BCCCP: Acute Ischemic Stroke Critical Care Questions

Question 1 of 10

1. Question

A 72-year-old man is admitted to the intensive care unit with an acute ischemic stroke in the left middle cerebral artery territory confirmed by MRI. His initial non-contrast head CT was negative for hemorrhage. His medical history includes uncontrolled hypertension (home blood pressure 160/95 mmHg), type 2 diabetes mellitus (HbA1c 9.2%), and recently diagnosed paroxysmal atrial fibrillation for which he is not yet anticoagulated. His current blood pressure on nicardipine infusion is 180/100 mmHg. He also has a 40 pack-year smoking history. Which pre-existing chronic condition most significantly increases his immediate risk for early recurrent ischemic stroke?

Uncontrolled hypertension
Type 2 diabetes mellitus
Paroxysmal atrial fibrillation without anticoagulation
Smoking history

Question 2 of 10

2. Question

A 62-year-old female is in the intensive care unit, intubated and on assist-control ventilation following a large vessel occlusion acute ischemic stroke. A central venous catheter is in place for vasopressor support. Her medical history is significant for uncontrolled hypertension and type 2 diabetes. During a family discussion, her daughter reports that the patient frequently struggled to afford her prescribed medications, often splitting pills or skipping doses. The daughter also mentions her mother had difficulty traveling to follow-up appointments due to a lack of reliable transportation and expressed confusion about the importance of strict blood pressure and glucose control. Considering the patient’s presentation and history, which of the following social determinants of health most directly contributed to the development and severity of her acute ischemic stroke?

Inadequate access to prescribed antihypertensive and antidiabetic medications
Limited transportation options hindering regular primary care visits
Low health literacy leading to misunderstanding of chronic disease management
Food insecurity resulting in inconsistent dietary patterns and glycemic control

Question 3 of 10

3. Question

A 62-year-old man is in the ICU on mechanical ventilation for acute respiratory distress syndrome, receiving a continuous norepinephrine infusion via a central venous catheter. At 1800 h during evening rounds, the nurse reports he developed new-onset left-sided weakness and facial droop at 1600 h (last known well 1600 h). Neurological exam yields an NIHSS score of 18. Vital signs: BP 148/82 mmHg, HR 98 bpm, SpO₂ 96% on ventilator settings. Point-of-care labs: glucose 105 mg/dL, platelets 210 × 10³/µL, INR 1.0. A non-contrast CT of the head shows no hemorrhage. Given this presentation and imaging, what is the MOST critical next step to guide initial management?

Administer intravenous alteplase at 0.9 mg/kg (10% bolus, 90% infusion) immediately, given presentation within the 4.5-hour window.
Perform CT perfusion imaging to evaluate ischemic core and penumbra before selecting reperfusion therapy.
Obtain CT angiography of the head and neck to assess for large vessel occlusion and penumbra.
Initiate low-dose aspirin for secondary stroke prevention.

Question 4 of 10

4. Question

A 65-year-old patient with septic shock is admitted to the ICU. Despite 30 mL/kg of crystalloid resuscitation, his mean arterial pressure remains at 55 mm Hg. The team plans to start a norepinephrine infusion. Which of the following routes and delivery devices is most appropriate for both initial and ongoing vasoactive therapy?

Peripheral IV catheter in the antecubital fossa with IV infusion pump
Central venous catheter with IV infusion pump
Peripherally inserted central catheter (PICC) with IV infusion pump
Intraosseous line with IV infusion pump

Question 5 of 10

5. Question

A 68-year-old man (height 175 cm, weight 70 kg) is in the neurocritical care unit after intubation for airway protection following a large acute ischemic stroke. He is deeply sedated (RASS –4) with no spontaneous respiratory effort and is receiving mechanical ventilation on assist-control (AC) mode with FiO2 0.40, PEEP 5 cmH2O, respiratory rate 16 breaths/min, and tidal volume 450 mL. A continuous norepinephrine infusion via central line maintains a MAP >90 mmHg. A recent ABG shows pH 7.32, PaCO2 52 mmHg, PaO2 95 mmHg, and HCO3– 26 mEq/L. His ICP is stable at 12 mmHg. To maintain normocapnia and optimize cerebral perfusion in acute ischemic stroke, which ventilator adjustment is most appropriate?

Increase respiratory rate to 20 breaths/min
Decrease tidal volume to 350 mL
Increase PEEP to 10 cmH2O
Switch to pressure support ventilation

Question 6 of 10

6. Question

A 72-year-old man is admitted to the ICU after a large-vessel occlusion acute ischemic stroke. He is on a propofol infusion and mechanical ventilation (SIMV). He received IV alteplase 0.9 mg/kg (72 mg total) 6 hours ago. A repeat noncontrast head CT shows no hemorrhage. His platelets are 250 × 10^3/µL and other labs are unremarkable. Given the increased bleeding risk within 24 hours of thrombolysis, which supportive care measure should be prioritized now to reduce his risk of venous thromboembolism?

Initiate aspirin 325 mg PO daily for secondary stroke prevention
Administer pantoprazole 40 mg IV daily for stress ulcer prophylaxis
Implement a daily chlorhexidine gluconate oral care regimen to prevent ventilator-associated pneumonia
Apply sequential compression devices to both legs immediately for mechanical VTE prophylaxis

Question 7 of 10

7. Question

A 72-year-old woman is in the critical care unit following a large vessel occlusion acute ischemic stroke. She is intubated and on assist-control ventilation. Three hours ago, she received alteplase 0.9 mg/kg. Her neurological examination has since deteriorated, revealing a new fixed and dilated left pupil. A non-contrast head CT now shows a large area of hypodensity consistent with extensive cerebral edema and midline shift. She is receiving a continuous norepinephrine infusion at 0.1 mcg/kg/min through a central line to maintain a mean arterial pressure > 65 mmHg. The neurology team has indicated a very poor prognosis for functional recovery. Given the patient’s clinical trajectory and poor prognosis, which of the following is the most appropriate next step to prioritize?

Review the patient’s medication list for potential drug-drug interactions contributing to neurological decline.
Initiate a multidisciplinary goals-of-care discussion with the medical team and the patient’s family.
Implement continuous EEG monitoring to detect non-convulsive seizures.
Ensure strict head-of-bed elevation and neck alignment are maintained.

Question 8 of 10

8. Question

A 65-year-old man is in the neuroscience ICU after a large-territory ischemic stroke. He is sedated with a propofol infusion and analgesized with fentanyl on mechanical ventilation. A central venous catheter is in place for medication administration. Over the past few hours, he has had rapid neurological decline: his right pupil is now fixed and dilated. A head CT shows diffuse cerebral swelling with a 7 mm midline shift. An intracranial pressure (ICP) monitor reads a sustained 25 mmHg. He has not yet received any hyperosmolar therapy. Which of the following is the MOST appropriate initial medical management for his malignant cerebral edema?

Administer hyperosmolar therapy with mannitol or hypertonic saline
Give high-dose corticosteroids
Initiate brief controlled hyperventilation to a PaCO₂ of 30–35 mmHg
Begin aggressive intravenous fluid boluses

Question 9 of 10

9. Question

A 68-year-old man is in the ICU 36 hours after an acute ischemic stroke. He remains on assist-control ventilation and is receiving norepinephrine 0.05 mcg/kg/min via a central venous catheter. Sedation was held 6 hours ago (RASS 0) for neurological assessment, and he is now alert and following commands. His NIHSS has improved from 18 on admission to 6, and a head CT 6 hours ago showed no hemorrhagic transformation. His blood pressure is 130/80 mmHg, and he has demonstrated strong respiratory effort with good tolerance of brief spontaneous breathing trials. Which of the following is the most appropriate next step to facilitate de-escalation of intensive therapies?

Initiate a gradual norepinephrine taper given stable hemodynamics.
Begin a formal spontaneous breathing trial to assess readiness for extubation.
Perform a daily sedation interruption to facilitate neurological evaluation.
Assess the necessity of the central venous catheter and remove it if no longer required.

Question 10 of 10

10. Question

A 68-year-old man with acute ischemic stroke is receiving continuous enteral nutrition via a 12-French nasogastric tube. His current medications are IV pantoprazole 40 mg daily, IV levetiracetam 500 mg every 12 hours, and a continuous IV labetalol infusion. The team plans to transition these to enteral administration. Which of the following is the most appropriate initial plan for administration via the NG tube?

Convert IV pantoprazole to crushed delayed-release tablets via NG tube; switch IV levetiracetam to oral solution via NG tube; convert IV labetalol to crushed immediate-release tablets via NG tube.
Convert IV pantoprazole to delayed-release granules for oral suspension via NG tube with a 30- to 60-minute hold of enteral feeds before and after; switch IV levetiracetam to oral solution via NG tube; convert IV labetalol to crushed immediate-release tablets via NG tube.
Convert IV pantoprazole to delayed-release granules for oral suspension via NG tube without holding feeds; switch IV levetiracetam to oral solution via NG tube; administer whole labetalol tablets via NG tube.
Convert IV pantoprazole to delayed-release tablets administered whole via NG tube; switch IV levetiracetam to oral solution via NG tube; convert IV labetalol to crushed tablets via NG tube.

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