FERNE On-Line CME Program

Emergency Department Ischemic Stroke Patient Care:
Advanced Diagnostics and Therapeutics

Please circle the correct answer.

Questions

1. All of the following are true regarding clinical information in the 2007 ASA ischemic stroke guidelines except:

a. In the new EMS section, it is recommended that acute ischemic stroke patients be transferred to "the     closest institution that can provide emergency stroke care".
b. Non-contrast CT is stated to be a sufficient test for the detection of findings that guide the use of tPA in     ED acute ischemic stroke patients.
c. It is recommended that caution be used when providing tPA to stroke patients with NIHSS scores greater     than 20 and those with severe deficits.
d. There is a clear protocol for therapy selection for the management of poorly controlled hypertension in the     setting of acute ischemic stroke.
e. The presence of a seizure is stated not to be a contraindication to the use of tPA in acute ischemic     stroke.

2. All of the following are true regarding stroke systems and stroke center designation except:

a. Less than 10% of the 5,000 acute care hospitals are designated as primary stroke centers by the Joint      Commission.
b. In a performance study from a sample of primary stroke centers, it was shown that tPA use increased     nearly 20% in these centers.
c. These is currently no Comprehensive Stroke Center designation provided by the Joint Commission.
d. Telemedicine is currently being used to allow for stroke patient care consultation to take place in     hospitals that do not have readily available neurology consultants.
e. There is a large body of evidence that demonstrates patient outcome improvement when guidelines are      followed in designated stroke centers.

3. Regarding the EMS triage and ED transfer of acute ischemic stroke patients to designated stroke centers or tertiary centers, which of the following is true?

a. There are clear guidelines regarding EMS triage of acute ischemic stroke patients.
b. There are clear guidelines regarding the ED transfer of acute ischemic stroke patients.
c. Current data supports the triage and transfer of most acute ischemic stroke patients to designated stroke     centers or tertiary centers.
d. The best current approach may be to rapidly provide IV tPA to appropriate acute ischemic stroke     patients in all hospitals with comprehensive EDs and then transfer patients who may benefit from     interventional radiology interventions to specialty centers.
e. In most hospitals, it is not possible to identify the anatomy of the CNS vascular occlusion in acute     ischemic stroke patients using CTA.

4. Which acute ischemic stroke patients might most benefit from transfer to stroke centers because of the ability to intervene in a delayed manner and because of the especially bad outcomes seen with these patients?

a. Vertebrobasilar artery occlusion stroke patients.
b. TIA patients.
c. Carotid artery occlusion stroke patients.
d. Middle cerebral artery occlusion stroke patients.
e. Stroke patients with minimal deficits and low NIHSS scores.

5. The four P's of acute ischemic stroke imaging include all of the following except:

a. Perfusion.
b. Pipes.
c. Paralysis.
d. Parenchyma.
e. Penumbra.

6. All of the following are true regarding neuroimaging in the diagnosis of acute ischemic patients except:

a. Non-contrast CT is sufficient in determining the emergency care that should be provided to ischemic     stroke patients.
b. Although the hyperdense middle cerebral artery (HDMCA) sign is possibly associated with a worse     outcome, its presence does not necessarily preclude the use of IV tPA in acute ischemic stroke patients.
c. DWI-PWI MRI imaging has been shown to be superior to CT perfusion studies in the identification of the     ischemic penumbra in ischemic stroke patients.
d. CT angiography is useful in detecting the location of the anatomical lesion that is causing the acute     ischemic stroke symptoms.
e. Vascular imaging is necessary in order to establish the utility of IA thrombolysis as well as surgical and     endovascular procedures.

7. In which of the following is the potential utility of thrombolysis in acute ischemic stroke patients the greatest:

a. Small core infarct and small ischemic penumbra.
b. Small core infarct and large ischemic penumbra.
c. Large core infarct and small ischemic penumbra.
d. Large core infarct and large ischemic penumbra.
e. Small core infarct with no ischemic penumbra.

8. The rationale for the use of intra-arterial (IA) thrombolysis in the treatment of acute ischemic stroke patients includes all of the following except:

a. Local administration may increase effectiveness and decrease hemorrhagic complications by allowing     for smaller drug doses to be utilized.
b. IA thrombolysis is proven to be more effective than the administration of IV tPA within the three hour     treatment window.
c. The effect of the thrombolysis on the thrombus can be directly observed radiographically while the therapy     is being provided.
d. The therapeutic window for the use of IA thrombolytics is longer that for IV tPA in ischemic stroke     patients.
e. IA thrombolysis after IV tPA may enhance the overall recanalization rates in acute ischemic stroke     patients.

9. All of the following are possible therapies that are provided in the interventional radiology suite in acute ischemic stroke patients except:

a. Intra-arterial (IA) thrombolysis.
b. Ultrasound assisted thrombolysis.
c. Mechanical clot extraction.
d. Vascular stenting.
e. Endovascular carotid endarterectomy.

10. Which of the following is the most important role of the emergency physician in the treatment of acute stroke patients?

a. Early treatment of eligible ischemic stroke patients with IV tPA.
b. Identification of the occlusive vascular lesion using advanced diagnostic neuroimaging such as CT     angiography.
c. Identification of the size of the infarct and ischemic penumbra using CT perfusion MRI diffusion perfusion     studies.
d. Transfer of all ischemic stroke patients to primary stroke centers.
e. Transfer of a maximal number of ischemic stroke patients to the interventional radiology suite.