Certified Stroke Rehabilitation Specialist
(CSRS) Actual Practice Exam & Certification
Prep for 2026/2027 Cycle
DOMAIN 1: STROKE PATHOPHYSIOLOGY & MEDICAL MANAGEMENT
(Q1-15)
1. A 72-year-old patient with atrial fibrillation presents to the emergency department
with sudden onset right-sided weakness and expressive aphasia. CT scan shows no
hemorrhage. According to the 2025 AHA/ASA guidelines for acute ischemic stroke, the
patient is within the 4.5-hour window. The rehabilitation specialist understands that the
priority medical intervention before initiating therapy is:
A. Immediate anticoagulation with warfarin to prevent further embolization.
B. High-dose steroids to reduce cerebral edema.
C. IV alteplase (tPA) administration if no contraindications exist.
D. Early initiation of intensive physical therapy to promote neuroplasticity.
Correct Answer: C
Rationale: C is correct per AHA/ASA 2025 guidelines - IV tPA within 4.5 hours is
standard care for eligible ischemic stroke patients. A is contraindicated acutely due to
hemorrhagic risk. B is not standard for acute ischemic stroke without significant
edema. D, while important, should follow acute medical management.
2. A 68-year-old patient presents 5 days post-hemorrhagic stroke with intracerebral
hemorrhage in the left basal ganglia. During the team rounds, the rehabilitation
specialist notes the patient has developed hyponatremia with serum sodium of 128
mEq/L. The specialist recognizes this most likely represents:
A. Syndrome of inappropriate antidiuretic hormone (SIADH) requiring fluid restriction.
,B. Cerebral salt wasting requiring sodium supplementation.
C. Cerebral salt wasting requiring aggressive fluid resuscitation and sodium
replacement.
D. Normal physiological response that requires no intervention.
Correct Answer: C
Rationale: C is correct - cerebral salt wasting is common after subarachnoid
hemorrhage and intracerebral hemorrhage, characterized by natriuresis and volume
depletion requiring fluid and sodium replacement. A describes SIADH which is
volume-expanded and treated with restriction, the opposite of CSW. B correctly
identifies CSW but misses the critical volume component. D ignores potentially
life-threatening electrolyte imbalance.
3. A 65-year-old patient with right MCA stroke develops increased somnolence,
headache, and pupillary changes on post-stroke day 3. Imaging confirms malignant
cerebral edema. The rehabilitation specialist understands that the evidence-based
medical management includes:
A. Immediate initiation of rehabilitation to prevent complications while awaiting medical
stabilization.
B. Hyperventilation to maintain PaCO2 below 25 mmHg to reduce intracranial pressure.
C. Hyperosmolar therapy with mannitol or hypertonic saline and possible
decompressive hemicraniectomy.
D. Corticosteroids as first-line therapy for vasogenic edema reduction.
Correct Answer: C
Rationale: C is correct per AHA/ASA guidelines - malignant edema requires
hyperosmolar therapy and surgical decompression when indicated. A is dangerous as
rehabilitation is contraindicated with increased ICP. B is outdated; aggressive
hyperventilation causes cerebral ischemia and is no longer recommended. D is
ineffective for cytotoxic edema of stroke and potentially harmful.
,4. During interdisciplinary rounds, a patient 10 days post-stroke is noted to have new
fever, elevated white count, and cloudy urine. The rehabilitation specialist recognizes
that the most common source of infection affecting stroke outcomes is:
A. Bloodstream infection from peripheral IV lines.
B. Clostridioides difficile colitis from antibiotic prophylaxis.
C. Urinary tract infection secondary to indwelling catheterization.
D. Surgical site infection from decompressive craniectomy.
Correct Answer: C
Rationale: C is correct - UTIs are the most common nosocomial infection in stroke
patients, strongly associated with indwelling catheters and linked to worse functional
outcomes. A occurs but is less common than UTI. B is a concern but not the most
common. D applies only to surgical patients, not the general stroke population.
5. A 70-year-old patient with lacunar infarct in the internal capsule is being prepared for
discharge. The rehabilitation specialist reviews the secondary prevention regimen and
recognizes the evidence-based antiplatelet strategy is:
A. Aspirin 81 mg daily alone for all lacunar strokes regardless of risk factors.
B. Clopidogrel 75 mg daily as monotherapy for better platelet inhibition.
C. Aspirin 81 mg daily, or dual antiplatelet therapy for 21-90 days if high-risk TIA/minor
stroke per CHANCE/POINT trials.
D. Warfarin anticoagulation as first-line for all ischemic stroke subtypes.
Correct Answer: C
Rationale: C is correct per AHA/ASA 2025 guidelines - short-term DAPT (aspirin +
clopidogrel) for 21-90 days reduces recurrent stroke in high-risk minor stroke/TIA, then
transition to single antiplatelet. A misses opportunity for DAPT in appropriate
candidates. B lacks evidence for clopidogrel monotherapy superiority in acute phase. D
is indicated for cardioembolic stroke, not lacunar infarcts.
6. A patient with ischemic stroke is being considered for blood pressure management.
The rehabilitation specialist understands that the optimal blood pressure management
in the acute phase (first 24-48 hours) is:
, A. Aggressive reduction to below 140/90 mmHg in all patients to prevent hemorrhagic
conversion.
B. Permissive hypertension up to 220/120 mmHg to maintain cerebral perfusion.
C. Allow permissive hypertension unless BP >220/120 mmHg or patient receives tPA
(then <185/110 mmHg).
D. Immediate normalization to patient's pre-stroke baseline regardless of timing.
Correct Answer: C
Rationale: C is correct per AHA/ASA guidelines - permissive hypertension preserves
penumbral perfusion unless BP exceeds safety thresholds or thrombolytics are
administered. A risks hypoperfusion and extension of ischemia. B is partially correct but
misses the tPA exception and need for treatment at extreme levels. D ignores the
critical perfusion window in acute stroke.
7. During a team conference, a patient 2 weeks post-stroke is noted to have declining
consciousness and CT shows hydrocephalus secondary to intraventricular hemorrhage
extension. The rehabilitation specialist anticipates the neurosurgical intervention will be:
A. Observation with diuretics as hydrocephalus often resolves spontaneously.
B. External ventricular drain placement for cerebrospinal fluid diversion.
C. External ventricular drain placement with potential for permanent shunting.
D. Lumbar puncture for serial CSF drainage.
Correct Answer: C
Rationale: C is correct - obstructive hydrocephalus from IVH requires EVD placement,
with many patients needing permanent VP shunting. A risks herniation and death from
untreated hydrocephalus. B is incomplete as it doesn't address the potential need for
permanent shunting. D is contraindicated with obstructive hydrocephalus and risk of
tonsillar herniation.
8. A 58-year-old patient presents with fluctuating neurological deficits and imaging
reveals arterial dissection as the stroke etiology. The rehabilitation specialist
understands that the optimal secondary prevention strategy is:
A. Immediate anticoagulation with heparin for all cervical artery dissections.
(CSRS) Actual Practice Exam & Certification
Prep for 2026/2027 Cycle
DOMAIN 1: STROKE PATHOPHYSIOLOGY & MEDICAL MANAGEMENT
(Q1-15)
1. A 72-year-old patient with atrial fibrillation presents to the emergency department
with sudden onset right-sided weakness and expressive aphasia. CT scan shows no
hemorrhage. According to the 2025 AHA/ASA guidelines for acute ischemic stroke, the
patient is within the 4.5-hour window. The rehabilitation specialist understands that the
priority medical intervention before initiating therapy is:
A. Immediate anticoagulation with warfarin to prevent further embolization.
B. High-dose steroids to reduce cerebral edema.
C. IV alteplase (tPA) administration if no contraindications exist.
D. Early initiation of intensive physical therapy to promote neuroplasticity.
Correct Answer: C
Rationale: C is correct per AHA/ASA 2025 guidelines - IV tPA within 4.5 hours is
standard care for eligible ischemic stroke patients. A is contraindicated acutely due to
hemorrhagic risk. B is not standard for acute ischemic stroke without significant
edema. D, while important, should follow acute medical management.
2. A 68-year-old patient presents 5 days post-hemorrhagic stroke with intracerebral
hemorrhage in the left basal ganglia. During the team rounds, the rehabilitation
specialist notes the patient has developed hyponatremia with serum sodium of 128
mEq/L. The specialist recognizes this most likely represents:
A. Syndrome of inappropriate antidiuretic hormone (SIADH) requiring fluid restriction.
,B. Cerebral salt wasting requiring sodium supplementation.
C. Cerebral salt wasting requiring aggressive fluid resuscitation and sodium
replacement.
D. Normal physiological response that requires no intervention.
Correct Answer: C
Rationale: C is correct - cerebral salt wasting is common after subarachnoid
hemorrhage and intracerebral hemorrhage, characterized by natriuresis and volume
depletion requiring fluid and sodium replacement. A describes SIADH which is
volume-expanded and treated with restriction, the opposite of CSW. B correctly
identifies CSW but misses the critical volume component. D ignores potentially
life-threatening electrolyte imbalance.
3. A 65-year-old patient with right MCA stroke develops increased somnolence,
headache, and pupillary changes on post-stroke day 3. Imaging confirms malignant
cerebral edema. The rehabilitation specialist understands that the evidence-based
medical management includes:
A. Immediate initiation of rehabilitation to prevent complications while awaiting medical
stabilization.
B. Hyperventilation to maintain PaCO2 below 25 mmHg to reduce intracranial pressure.
C. Hyperosmolar therapy with mannitol or hypertonic saline and possible
decompressive hemicraniectomy.
D. Corticosteroids as first-line therapy for vasogenic edema reduction.
Correct Answer: C
Rationale: C is correct per AHA/ASA guidelines - malignant edema requires
hyperosmolar therapy and surgical decompression when indicated. A is dangerous as
rehabilitation is contraindicated with increased ICP. B is outdated; aggressive
hyperventilation causes cerebral ischemia and is no longer recommended. D is
ineffective for cytotoxic edema of stroke and potentially harmful.
,4. During interdisciplinary rounds, a patient 10 days post-stroke is noted to have new
fever, elevated white count, and cloudy urine. The rehabilitation specialist recognizes
that the most common source of infection affecting stroke outcomes is:
A. Bloodstream infection from peripheral IV lines.
B. Clostridioides difficile colitis from antibiotic prophylaxis.
C. Urinary tract infection secondary to indwelling catheterization.
D. Surgical site infection from decompressive craniectomy.
Correct Answer: C
Rationale: C is correct - UTIs are the most common nosocomial infection in stroke
patients, strongly associated with indwelling catheters and linked to worse functional
outcomes. A occurs but is less common than UTI. B is a concern but not the most
common. D applies only to surgical patients, not the general stroke population.
5. A 70-year-old patient with lacunar infarct in the internal capsule is being prepared for
discharge. The rehabilitation specialist reviews the secondary prevention regimen and
recognizes the evidence-based antiplatelet strategy is:
A. Aspirin 81 mg daily alone for all lacunar strokes regardless of risk factors.
B. Clopidogrel 75 mg daily as monotherapy for better platelet inhibition.
C. Aspirin 81 mg daily, or dual antiplatelet therapy for 21-90 days if high-risk TIA/minor
stroke per CHANCE/POINT trials.
D. Warfarin anticoagulation as first-line for all ischemic stroke subtypes.
Correct Answer: C
Rationale: C is correct per AHA/ASA 2025 guidelines - short-term DAPT (aspirin +
clopidogrel) for 21-90 days reduces recurrent stroke in high-risk minor stroke/TIA, then
transition to single antiplatelet. A misses opportunity for DAPT in appropriate
candidates. B lacks evidence for clopidogrel monotherapy superiority in acute phase. D
is indicated for cardioembolic stroke, not lacunar infarcts.
6. A patient with ischemic stroke is being considered for blood pressure management.
The rehabilitation specialist understands that the optimal blood pressure management
in the acute phase (first 24-48 hours) is:
, A. Aggressive reduction to below 140/90 mmHg in all patients to prevent hemorrhagic
conversion.
B. Permissive hypertension up to 220/120 mmHg to maintain cerebral perfusion.
C. Allow permissive hypertension unless BP >220/120 mmHg or patient receives tPA
(then <185/110 mmHg).
D. Immediate normalization to patient's pre-stroke baseline regardless of timing.
Correct Answer: C
Rationale: C is correct per AHA/ASA guidelines - permissive hypertension preserves
penumbral perfusion unless BP exceeds safety thresholds or thrombolytics are
administered. A risks hypoperfusion and extension of ischemia. B is partially correct but
misses the tPA exception and need for treatment at extreme levels. D ignores the
critical perfusion window in acute stroke.
7. During a team conference, a patient 2 weeks post-stroke is noted to have declining
consciousness and CT shows hydrocephalus secondary to intraventricular hemorrhage
extension. The rehabilitation specialist anticipates the neurosurgical intervention will be:
A. Observation with diuretics as hydrocephalus often resolves spontaneously.
B. External ventricular drain placement for cerebrospinal fluid diversion.
C. External ventricular drain placement with potential for permanent shunting.
D. Lumbar puncture for serial CSF drainage.
Correct Answer: C
Rationale: C is correct - obstructive hydrocephalus from IVH requires EVD placement,
with many patients needing permanent VP shunting. A risks herniation and death from
untreated hydrocephalus. B is incomplete as it doesn't address the potential need for
permanent shunting. D is contraindicated with obstructive hydrocephalus and risk of
tonsillar herniation.
8. A 58-year-old patient presents with fluctuating neurological deficits and imaging
reveals arterial dissection as the stroke etiology. The rehabilitation specialist
understands that the optimal secondary prevention strategy is:
A. Immediate anticoagulation with heparin for all cervical artery dissections.
