Stroke, TIA & haemorrhage flashcards
23 high-yield MRCP Part 1 cards from the Intellect Medicos Neurology course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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What is the first-line imaging in a patient with suspected acute stroke?
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Urgent non-contrast CT head.
Why? The immediate question is whether there is haemorrhage, because that decides whether thrombolysis is possible. Non-contrast CT answers this fastest.
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Within what time from symptom onset should IV thrombolysis be started for acute ischaemic stroke (standard window)?
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Within 4.5 hours of onset (as soon as possible), once haemorrhage is excluded.
Why? Benefit falls steeply with time. Beyond 4.5 h thrombolysis is only considered in selected patients with salvageable tissue on advanced imaging.
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What is the dose regimen of IV alteplase for acute ischaemic stroke?
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0.9 mg/kg (maximum 90 mg): 10% as an IV bolus over 1 minute, the rest infused over 60 minutes.
Why? Weight-based dosing with a cap limits bleeding risk while keeping the clot-lysing effect.
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CT confirms ischaemic stroke and thrombolysis was NOT given. What antiplatelet is started, and at what dose?
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Aspirin 300 mg as soon as possible (daily for 2 weeks), then long-term clopidogrel.
Why? Early aspirin reduces early recurrence. High-dose aspirin is used for the acute phase only.
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What is the standard long-term antiplatelet after ischaemic stroke or TIA?
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Clopidogrel 75 mg once daily.
Why? Clopidogrel is the NICE first choice for long-term secondary prevention after ischaemic stroke or TIA.
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A patient with AF has a disabling ischaemic stroke. When is anticoagulation usually started?
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After about 14 days (2 weeks); give antiplatelet therapy in the meantime.
Why? Early anticoagulation of a large fresh infarct increases the risk of haemorrhagic transformation.
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Mechanical thrombectomy needs a pre-stroke modified Rankin score ______ and an NIHSS score ______.
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below 3; above 5
Why? Thrombectomy helps patients with a significant deficit from a large-vessel occlusion who were functionally independent beforehand.
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What is the immediate management of a suspected TIA (symptoms resolved)?
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Aspirin 300 mg immediately (unless contraindicated) and referral to be seen by a stroke specialist within 24 hours.
Why? Stroke risk is highest in the first days after TIA, so start antiplatelet therapy and see the patient urgently whatever the ABCD2 score.
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A 68-year-old with a non-disabling left carotid-territory TIA has carotid duplex showing 75% stenosis by NASCET criteria. What is the definitive management, and how soon?
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Carotid endarterectomy, as soon as possible and within 7 days of symptom onset.
Why? Endarterectomy benefits symptomatic stenosis of 50-99% (NASCET) or 70-99% (ECST). The benefit is greatest when surgery is early.
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Acute intracerebral haemorrhage presenting within 6 hours, systolic BP 150-220 mmHg: what BP target, and how fast?
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Consider rapid lowering to a systolic BP of 140 mmHg or below (2023 UK stroke guideline: 130-139 mmHg within 1 hour), with a fall of no more than 60 mmHg within 1 hour of starting treatment.
Why? Rapid BP lowering limits haematoma expansion. IV labetalol is commonly used (nicardipine is an alternative).
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What is the first-line investigation for suspected subarachnoid haemorrhage (thunderclap headache)?
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Urgent non-contrast CT head.
Why? CT shows blood in the basal cisterns, sulci and ventricles. It is most sensitive within the first 6 hours.
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CT for suspected SAH was done more than 6 h after onset and is negative. What is the next test, and when?
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Lumbar puncture at least 12 hours after symptom onset, looking for xanthochromia (raised bilirubin).
Why? Bilirubin takes about 12 hours to form from red cells in the CSF. It separates a true bleed from a traumatic tap.
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Which drug is given after aneurysmal SAH to prevent delayed cerebral ischaemia, and for how long?
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Oral nimodipine for 21 days.
Why? Nimodipine is a dihydropyridine calcium-channel blocker. It reduces ischaemia from vasospasm, which peaks at days 3-14.
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What is the gold-standard investigation for cerebral venous sinus thrombosis?
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MR venography.
Why? MRV shows absent flow in the thrombosed sinus. Contrast CT may show the "empty delta" sign in sagittal sinus thrombosis.
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A patient with acute ischaemic stroke takes warfarin. Above what INR is IV thrombolysis contraindicated?
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INR above 1.7.
Why? Anticoagulation adds to the bleeding risk of thrombolysis, especially symptomatic intracranial haemorrhage.
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Which thrombolytic, given as a single IV bolus, is a NICE-approved alternative to alteplase for acute ischaemic stroke within 4.5 hours?
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Tenecteplase.
Why? It is more fibrin-specific and has a longer half-life than alteplase, so one bolus is enough. It needs the same eligibility checks, including haemorrhage excluded on imaging.
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NICE: offer thrombectomy for confirmed proximal anterior-circulation occlusion up to ______ after onset (with thrombolysis if eligible), and up to 24 hours after last known well if imaging shows salvageable brain tissue.
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6 hours
Why? Large-vessel occlusions respond poorly to thrombolysis alone. Later treatment (DAWN, DEFUSE-3 trials) depends on perfusion imaging showing tissue that can still be saved.
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NICE: offer thrombectomy for confirmed proximal anterior-circulation occlusion up to 6 hours after onset (with thrombolysis if eligible), and up to ______ after last known well if imaging shows salvageable brain tissue.
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24 hours
Why? Large-vessel occlusions respond poorly to thrombolysis alone. Later treatment (DAWN, DEFUSE-3 trials) depends on perfusion imaging showing tissue that can still be saved.
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Which statin, and at what dose, is used for secondary prevention after ischaemic stroke or TIA?
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Atorvastatin 80 mg once daily.
Why? A high-intensity statin lowers recurrent stroke and cardiac events.
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Intracerebral haemorrhage in a patient taking warfarin: how is the anticoagulation reversed?
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Prothrombin complex concentrate plus IV vitamin K.
Why? PCC replaces factors II, VII, IX and X within minutes. Vitamin K keeps the INR down once the PCC wears off.
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Which drug reverses dabigatran in life-threatening bleeding such as intracerebral haemorrhage?
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Idarucizumab.
Why? Idarucizumab is a monoclonal antibody fragment that binds dabigatran very tightly and reverses its effect within minutes.
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Head injury with a lucid interval, then rapid deterioration; CT shows a biconvex (lens-shaped) hyperdensity. Which vessel is usually the source?
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Middle meningeal artery (extradural haematoma).
Why? Arterial blood strips the dura off the skull but is stopped at suture lines, giving the lens shape. It needs urgent neurosurgical evacuation.
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A 42-year-old has left-sided neck pain and headache after a yoga class, a left partial Horner's syndrome and right arm weakness. What is the likely diagnosis, and how is it confirmed?
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Left internal carotid artery dissection; CT or MR angiography.
Why? Sympathetic fibres run on the carotid wall, so the Horner's is on the same side. The hemisphere deficit is on the opposite side.