Ischemic Stroke

Course #90282 - $40 • 10 Hours/Credits


Self-Assessment Questions

    1 . Which of the following is excluded from the cerebrovascular disease category in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10)?
    A) Cerebral infarction
    B) Intracerebral hemorrhage
    C) Subarachnoid hemorrhage
    D) Transient ischemic attacks (TIAs)

    OVERVIEW OF CEREBROVASCULAR DISEASE

    The multiple sources, pathophysiologic mechanisms, and sequelae of stroke are reflected in the diverse types of cerebrovascular disorders. The World Health Organization classifies cerebrovascular diseases under "Diseases of the circulatory system" in the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), the international standard diagnostic classification for all general epidemiologic purposes and many health management purposes (Table 2) [22]. Although TIAs, traumatic intracranial hemorrhage, and vascular dementia pertain to cerebrovascular disorders, they are excluded from the cerebrovascular disease category in the ICD-10. Their exclusion illustrates the heterogeneity of stroke and its sequelae. TIAs are classified under "Diseases of the nervous system: Episodic and paroxysmal disorders." Traumatic intracranial hemorrhage is listed under "Injury, poisoning, and certain other consequences of external causes: Injuries to the head," and vascular dementia, a common sequelae of stroke, is categorized under "Mental and behavioral disorders: Organic, including symptomatic, mental disorders."

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    2 . Which of the following is a classic sign/symptom of subarachnoid hemorrhage?
    A) Seizure
    B) Aphasia
    C) Photophobia
    D) Numbness/weakness

    OVERVIEW OF CEREBROVASCULAR DISEASE

    Subarachnoid hemorrhages occur less frequently than ICHs. The hallmark of subarachnoid hemorrhage is the immediate onset of a severe headache with signs of meningeal irritation [36]. Individuals may describe this headache as their "worst ever." Nausea, vomiting, neck pain, and photophobia are also classic symptoms, although they are not always present [36]. Neurologic deficits may be acute or may manifest hours to days after the onset of bleeding.

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    3 . What is the risk of a stroke within 7 days after a TIA for individuals who sought treatment for this event?
    A) 5%
    B) 10%
    C) 20%
    D) 50%

    OVERVIEW OF CEREBROVASCULAR DISEASE

    The risk of ischemic stroke is dangerously high in the period following a TIA. Research indicates that one-half of subsequent strokes occur within the first 48 hours, and a meta-analysis showed that approximately 5% of patients who have a TIA will have an ischemic stroke within 7 days of that event [11,43]. The risk of stroke within 3 months after a TIA is approximately 10% to 20% and is 24% to 29% over the following 5 years [11]. Early initiation of treatment for TIA and minor stroke with existing therapies has been shown to reduce the risk of early recurrent stroke by 80% [48].

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    4 . The most common focal neurologic sign of a TIA is the sudden onset of
    A) paralysis.
    B) imbalance.
    C) transient monocular blindness.
    D) unilateral weakness/numbness.

    OVERVIEW OF CEREBROVASCULAR DISEASE

    As with any stroke, the symptoms of TIA depend on the affected vascular territory. For instance, involvement of the carotid artery causes disturbances in the ipsilateral eye or brain [49]. Although the most common focal neurologic signs of TIA are sudden-onset unilateral weakness and numbness or tingling in a limb, a TIA can cause any of the following symptoms [49,50]:

    • Numbness of the face, hand, or leg, with or without weakness

    • Paralysis

    • Slurred speech

    • Dizziness

    • Double vision

    • Hemianopia

    • Transient monocular blindness

    • Imbalance

    • Aphasia

    • Confusion

    • Head pain

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    5 . Most individuals with stroke have recoverable penumbral tissue for at least how long after the onset of symptoms?
    A) 30 minutes
    B) 1 hour
    C) 2 hours
    D) 3 hours

    OVERVIEW OF CEREBROVASCULAR DISEASE

    Within minutes of the onset of ischemic stroke, the core of an infarct can begin to form at the least-perfused site. This site is encircled by an area partially altered metabolically and ionically by cytotoxic edema [55]. This area, the ischemic penumbra, is structurally intact and generally salvageable if reperfusion is achieved promptly. Because cerebral function deficits develop rapidly (within minutes to hours) as an ischemic stroke progresses, these brain attacks are a medical emergency. Each minute that passes results in an average loss of 1.9 million neurons and 14 billion synapses; an ischemic brain ages 3.6 years for every hour that passes after the onset of stroke [56]. For this reason, stroke specialists use the mantra, "time is brain." Although irreversible damage occurs, most individuals with stroke have recoverable penumbral tissue for at least 3 hours following the onset of symptoms [16].

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    6 . An ischemic stroke in the right anterior hemisphere would cause which of the following neurologic deficits?
    A) Ataxia
    B) Aphasia
    C) Nystagmus
    D) Left field visual neglect

    OVERVIEW OF CEREBROVASCULAR DISEASE

    GENERAL REGIONS OF ISCHEMIC STROKE AND CORRESPONDING NEUROLOGIC DEFICITS

    Affected RegionCommon Signs and Potential Sequelae
    Left anterior hemisphere
    Aphasia (esp. difficulty reading, writing, calculating)
    Right limb weakness and sensory loss Right field visual defect
    Right anterior hemisphere
    Limb motor weakness or loss
    Left field visual neglect
    Unable to determine two-point stimuli on left side
    Left posterior cerebral artery
    Aphasia (esp. difficulty reading, naming objects)
    Right visual field defect
    Occasionally, right-sided numbness
    Right posterior cerebral artery
    Left limb sensory loss
    Left-sided neglect Left field visual defect
    Vertebrobasilar territory (posterior circulation)
    Bilateral vision disturbances and nystagmus
    Dysarthria and dysphagia
    Ataxia
    Dizziness, vomiting, headache
    No cortical deficits (e.g., aphasia, cognitive impairments)
    Caudate nucleus, thalamus, frontal lobe (anterior circulation)Sudden abnormal behavior
    Thalamus (posterior circulation)Numbness, decreased sensation on face, arm, leg on same side
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    7 . Which of the following is part of the posterior circulation of the brain?
    A) Choroidal artery
    B) Vertebrobasilar artery
    C) Internal carotid artery
    D) Posterior communicating artery

    OVERVIEW OF CEREBROVASCULAR DISEASE

    Posterior circulation is primarily composed of the vertebrobasilar artery, the posterior cerebral artery, which it supplies, and other branching vessels [57]. The posterior cerebral artery provides blood to the occipital and medial temporal lobes, as well as regions of the midbrain, subthalamic nucleus, basal nucleus, thalamus, mesial inferior temporal lobe, and occipitoparietal cortices. The two main segments of the posterior cerebral artery (P1 and P2) are connected by the posterior communicating artery. The Circle of Willis links the anterior and posterior circulation at the base of the brain.

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    8 . The most common cause of embolic stroke is
    A) atrial fibrillation.
    B) valvular thrombi.
    C) myocardial infarction.
    D) congestive heart failure.

    OVERVIEW OF CEREBROVASCULAR DISEASE

    AF is the most common cause of embolic stroke, increasing the risk of embolic stroke fivefold and doubling the risk of death [76,77]. Patients with valvular thrombi, from endocarditis or prosthetic valves, or mural thrombi from myocardial infarction (MI), AF, severe heart failure, or patent foramen ovale, are at high risk for the development of emboli [78,79]. MI is associated with a 2% to 3% incidence of embolic stroke, 70% of which occur in the first week after the event [77,79].

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    9 . At 3 months after a stroke, what percentage of stroke survivors need long-term care?
    A) 10%
    B) 20%
    C) 40%
    D) 60%

    OVERVIEW OF CEREBROVASCULAR DISEASE

    Approximately 16% of men and 14% of women have a stroke by 85 years of age, and stroke is the fifth leading cause of death in the United States, accounting for nearly 133,000 deaths in 2014 [1,3,84]. Morbidity associated with stroke is also high, with at least 65% of stroke survivors having some sort of impairment [85]. At 3 months after a stroke, approximately 20% of survivors depend on long-term care. Between 15% and 30% of stroke survivors are permanently disabled [86]. A 6-month follow-up of ischemic stroke survivors (65 years of age and older) demonstrated that [87]:

    • 50% had some degree of hemiparesis

    • 35% had depressive symptoms

    • 30% were unable to walk without some assistance

    • 26% were dependent in activities of daily living

    • 26% were in a nursing home

    • 19% had aphasia

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    10 . The average age at the time of ischemic stroke is
    A) 65 years in men and 70 years in women.
    B) 70 years in both men and women.
    C) 71 years in men and 75 years in women.
    D) 80 years in men and 81 years in women.

    OVERVIEW OF CEREBROVASCULAR DISEASE

    Prolonged damage of the aging cardiovascular system by various risk factors for stroke doubles the risk of ischemic stroke for each decade of life after 55 years of age [9]. Thus, clinicians should be sensitive to their patients' modifiable risk factors, most notably hypertension, starting at an early age [1]. As many as 70% of strokes occur in individuals older than 65 years of age, and the average age at the time of ischemic stroke is 71 years in men and 75 years in women [1]. Stroke patients 85 years of age and older comprise 17% of all stroke patients [1].

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    11 . According to statistics presented by the American Heart Association (AHA), which of the following populations has the highest prevalence for stroke?
    A) Black
    B) White
    C) Hispanic or Latino
    D) Non-Hispanic black

    OVERVIEW OF CEREBROVASCULAR DISEASE

    RACIAL/ETHNIC VARIATIONS IN PREVALENCE OF STROKE AND HYPERTENSION

    PopulationStroke PrevalenceHypertension Prevalence
    Non-Hispanic Black4.5%42.1%
    American Indian/Alaskan Native3.0%NA
    Non-Hispanic White2.5%28.0%
    Hispanic or Latino2.4%24.7%
    NA = Not available
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    12 . Which of the following has the most evidence as a risk factor for ischemic stroke?
    A) Hypertension
    B) Hypercoagulability
    C) Metabolic syndrome
    D) Sleep-disordered breathing

    OVERVIEW OF CEREBROVASCULAR DISEASE

    MODIFIABLE RISK FACTORS FOR STROKE

    Well-Documented FactorsaLess-Documented Factorsb
    Hypertension
    Atrial fibrillation (AF)
    Diet and nutrition
    Diabetes
    Cigarette smoking
    Dyslipidemia
    Obesity and body fat distribution
    Cardiac conditions other than AF
    Asymptomatic carotid stenosis
    Sickle cell disease
    Physical inactivity
    Metabolic syndrome
    Inflammation and infection
    Migraine
    Alcohol abuse
    Hypercoagulability
    Sleep-disordered breathing
    Elevated lipoprotein (a)
    Drug abuse
    Hyperhomocysteinemia
    aListed in descending order of quality of documentation.
    bInformation on less-documented risks for stroke can be found in the American Heart Association (AHA) guideline, "Primary Prevention of Stroke."
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    13 . According to the 2017 guideline, how often should an individual with a blood pressure of 124/85 mm Hg be screened for hypertension?
    A) Every month
    B) Every 3 to 6 months
    C) Every 2 years
    D) Every 3 years

    PREVENTION

    The 2017 Guideline for High Blood Pressure in Adults recommends screening every 2 years for adults with a blood pressure less than 120/80 mm Hg and screening every 3 to 6 months for people with systolic blood pressure of 120 to 129 mm Hg or with diastolic blood pressure less than 80 mm Hg [124]. The AHA/ASA recommends that women be screened for high blood pressure before taking birth control pills, as the combination increases the risk of stroke [125].

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    14 . What percentage of individuals with acute ischemic stroke receive thrombolytic therapy when they arrive at an emergency department within 3 hours after the onset of symptoms?
    A) 2% to 4%
    B) 8% to 10%
    C) 20% to 30%
    D) 50% to 70%

    PREVENTION

    Although public knowledge regarding the warning signs and risks of stroke has improved, the majority of the general public is still unaware that early treatment can prevent severe disability and death [132,133]. Estimates vary widely, however; the International Stroke Trial found that only 4% of patients with acute ischemic stroke arrive at the emergency department (ED) within 3 hours after the onset of symptoms, and a separate study found that 21% to 25% of individuals with acute ischemic stroke arrive at an ED within the same timeframe [134,135]. Of these individuals, 2% to 4% receive thrombolytic treatment [136,137]. It has been estimated that if all individuals called for emergency help at the onset of symptoms, as many as 29% could realistically receive treatment within 3 hours [136]. In addition, if all patients arrived at the ED within 1 hour after known symptom onset and received optimal treatment, the projected rate of thrombolysis would be 57%.

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    15 . Which of the following statements regarding predicting stroke risk is TRUE?
    A) Validated tools are available to assess the risk of stroke.
    B) The ABCD assessment includes points for laboratory results.
    C) Risk assessment tools have been shown to improve primary prevention.
    D) Interactivity among independent risk factors can affect risk prediction.

    PREVENTION

    The numerous nonmodifiable and modifiable factors that contribute to the risk of stroke have been discussed. Although many of these are independent risk factors, their interactions can affect predictions and management decisions in unexpected ways. No simple, validated stroke risk-assessment tool is currently available [9]. Although risk-assessment tools may have some utility, it is unknown if they improve primary prevention, especially when applied across subgroups according to age, gender, and race/ethnicity [9,143].

    Because TIA is a substantial risk factor for a subsequent stroke, clinicians in many EDs are stratifying such patients by degree of risk with use of the ABCD or ABCD2 assessments [144,145]. The ABCD clinical tool is designed to predict 7-day risk of stroke through assessment of age (1 point for patients 60 years of age or older), blood pressure (1 point for a blood pressure greater than 140/90 mm Hg), clinical features (2 points for unilateral weakness with or without speech impairment or 1 point for speech impairment without weakness), and duration (1 point for 10 to 59 minutes, 2 points for greater than 59 minutes) [146]. The "2" designation in ABCD2 was added to represent the presence or absence of diabetes. The effectiveness of these screening tools is lessened by the fact that some individuals do not seek emergency care for a TIA or do not report a TIA to their clinician. However, the ABCD2 assessment has been shown to identify 21% of individuals with a high 2-day risk of having an ischemic stroke [144]. Individuals with high-risk TIA require the same intensity of evaluation and stroke prevention as individuals with ischemic stroke.

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    16 . Which of the following is NOT recommended as part of the initial evaluation (in the emergency department) of an individual with suspected stroke?
    A) Urine culture
    B) Oxygen saturation
    C) Determination of electrolyte levels
    D) Computed tomography of the brain

    EARLY MANAGEMENT

    IMMEDIATE DIAGNOSTIC STUDIES TO EVALUATE PATIENTS WITH SUSPECTED ISCHEMIC STROKE, AS RECOMMENDED BY THE AMERICAN HEART ASSOCIATION

    PopulationDiagnostic Test
    All patients Cerebral computed tomography or magnetic resonance imaging (without contrast medium)
    Blood glucose
    Serum electrolytes/renal function tests
    Markers of cardiac ischemia
    Complete blood count, including platelet count
    Prothrombin time/international normalized ratio (INR)
    Activated partial thromboplastin time
    Oxygen saturation
    Electrocardiography
    Selected patients Hepatic function tests
    Toxicology screen
    Blood alcohol level
    Pregnancy test
    Arterial blood gas tests (if hypoxia is suspected)
    Chest radiography (if lung disease is suspected)
    Lumbar puncture (only if stroke is suspected to be secondary to an infectious disease)
    Electroencephalography (if seizures are suspected)
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    17 . Which of the following clinical signs suggests subarachnoid hemorrhage rather than ischemic stroke?
    A) Ptosis or miosis
    B) Severe headache
    C) Fever and cardiac murmur
    D) Elevated erythrocyte sedimentation rate

    EARLY MANAGEMENT

    If a patient presents with classic signs of stroke and has one or more cardiovascular risk factors, the diagnosis of stroke can be straightforward. However, identifying more unusual cases may be a challenge. If fever and a cardiac murmur are present, the cause of the stroke may be infective endocarditis [151,152]. Giant cell arteritis may be the cause if the patient is 50 years of age or older, has a headache, and has an elevated erythrocyte sedimentation rate. The presence of ptosis and miosis contralateral to the deficit may suggest carotid artery dissection [151,152]. If the symptoms were maximal at their onset, a subarachnoid hemorrhage or embolic stroke should be suspected [153]. In up to 40% of patients with subarachnoid hemorrhage, a severe headache (sometimes called a thunderclap or sentinel headache) that may abate within minutes or hours is the only symptom [153]. Cerebral CT should be immediately performed in any patient with a suspected subarachnoid hemorrhage [36].

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    18 . Which of the following statements regarding stroke centers is TRUE?
    A) A stroke system of care improves acute and post-acute care but has no effect on EMS.
    B) There is no formal certification process for designating an institution as a comprehensive stroke center.
    C) Most states have policies mandating direct routing of individuals with suspected stroke to a primary stroke center.
    D) Individuals with stroke are more likely to receive thrombolytic therapy at a primary or comprehensive stroke center.

    TREATMENT

    Comprehensive stroke centers are designed to accommodate the needs of patients with complicated forms of stroke, intracranial hemorrhages, and subarachnoid hemorrhages, as well as patients in need of aggressive intervention measures and intensive care [19]. In general, primary and comprehensive stroke centers have been shown to be associated with better adherence to evidence-based guidelines and with an increased use of intravenous rt-PA [173]. Nationally, only 2% to 3% of individuals with stroke are treated with rt-PA, but the rate is typically greater than 10% at primary and comprehensive stroke care centers [19,137]. Overall care may also be improved at comprehensive stroke centers [173,174]. A formal certification process for comprehensive stroke centers has been established by the Joint Commission and the ASA. The Joint Commission has been certifying primary stroke centers since 2004, and it began providing certification for comprehensive stroke centers in 2014 [16]. Because patients are more likely to receive thrombolytic therapy at primary and comprehensive stroke centers, many states have enacted policies mandating the direct routing of individuals with suspected stroke (with onset of symptoms less than 3 hours previously) to either of these types of facilities. As of 2015, 1,505 of the 4,640 general hospitals and emergency rooms in the United States have been certified as primary stroke centers [175]. Seventy-four percent of the primary stroke centers have been certified by the Joint Commission and the AHA/ASA, 20% have been certified by state organizations, and 6% have been certified by other organizations. The highest proportion of primary stroke center certifications has occurred in the Northeastern United States [175]. Telemedicine for stroke (also called telestroke) and air transport are being increasingly used to serve individuals in rural areas that lack local stroke expertise [16,174].

    Stroke centers are commonly part of a comprehensive support network known as a stroke system of care [16]. The system seeks ways to coordinate the highest quality of stroke prevention, community education, EMS, acute care, and post-acute care. Without a system of care, these components often operate less effectively and in isolation. Implementation of a stroke system of care in underserved regions could substantially improve treatment statistics statewide or nationwide; for example, one study showed that the additional resources at as few as six target hospitals in the western part of North Carolina would increase patient access to stroke care by 61.5% throughout the state [176].

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    19 . The most common serious medical complication of rt-PA is
    A) angioedema.
    B) anaphylaxis.
    C) myocardial rupture.
    D) secondary brain hemorrhage.

    TREATMENT

    The most common serious medical complication of rt-PA is secondary brain hemorrhage, which occurs in 6% of patients [16,180]. Yet, the risk does not outweigh the benefits of rt-PA. Three months following rt-PA therapy, approximately 30% of patients are neurologically normal or near normal; 30% have mild-to-moderate neurologic deficits; 20% have moderate-to-severe deficits; and 20% have died [181]. Other dangerous complications of rt-PA, although rare, are angioedema, anaphylaxis, systemic hemorrhage, and, if rt-PA is administered soon after an acute MI, myocardial rupture [16,182].

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    20 . Which of the following settings is associated with the best rehabilitation care for patients with ischemic stroke?
    A) Patient's home
    B) Inpatient stroke unit
    C) Long-term care facility
    D) Outpatient therapy clinic

    REHABILITATION

    Rehabilitation in a stroke unit has been associated with better outcomes than rehabilitation in a general healthcare facility, with improved quality of life, survival, and functional status at 5 years [17,21,217,218,219,220,221]. Yet the decision to refer a stroke patient to a particular setting after discharge is dictated by a complex set of demographic, clinical, and nonclinical factors that are also inevitably related to patient outcomes [21]. Variations in outcomes for inpatient stroke rehabilitation have been found among racial/ethnic populations [21,222,223,224,225,226]. Black individuals have less functional improvement at discharge compared with white individuals and are more likely to be discharged to home despite worse functional independence measure (FIM) scores [227]. Asian individuals have functional improvements similar to those for white individuals but have less improvement at 3 months after discharge [227]. These disparities point to the need for focused attention on appropriate rehabilitation services for minority populations.

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    21 . Which of the following statements regarding pressure ulcers is TRUE?
    A) Pain is a hallmark characteristic of a severe pressure ulcer.
    B) Lower body mass index is a risk factor for pressure ulcer.
    C) Patients should be monitored every other day for skin breakdown.
    D) Most pressure ulcers are associated with superficial tissue injury only.

    REHABILITATION

    Pressure ulcers are a commonly encountered complication in hospital and long-term care facilities, occurring in approximately 10% and 25% of patients in those settings, respectively [254]. According to the National Pressure Ulcer Advisory Panel, a pressure ulcer is a "localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear" [255,256]. Although ulcers typically occur proximal to osseous prominences (e.g., the sacrum, hips, ankles), skin breakdown at the ears is also common in certain settings [257,258]. Most pressure ulcers are associated with deep tissue injury [259]. Regular assessment of skin and the use of objective risk scales (e.g., the Braden scale) may help prevent skin injury and should be followed by regular skin inspection with documentation [21,260]. Risk factors for pressure ulcers include [254]:

    • Immobility

    • Poor hygiene

    • Urinary incontinence and other sources of moisture

    • Diabetes and other causes of poor circulation

    • Peripheral vascular disease

    • Lower body mass index

    • Localized infection or trauma

    • Edema

    • Poor hydration and/or nutrition

    Conditions secondary to pressure ulcers include pain, localized infection, cellulitis, osteomyelitis, sepsis, and even death [261,262]. However, not all pressure ulcers, even those that are severe, will elicit a pain sensation [263].

    Ulcers can be prevented or minimized with several measures, including proper positioning, turning, and transferring techniques; good hygiene; proper nutrition and hydration; and the use of barrier sprays, special mattresses, and protective dressings [21,260]. Good pain management may be necessary to perform correct positioning and frequent turning. Patients should be monitored daily for skin breakdown [21]. Any sign of a pressure ulcer warrants daily treatment [21].

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    22 . The diagnosic study of choice for deep vein thrombosis is
    A) D-dimer test.
    B) echocardiography.
    C) Doppler ultrasound.
    D) Well's prediction model.

    REHABILITATION

    The D-dimer test alone is not recommended to rule out DVT in patients who have had a stroke. Patients with intermediate-to-high risk for DVT should be screened with use of ultrasonography. This imaging modality may not detect DVT in the calf, however, and repeat ultrasonography or venography should be used when DVT in the calf is suspected. Contrast venography was previously the most definitive test for the diagnosis of DVT, but today, Doppler ultrasound is the diagnostic study of choice [267].

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    23 . Which of the following statements regarding assessment of patients with stroke is TRUE?
    A) Psychosocial support is not useful for fecal incontinence.
    B) Pain is most commonly caused by sensorimotor pathway damage.
    C) Cognitive impairment is associated with post-stroke urinary dysfunction.
    D) The STRATIFY tool is effective in predicting the risk of a fall in stroke survivors.

    REHABILITATION

    Large infarcts, aphasia, cognitive impairment, functional disability, lesions in the frontal cortex or frontoparietal lobes, and advanced age are associated with post-stroke urinary dysfunction [278]. Medications such as diuretics, alpha-adrenoreceptor blockers, and anticholinergic drugs can cause or exacerbate this complication [279,280]. Hyper-reflexia and hyporeflexia are the most common mechanisms of urinary incontinence in stroke survivors [281]. Detrusor sphincter dyssynergia, a cause of incomplete bladder voiding, is uncommon because its pathogenesis involves lesions between the brain stem and spine [280]. When assessing bladder function in patients with acute stroke, it is important to evaluate urinary retention with use of a bladder scanner or an in-and-out catheterization; urinary frequency, volume, and control; and the presence of dysuria. Patients who have urinary incontinence may benefit from bladder-training regimens and scheduled voiding [279,282].

    Risk factors for impaction and constipation include immobility, inactivity, dehydration, some medications, mood disorders, and cognitive deficits [284,285]. Multivariate analysis has shown that advanced age and diabetes are risk factors for fecal incontinence [285]. Patients with persistent constipation or fecal incontinence may benefit from bowel-management programs and psychosocial support [286]. Because of the risk of skin breakdown, the social stigma, and the burden of care associated with bowel and bladder incontinence, management is an essential component of the rehabilitation process [21].

    The Berg Balance Scale may be the most appropriate screen for patients who are likely to fall [291,292]. This scale tests 14 specific functional movements of daily living of increasing difficulty [293]. The 56-point maximum score indicates adequate balance and low risk of a fall. A score of less than 45 is associated with a proclivity for falling [291,293]. The score at 2 months post-stroke is useful for informing a patient's risk of falls, but it does not account for the multifactorial nature of the problem and should not preclude risk management provided in conjunction with exercise interventions, such as rehabilitation that targets gait coordination, to improve mobility [288,294]. If the patient is able to walk, the Stops Walking When Talking test may further help to identify the risk for a fall [291]. With this test, the examiner initiates a conversation with the patient while walking; if the patient stops walking to respond, the risk of a fall is increased [295]. St. Thomas' Risk Assessment Tool in Falling Elderly Inpatients (known as STRATIFY), a tool used commonly in the rehabilitation setting, has been shown to be a poor predictor of the risk for fall when screening patients with stroke [296].

    Pain is one of the most frequently experienced complications. Almost one-half of all stroke survivors experience chronic pain, 65% of whom have shoulder pain [254]. Whether chronic or periodic, pain can delay functional recovery by masking motor function improvement, diminishing a patient's motivation or willingness to perform rehabilitative tasks, or limiting the patient's movement or requiring the use of a cane or wheelchair for ambulation [17]. Pain most often results from joint immobilization and the fixation of tendons and ligaments in one position [85]. In some patients, however, stroke-induced sensorimotor pathway damage leads to the sensation of pain in an affected extremity or side of the body. The most common pain syndrome of this type is central post-stroke pain, which affects 8% of patients, or at least 56,000 stroke patients in the United States each year [21,297,298]. Four percent of patients with central post-stroke pain experience it as shoulder pain. Central post-stroke pain can be difficult to manage, even with medications. Only amitriptyline and lamotrigine have been shown to be effective in placebo-controlled studies [299].

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    24 . Chronic pain after stroke most commonly involves a
    A) hip.
    B) hand.
    C) shoulder.
    D) lower extremity.

    REHABILITATION

    Pain is one of the most frequently experienced complications. Almost one-half of all stroke survivors experience chronic pain, 65% of whom have shoulder pain [254]. Whether chronic or periodic, pain can delay functional recovery by masking motor function improvement, diminishing a patient's motivation or willingness to perform rehabilitative tasks, or limiting the patient's movement or requiring the use of a cane or wheelchair for ambulation [17]. Pain most often results from joint immobilization and the fixation of tendons and ligaments in one position [85]. In some patients, however, stroke-induced sensorimotor pathway damage leads to the sensation of pain in an affected extremity or side of the body. The most common pain syndrome of this type is central post-stroke pain, which affects 8% of patients, or at least 56,000 stroke patients in the United States each year [21,297,298]. Four percent of patients with central post-stroke pain experience it as shoulder pain. Central post-stroke pain can be difficult to manage, even with medications. Only amitriptyline and lamotrigine have been shown to be effective in placebo-controlled studies [299].

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    25 . The cognitive function that shows the most improvement by 6 months after stroke is
    A) language.
    B) calculation.
    C) visual memory.
    D) abstract reasoning.

    REHABILITATION

    Calculation, executive functioning (the integration of multiple and complex processes), and visual perception/construction are the cognitive arenas most often affected during the first several weeks after a stroke [303,304]. Up to 88% of patients with a cerebellar stroke have cognitive deficits, such as impairments in abstract thought, attention, control, memory, planning, and speech [305]. In many cases, patients with stroke-associated right brain damage have anosognosia, a condition in which patients are rendered unaware of their contralateral sensory and motor neurologic deficits (hemiplegia, hemianesthesia, and hemianopia) [306]. Although many survivors regain some or all cognitive skills soon following a stroke, up to 38% remain cognitively impaired at 3 months [307]. Recovery rates may be as high as 80% within 6 months for stroke survivors, with visual perception and visual memory showing the most improvement and language and abstract reasoning showing the least [308,309]. At 1 and 3 years after a stroke, cognitive impairment is one of the factors most strongly linked with poor physical and mental health status [310]. Cognitive status is an important determinant of post-stroke success. The AHA/ASA recommend that all stroke patients be screened for cognitive deficits before being discharged to home [21].

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    26 . A stroke survivor who interprets figurative speech literally has
    A) dysarthria.
    B) receptive aphasia.
    C) apraxia of speech.
    D) expressive aphasia.

    REHABILITATION

    CHARACTERISTICS OF EXPRESSIVE AND RECEPTIVE APHASIA

    Patients with expressive aphasia may:
    Use single words or short phrases
    Omit smaller words like "the," "of," or "and" (the patient's message may sound like a telegram)
    Say words out of sequence
    Switch sounds or first letters of words (e.g., dishwasher becomes a "wish dasher")
    Invent words
    Create meaningless sentences by fluently stringing nonsense words and real words together
    Patients with receptive aphasia may:
    Require a significant amount of extra time to understand verbal communication, especially if the speech is fast
    Have difficulty following radio or television news
    Interpret figurative speech (e.g., "It's raining cats and dogs.") literally
    Patients frequently have global aphasia, with various combinations of expressive and receptive difficulties.
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    27 . Which of the following statements regarding psychologic issues in stroke patients is TRUE?
    A) Symptoms of post-stroke depression are obvious.
    B) Depression occurs in 15% of patients after stroke.
    C) Generalized anxiety disorder often coexists with post-stroke depression.
    D) Post-stroke depression does not respond well to selective serotonin reuptake inhibitors.

    REHABILITATION

    Following a stroke, it is understandable that patients and their families experience intense emotions. In many cases, the staff's kindness and helpfulness, familial support, and the passage of time allow patients and their families to deal with the grief and other feelings precipitated by the stroke without medication or psychologic therapy. However, approximately 33% of patients experience post-stroke depression, and other mood disorders also manifest in stroke survivors [1,319,320]. In general, psychologic conditions can have a significant impact on the success of rehabilitation. Thus, all patients should be thoroughly evaluated for psychologic disorders as early as possible and on an ongoing basis [21].

    Detecting post-stroke depression can be particularly challenging, as symptoms often appear to be typical post-stroke symptoms or are subtle. Patients may experience fatigue, sleeping difficulties, loss of appetite, tearfulness, and feelings of hopelessness. They may refuse to participate in therapy [21]. Additionally, cognitive deficits may prevent the patient from recognizing or having the ability to communicate depressive symptoms. Patients with an acquired flat affect may "sound sad" or indifferent to their situation without having post-stroke depression. Although several screening tools for depression in the older population are available (Table 24), a single, universally accepted evaluation tool for post-stroke depression has not been developed. Because little research in this area is available and the condition is underdiagnosed by nonpsychiatric physicians, the diagnosis of post-stroke depression should be based on information from multiple sources, including medical evaluation, patient self-report, observation of patient behavior, patient history, and staff reports of changes in behavior and motivation.

    The accompaniment of post-stroke depression with other psychologic disorders is not uncommon [21]. Therefore, the medical evaluation should also screen for other categories of psychiatric symptoms [21]. Generalized anxiety disorder, which affects 20% of survivors, often coexists with post-stroke depression [324]. Generalized anxiety disorder delays the recovery of the ability to carry out activities of daily living and negatively affects social functioning [21]. Additionally, up to 15% of stroke survivors have pseudobulbar affect, characterized by uncontrollable laughing/crying [21].

    Both post-stroke depression and pseudobulbar affect respond well to selective serotonin reuptake inhibitors [325]. Although these drugs carry some risk, they are safe in most patients who have had a stroke. However, these medications should not be administered prophylactically [326,327]. Although studies are limited, the use of cognitive-behavioral therapy techniques and brief supportive therapy in conjunction with medication may be beneficial to those with post-stroke depression and other neuropsychiatric sequelae of stroke [21].

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    28 . Increasing safety during activities of daily living is a major goal of which type of exercise?
    A) Aerobic
    B) Neuromuscular
    C) Strength training
    D) Flexibility/stretching

    REHABILITATION

    SUMMARY OF EXERCISE PROGRAM RECOMMENDATIONS FOR STROKE SURVIVORS

    Mode of ExerciseMajor GoalsIntensity, Frequency, Durationa
    Poor specificity in detecting major depression
    Increase independence in activities of daily living
    Increase walking speed/efficiency
    Improve tolerance for prolonged physical activity
    Reduce risk of cardiovascular disease
    Reduce motor impairment; improve cognition
    40% to 70% peak oxygen uptake; 40% to 70% heart rate reserve; 55% to 80% maximal heart rate; rating of perceived exertion (RPE) 11–14 (6–20 scale) 3 to 5 days/week 20 to 60 min/session (or multiple 10-min sessions)
    Complement with pedometers to increase lifestyle physical activity
    Strength (e.g., circuit training, weight machines, free weights, isometric exercise)
    Increase independence in activities of daily living
    Increase muscle strength and endurance
    Reduce cardiac demands during lifting/carrying objects by increasing muscular strength
    1–3 sets of 10–15 repetitions of 8–10 exercises involving the major muscle groups
    2 to 3 days/week, with resistance gradually increased over time as tolerance permits
    Flexibility/stretching
    Increase range of motion (ROM) of involved extremities
    Prevent contractures
    Decrease risk of injury
    Increase activities of daily living
    2 to 3 days/week (Before or after aerobic or strength training) Hold each stretch for 10 to 30 seconds
    Neuromuscular (coordination and balance activities)
    Improve level of safety during activities of daily living
    Improve balance, skill reacquisition, quality of life, mobility
    Decrease fear of falling
    2 to 3 days/week (Consider performing on same day as strength activities)
    aRecommended intensity, frequency, and duration of exercise depend on each individual patient's level of fitness.
    Intermittent training sessions may be indicated during the initial weeks of rehabilitation.
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    29 . The risk for recurrent stroke is highest during the first
    A) 3 months.
    B) 6 months.
    C) 12 months.
    D) 18 months.

    SECONDARY PREVENTION: EVIDENCE-BASED RECOMMENDATIONS

    A patient's risk for a recurrent stroke is highest during the first year; 14% of survivors have a recurrent stroke within 1 year after the initial cerebrovascular event, suggesting that secondary prevention is time-critical and should be initiated during the rehabilitation process [341]. After the first year, the chance of recurrent stroke decreases to 4% per year [340]. Because TIA is an important determinant of stroke, the AHA secondary prevention guidelines for patients with TIA tend to be as aggressive as those established for ischemic stroke [10]. The guidelines focus on controlling several important modifiable risk factors.

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    30 . Which of the following hypertensive agents most significantly reduces the risk of recurrent ischemic stroke?
    A) Beta blocker alone
    B) Angiotensin receptor blocker (ARB) alone
    C) Angiotensin converting enzyme (ACE) inhibitor alone
    D) Diuretic alone or combined with an ACE inhibitor

    SECONDARY PREVENTION: EVIDENCE-BASED RECOMMENDATIONS

    The results of meta-analyses have indicated that lowering blood pressure reduces the risk of stroke 30% to 40% [342,343]. The findings of longitudinal studies suggest that treatment with antihypertensive medications in hypertensive and normotensive patients reduces the incidence of recurrent strokes, MI, and other vascular events [344]. In particular, diuretics or diuretics combined with ACE inhibitors (e.g., ramipril, perindopril) most significantly reduce the risk of recurrent ischemic stroke [10,344]. However, lifestyle modifications that include weight loss; increased intake of fruits, vegetables, and low-fat dairy products; habitual aerobic physical activity; and limited alcohol consumption are crucial components of controlling blood pressure [122]. Although most studies address the prevention of additional ischemic strokes, hypertension management has also been shown to reduce the risk of recurrent hemorrhagic stroke and is included in guideline recommendations published by the AHA/ASA [10,344].

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