1
ABFM
ABFM CVA EXAM QUESTIONS AND
ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
A 36-year-old female presents to the emergency department with right-sided
upper and lower extremity weakness. She denies any history of hypertension,
diabetes mellitus, high cholesterol, or smoking. Which of the following would
increase the likelihood that a stroke is the cause of her focal weakness? (Mark all
that are true.)
Cocaine use
The presence of lupus anticoagulant antibody
Marfan's syndrome
A history of cranial radiation in childhood for CNS lymphoma - ANS ✓ALL OF
THE ABOVE
All of the factors listed increase a person's risk for stroke. The presence of lupus
anticoagulant antibody has been found to confer an increased risk of stroke, as
has Marfan's syndrome. A history of intracranial radiation therapy, such as for
CNS lymphoma, also confers an increased risk of ischemic stroke in adulthood.
Cocaine use represents a significant cause of stroke, often hemorrhagic,
particularly in younger individuals. The increase in relative risk may be as great
as 14 times the risk seen in age-matched individuals who do not use cocaine.
You see an active 65-year-old male for a routine annual evaluation. He recently
received a flyer in the mail advertising screening carotid ultrasonography at his
local senior center, and asks whether you think it would be worthwhile. Which
one of the following would be appropriate advice?
All patients with a 10-year Framingham coronary artery disease risk >10%
should be screened for carotid artery stenosis (CAS)
The U.S. Preventive Services Task Force recommends against screening for
asymptomatic CAS in the healthy adult population
ABFM CVA
, 2
ABFM
Asymptomatic women have been shown to derive a greater benefit from carotid
endarterectomy than asymptomatic men
Patients over the age of 80 with asymptomatic CAS have been found to benefit
more from carotid endarterectomy compared to younger patients - ANS ✓B
The U.S. Preventive Services Task Force recommends against screening
asymptomatic patients for carotid stenosis (SOR B). However, in the event that
an asymptomatic patient is screened, the American Academy of Neurology
suggests it is reasonable to consider carotid endarterectomy for patients
between the ages of 40 and 75 years with asymptomatic stenosis of 60%-99%, if
the patient has a life expectancy ≥5 years and the death rate from stroke or other
complications of surgery can be reliably documented to be <3%. The American
Heart Association and the American Stroke Association do not recommend
carotid endarterectomy for asymptomatic patients over the age of 80 (SOR B).
Men have been shown to derive a greater benefit than women from carotid
endarterectomy (SOR B).
True statements regarding the evaluation of dysphagia in stroke patients include
which of the following? (Mark all that are true.)
Dysphagia increases the risk of aspiration
Abnormal pharyngeal sensation may predict aspiration
All stroke patients should have a video fluoroscopy swallowing study or a
modified barium swallow
Only stroke patients with obvious swallowing difficulty should undergo a
swallowing evaluation
Routine screening for dysphagia in all stroke patients reduces the risk of
pneumonia - ANS ✓A, B, E
It is difficult to tell which stroke patients have a high risk for pneumonia or
aspiration. Routine screening reduces pneumonia risk by about threefold (SOR
A). Patients who report abnormal feelings in their pharyngeal area have a higher
risk of aspiration (SOR A). The more severe the dysphagia, the higher the risk for
aspiration (SOR A). All stroke patients should undergo an evaluation for
dysphagia (SOR A). Imaging studies are not necessary for all stroke patients (SOR
A).
ABFM CVA
, 3
ABFM
Which one of the following statements is true regarding the acute hypertensive
response in patients with stroke?
It occurs only when the stroke affects areas of the brain involved in blood
pressure regulation
Nearly all patients who develop this problem have a previous history of
hypertension
Cushing's phenomenon (increased blood pressure secondary to elevated
intracranial pressure) is thought to be the cause in most cases
It occurs only in patients whose stroke is due to intracerebral hemorrhage
Patients who experience this problem have worse outcomes - ANS ✓E
A systematic review of the literature found an association between the acute
hypertensive response and death and dependency (SOR B). There seems to be no
definite correlation with lesion size or location (SOR C). A significant proportion
of patients who experience an acute hypertensive response to stroke do not have
a history of hypertension (SOR B). The pathophysiologic response is thought to
be multifactorial and related to pre-existing high blood pressure, activation of the
neuroendocrine systems (sympathetic nervous system, renin-angiotensin axis,
and glucocorticoid system), increased cardiac output, and "white coat"
hypertension (SOR B). The acute hypertensive response is seen in patients with
lacunar stroke, ischemic stroke, transient ischemic response, and intracerebral
hemorrhage (SOR C).
Assuming that CT of the head is negative for bleeding, which one of the following
patients would be a candidate for thrombolytic therapy for stroke?
A 67-year-old who awakened with left arm and left leg weakness
A 70-year-old with right arm and leg weakness that started 1 hour ago and
whose symptoms have improved during his time in the emergency department,
causing mild impairment
A comatose 70-year-old with a flaccid left side whose CT shows a large area of
infarct in the perfusion area of the middle cerebral artery
A 72-year-old who takes warfarin and has an INR of 2.2, and whose stroke
symptoms started 1 hour ago
ABFM CVA
, 4
ABFM
A 74-year-old with diabetes mellitus and a history of left arm and left leg
weakness starting 1 hr ago, a blood pressure of 170/100 mm Hg, and a blood
glucose level of 311 mg/dL - ANS ✓E
Inclusion criteria for treatment with intravenous (IV) alteplase during a stroke
include symptoms of <3 hours' duration and the absence of evidence of
intracranial hemorrhage on CT. Contraindications to thrombolysis include the
following:
a history of ischemic stroke, severe head trauma, or intracranial/spinal surgery
within the preceding 3 months
a previous history of intracranial hemorrhage
symptoms and signs consistent with subarachnoid hemorrhage
a structural gastrointestinal malignancy or recent bleeding event within 21 days
of the stroke event
infective endocarditis
aortic arch dissection
an intra-axial intracranial neoplasm
pregnancy
a treatment dose of LMWH within the previous 24 hours
coagulopathy with a platelet count <100,000/mm3
INR >1.7, aPTT >40 sec, or PT >15 sec
current use of direct thrombin inhibitors, factor Xa inhibitors, or glycoprotein
IIb/IIIa receptor inhibitors
Based on 2018 AHA guidelines, IV alteplase can be used in stroke patients taking
antiplatelet monotherapy, as well as those taking antiplatelet combination
therapy before the stroke. In addition, the guidelines regard IV alteplase as
reasonable in patients with a seizure at the time of onset of the acute stroke if
evidence suggests that residual impairments are secondary to stroke and not a
postictal phenomenon. IV alteplase can even be considered in patients with an
acute ischemic stroke who may have undergone a lumbar dural puncture within
the preceding 7 days as well as carefully selected patients who have undergone
major surgery in the preceding 14 days. It is recommended that patients who
have elevated blood pressure (BP) and are otherwise eligible for treatment with
IV alteplase should have their BP carefully lowered so that their systolic BP is
ABFM CVA
ABFM
ABFM CVA EXAM QUESTIONS AND
ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
A 36-year-old female presents to the emergency department with right-sided
upper and lower extremity weakness. She denies any history of hypertension,
diabetes mellitus, high cholesterol, or smoking. Which of the following would
increase the likelihood that a stroke is the cause of her focal weakness? (Mark all
that are true.)
Cocaine use
The presence of lupus anticoagulant antibody
Marfan's syndrome
A history of cranial radiation in childhood for CNS lymphoma - ANS ✓ALL OF
THE ABOVE
All of the factors listed increase a person's risk for stroke. The presence of lupus
anticoagulant antibody has been found to confer an increased risk of stroke, as
has Marfan's syndrome. A history of intracranial radiation therapy, such as for
CNS lymphoma, also confers an increased risk of ischemic stroke in adulthood.
Cocaine use represents a significant cause of stroke, often hemorrhagic,
particularly in younger individuals. The increase in relative risk may be as great
as 14 times the risk seen in age-matched individuals who do not use cocaine.
You see an active 65-year-old male for a routine annual evaluation. He recently
received a flyer in the mail advertising screening carotid ultrasonography at his
local senior center, and asks whether you think it would be worthwhile. Which
one of the following would be appropriate advice?
All patients with a 10-year Framingham coronary artery disease risk >10%
should be screened for carotid artery stenosis (CAS)
The U.S. Preventive Services Task Force recommends against screening for
asymptomatic CAS in the healthy adult population
ABFM CVA
, 2
ABFM
Asymptomatic women have been shown to derive a greater benefit from carotid
endarterectomy than asymptomatic men
Patients over the age of 80 with asymptomatic CAS have been found to benefit
more from carotid endarterectomy compared to younger patients - ANS ✓B
The U.S. Preventive Services Task Force recommends against screening
asymptomatic patients for carotid stenosis (SOR B). However, in the event that
an asymptomatic patient is screened, the American Academy of Neurology
suggests it is reasonable to consider carotid endarterectomy for patients
between the ages of 40 and 75 years with asymptomatic stenosis of 60%-99%, if
the patient has a life expectancy ≥5 years and the death rate from stroke or other
complications of surgery can be reliably documented to be <3%. The American
Heart Association and the American Stroke Association do not recommend
carotid endarterectomy for asymptomatic patients over the age of 80 (SOR B).
Men have been shown to derive a greater benefit than women from carotid
endarterectomy (SOR B).
True statements regarding the evaluation of dysphagia in stroke patients include
which of the following? (Mark all that are true.)
Dysphagia increases the risk of aspiration
Abnormal pharyngeal sensation may predict aspiration
All stroke patients should have a video fluoroscopy swallowing study or a
modified barium swallow
Only stroke patients with obvious swallowing difficulty should undergo a
swallowing evaluation
Routine screening for dysphagia in all stroke patients reduces the risk of
pneumonia - ANS ✓A, B, E
It is difficult to tell which stroke patients have a high risk for pneumonia or
aspiration. Routine screening reduces pneumonia risk by about threefold (SOR
A). Patients who report abnormal feelings in their pharyngeal area have a higher
risk of aspiration (SOR A). The more severe the dysphagia, the higher the risk for
aspiration (SOR A). All stroke patients should undergo an evaluation for
dysphagia (SOR A). Imaging studies are not necessary for all stroke patients (SOR
A).
ABFM CVA
, 3
ABFM
Which one of the following statements is true regarding the acute hypertensive
response in patients with stroke?
It occurs only when the stroke affects areas of the brain involved in blood
pressure regulation
Nearly all patients who develop this problem have a previous history of
hypertension
Cushing's phenomenon (increased blood pressure secondary to elevated
intracranial pressure) is thought to be the cause in most cases
It occurs only in patients whose stroke is due to intracerebral hemorrhage
Patients who experience this problem have worse outcomes - ANS ✓E
A systematic review of the literature found an association between the acute
hypertensive response and death and dependency (SOR B). There seems to be no
definite correlation with lesion size or location (SOR C). A significant proportion
of patients who experience an acute hypertensive response to stroke do not have
a history of hypertension (SOR B). The pathophysiologic response is thought to
be multifactorial and related to pre-existing high blood pressure, activation of the
neuroendocrine systems (sympathetic nervous system, renin-angiotensin axis,
and glucocorticoid system), increased cardiac output, and "white coat"
hypertension (SOR B). The acute hypertensive response is seen in patients with
lacunar stroke, ischemic stroke, transient ischemic response, and intracerebral
hemorrhage (SOR C).
Assuming that CT of the head is negative for bleeding, which one of the following
patients would be a candidate for thrombolytic therapy for stroke?
A 67-year-old who awakened with left arm and left leg weakness
A 70-year-old with right arm and leg weakness that started 1 hour ago and
whose symptoms have improved during his time in the emergency department,
causing mild impairment
A comatose 70-year-old with a flaccid left side whose CT shows a large area of
infarct in the perfusion area of the middle cerebral artery
A 72-year-old who takes warfarin and has an INR of 2.2, and whose stroke
symptoms started 1 hour ago
ABFM CVA
, 4
ABFM
A 74-year-old with diabetes mellitus and a history of left arm and left leg
weakness starting 1 hr ago, a blood pressure of 170/100 mm Hg, and a blood
glucose level of 311 mg/dL - ANS ✓E
Inclusion criteria for treatment with intravenous (IV) alteplase during a stroke
include symptoms of <3 hours' duration and the absence of evidence of
intracranial hemorrhage on CT. Contraindications to thrombolysis include the
following:
a history of ischemic stroke, severe head trauma, or intracranial/spinal surgery
within the preceding 3 months
a previous history of intracranial hemorrhage
symptoms and signs consistent with subarachnoid hemorrhage
a structural gastrointestinal malignancy or recent bleeding event within 21 days
of the stroke event
infective endocarditis
aortic arch dissection
an intra-axial intracranial neoplasm
pregnancy
a treatment dose of LMWH within the previous 24 hours
coagulopathy with a platelet count <100,000/mm3
INR >1.7, aPTT >40 sec, or PT >15 sec
current use of direct thrombin inhibitors, factor Xa inhibitors, or glycoprotein
IIb/IIIa receptor inhibitors
Based on 2018 AHA guidelines, IV alteplase can be used in stroke patients taking
antiplatelet monotherapy, as well as those taking antiplatelet combination
therapy before the stroke. In addition, the guidelines regard IV alteplase as
reasonable in patients with a seizure at the time of onset of the acute stroke if
evidence suggests that residual impairments are secondary to stroke and not a
postictal phenomenon. IV alteplase can even be considered in patients with an
acute ischemic stroke who may have undergone a lumbar dural puncture within
the preceding 7 days as well as carefully selected patients who have undergone
major surgery in the preceding 14 days. It is recommended that patients who
have elevated blood pressure (BP) and are otherwise eligible for treatment with
IV alteplase should have their BP carefully lowered so that their systolic BP is
ABFM CVA
