administration should not be delayed waiting for any other lab tests. Patients whose creatinine comes back elevated will have a decision made on an individual-case basis as to whether to stop the tPA, or continue (Jauch et al., 2013). 2. Patient X presents to the emergency department (ED) with right-sided weakness and speech difficulty at 10:00 a.m., reporting onset at 8:30 a.m. The CT was unremarkable. The wife says the only medication her husband takes is Coumadin. The international normalized ratio (INR) result is 1.9. What can you expect to do next? A. Mix and administer tissue plasminogen activator (EPA) according to the patient's actual weight B. Repeat the INR C. Continue to monitor vital signs and neurologic checks according to ED policy D. Prepare to discharge the patient from the ED - Answer- 2. C An INR of greater than 1.7 is a contraindication for administration of IV IPA 3. Identify the main reason why a CT scan is the first imaging study done in acute stroke. A. Most hospitals only have CT scan capability B. While not completely reliable, it is least expensive and the one insur. ance will cover C. There is less radiation involved than MRI D. CT is fast and reliable in ruling out cerebral hemorrhage - Answer- 3. D CT scans are more readily available in the majority of hospitals, are significantly quicker, and are reliable in ruling out hemorrhage. 4. The consulting neurologist recommends vascular imaging in order to determine if there is a large vessel occlusion. What test would you expect to see done next? A. PET scan B. CT angiogram (CTA) C. MRI D. Transcranial Doppler (TCD) - Answer- 4. B CTA is the most frequent emergent imaging test to visualize blood vessels. The prefix angio refers to blood vessels, so anytime you see angio in the name of a radiologic test it indicates that there will be evaluation of blood vessels. A plain CT looks at brain tissue, and a CTA looks at the cerebral vessels. An MRI looks at brain tissue, and a magnetic resonance mine angiography (MRA) looks at cerebral vessels. A PET scan is used to detect cancer, and a TCD is used to detect vasospasm and measure the velocity of the blood flow in the major cerebral arteries. 5. Patient Y presents to your emergency department (ED) at 3:00 p.m. with left-sided weakness onset at 10:30 a.m. The CT software is out of service so a stat MRI/magnetic resonance angiography (MRA) package is done that shows a perfusion-diffusion mismatch. This indicates which of the following? A. Presence of salvageable brain tissue, so thrombectomy should be considered B. Absence of salvageable brain tissue, so thrombectomy is not an option C. Technical error by imaging staff D. Presence of an uncommon cerebral anomaly - Answer- 5. A Perfusion-diffusion mismatch has been used in acute stroke to deterpresence or absence of salvageable tissue. The difference between the diffusion (water content) of the tissue and perfusion (blood supply) abnormalities provides a measure of the ischemic penumbra, or salvageable tissue. If the perfusion abnormality is larger than the area of restricted diffusion, the difference identifies the region of reversible ischemia. 6. Why is an echocardiogram done during acute hospital stays? A. The cause of up to 30% of strokes is cardiac related B. It is only required on patients older than 80 years C. To rule out incidental cardiomyopathy D. All patients with stroke are at risk for cardiomyopathy within 10 years - Answer- 6. A The cause of up to 30% of ischemic strokes is cardiac problems, so an echocardiogram is an essential component of acute stroke workup. 7. Why would the neurologist order a transesophageal echocardiogram (TEE) after the patient has already had a transthoracic echocardiogram (TTE)? A. Patient would not lie still for the TTE B. TEE offers superior visualization as there is no impedance from the chest muscles or rib cage NOST C. Latest guidelines recommend both be done for confirmed stroke patients D. The neurologist made a mistake and should be reminded that an echocardiogram was already done - Answer- 7. B For patients with a high suspicion of a cardiac source, or if an abnormality was seen on the TTE that the provider wants to examine more closely, a TEE is used because it is not impeded by the structures of chest muscles or rib cage. It is superior at identifying atrial and aortic abnormalities, such as patent foramen ovale (PFO) or aortic arch atherosclerosis. 8. Your stroke patient has just been ordered to have a video fluoroscopic swallowing exam. What is the provider looking for? A. Confirmation of successful bedside swallow screen B. Evaluation of swallowing function C. Evidence of aspiration D. Both B and C - Answer- 8. D A video fluoroscopic swallowing exam involves having the patient swallow contrast material while a visualization is done with fluoroscopic equipment. This provides information about swallowing ability as well as evidence of aspiration. 9. What further diagnostic tool might be used for a patient with cryptogenic stroke prior to or shortly after discharge from the hospital? A. Serial cardiac enzymes B. Genetic mapping C. Repeat CT in 1 month D. Implantable cardiac monitor to check for atrial fibrillation - Answer- 9. D For patients with a cryptogenic stroke (unknown cause), evidence has shown that implantable monitors detected atrial fibrillation during the months after discharge in up to 12% of patients who did not have atrial fibrillation detected on standard Holter monitor. 10. Your patient was told that she had a stroke at some time in the past, but she insists she has never had symptoms. How did her neurologist know this? A. Presence of encephalomacia on CT scan B. Presence of positive Babinski's sign during neurologic exam C. Prolonged QT interval on 12-lead EKG D. Information from the spouse during history taking - Answer- 10. A Encephalomacia is described as "softening of the brain tissue" and has numerous causes, one of which is stroke. It has a characteristic appearance on CT, and is also referred to as scar tissue after stroke. 11. A patient is brought to the emergency department (ED) by emergency medical services (EMS) with an original complaint of the worst headache of the patient's life, and is sleepy on arrival. You look to your ED colleague and say, "I'll bet you it's a A. Left middle cerebral artery (MCA) stroke B. Lacunar stroke in the right basal ganglia C. Complex migraine D. Subarachnoid hemorrhage - Answer- 11. D Subarachnoid hemorrhage patients often have a classic presentation of thunderclap headache, often called "the worst headache of their life." This is thought to be due to the irritation by the blood, increased pres- sure, and vasospasm. 12. Your patient's CT is negative for blood and there is high suspicion for subarachnoid hemorrhage (SAH). What other diagnostic test might you be told to set up for? A. Lumbar puncture B. Repeat CT C. Blood cultures D. Caloric testing - Answer- 12. A If CT is negative in a patient with a high suspicion for SAH, lumbar puncture will provide evidence whether or not there is xanthochromia in the cerebrospinal fluid (CSF). 13. Which diagnostic tool has been proven to not only diagnose and vasospasm in subarachnoid hemorrhage (SAH) but also to predict and enhance IV tissue plasminogen activator (EPA) outcomes? A. EEG B. Diffusion-weighted MRI C. PET scan D. Transcranial Doppler (TCD) - Answer- 13. D TCD studies done during infusion of IV tPA to monitor for vessel patency were found to augment the effect of the tPA, supposedly via the effect of ultrasound waves on the clot-it can hasten the dissolution of the clot. 14. Your patient has just had a diagnostic cerebral angiography. What are the most common complications you will monitor over the next 24 hours? A. Insertion site hematoma, stroke, and adverse reaction to contrast dye B. Insertion site hematoma, deep vein thrombosis (DVT), and adverse reaction to contrast dye C. Fever, headache, and insertion site hematoma D. Vessel wall tear, stroke, and DVT - Answer- 14. A Common complications associated with diagnostic cerebral angiography are insertion site hematoma, stroke, and adverse reaction to dye. As this test is done via an artery, DVT would not be a complication. 15. The Brain Attack Coalition set separate standards for door-to-CT scan initiation and results. Which of the following is correct? A. Door to CT in 35 minutes, results in 45 minutes B. Door to CT in 25 minutes, results in 45 minutes C. Door to CT in 10 minutes, results in 45 minutes D. No completion standard timeframe; just results within 60 minutes - Answer- 15. B The Brain Attack Coalition's recommendations for timeframes for CT are initiation in 25 minutes and interpretation in 45 minutes. 16. You are a stroke unit nurse and your new stroke patient has arrived from the emergency department (ED) without having a carotid ultrasound done. You call the provider to order one stat. Which would be the correct response by the provider? A. "Get a carotid ultrasound done stat" B. "A CT angiogram was done that provided carotid imaging" C. "The patient has an allergy to contrast dye, so a carotid ultrasound cannot be done" D. "Carotid disease is so rare that it is not necessary to do carotid imaging in stroke patients" - Answer- 16. B CT angiography provides carotid vessel imaging superior to standard carotid ultrasound, making it generally unnecessary to do a carotid ultrasound during the acute workup (Jauch et al., 2013, p. 885).