APEX NIH STROKE SCALE GROUP B
COMPREHENSIVE EXAM SCRIPT 2026 SOLVED
QUESTIONS WITH CORRECT ANSWERS
◉ The stellate ganglion provides sympathetic innervation to...
Answer: the ipsilateral upper extremity and a portion of the head
and neck
◉ Why might you block the stellate ganglion? Answer: Treatment of
upper extremity sympathetic dystrophy, complex regional pain
syndrome, or to increase blood flow to the upper extremity. (NE
infiltration)
◉ Which nerve block unintentionally blocks the stellate ganglion?
Answer: brachial plexus block
◉ Blockage of the stellate ganglion manifests as... Answer: Horner's
syndrome
◉ Symptoms of Horner's syndrome (4) Answer: Ptosis (eyelid
drooping), anhidrosis (no sweat), miosis (pupil constriction),
enophthalmos (sinking of eye into face)
,-"Very Horney PAM" - Vasodilation, horners, ptosis, anhidrosis,
miosis
◉ The adrenal gland is divided into 2 key areas and what do they
secrete: Answer: Medulla (inside): secretes catecholamines
Cortex (outside): secretes glucocorticoids, mineralocorticoids, and
androgens
◉ Preganglionic sympathetic nerves that synapse with the adrenal
medulla arise from... (area on spinal cord) Answer: Thoracic region
(T5-T9)
◉ Preganglionic fibers release acetylcholine directly onto what in
the adrenal medulla? What are these cells derived from? Answer: -
Chromaffin cells
-Derived from neural tissue
◉ SNS activity stimulates the chromaffin cells to release what?
Answer: Epi and NE directly into the blood stream
◉ Adrenal medulla is basically a ____ in direct contact with systemic
circulation. Any organ with ____ receptors (except ____) is activated by
____ released from the adrenal medulla. Answer: Sympathetic
ganglion
adrenergic receptors (except brain)
,catecholamines
◉ At rest, how much epi does the adrenal medulla secrete? Answer:
0.2mcg/kg/min
◉ At rest, how much norepi does the adrenal medulla secrete?
Answer: 0.05mcg/kg/min
◉ Catecholamines remain in the blood stream how much longer
than they do in the synaptic cleft? Why? Answer: 5-10 times longer
-Catecholamines in circulation must travel to the kidneys and liver
where they are metabolized by COMT and MAO
◉ What is the final metabolite of Epi and NE metabolism? Answer:
Vanillylmandelic Acid (VMA)
◉ What is pheochromocytoma?
Where do pheochromocytomas usually originate? Answer: -
Catecholamine secreting tumor (usually NE)
-Chromaffin tissue in the adrenal gland
◉ Clinical presentation of a pheochromocytoma?
What lab aid in diagnosis of pheochromocytoma? Answer: -
Excessive SNS activation (Headache, diaphoresis, and tachycardia)
, -Elevated VMA level in urine
◉ With a pheochromocytoma, should you block alpha or beta first?
Why? Answer: -Alpha before beta (A before B)
-Beta-2 blockade inhibits skeletal muscle vasodilation and increases
SVR
-Beta-1 blockade reduces inotropy and can precipitate CHF in the
setting of increased SVR
(unclamp before increasing HR)
◉ Commonly used nonselective alpha antagonists Answer:
Phenoxybenzamine and phentolamine
◉ Commonly used alpha-1 selective antagonists Answer: Doxazosin
and prazosin
◉ Conditions to prepare for after the pheochromocytoma is
removed Answer: Hypotension and hypoglycemia
-Tumor gone, catecholamines it secreted are gone too
◉ Effect of sympathetic stimulation on hepatocytes Answer: Causes
hepatocytes to release glucose and potassium into the systemic
circulation
COMPREHENSIVE EXAM SCRIPT 2026 SOLVED
QUESTIONS WITH CORRECT ANSWERS
◉ The stellate ganglion provides sympathetic innervation to...
Answer: the ipsilateral upper extremity and a portion of the head
and neck
◉ Why might you block the stellate ganglion? Answer: Treatment of
upper extremity sympathetic dystrophy, complex regional pain
syndrome, or to increase blood flow to the upper extremity. (NE
infiltration)
◉ Which nerve block unintentionally blocks the stellate ganglion?
Answer: brachial plexus block
◉ Blockage of the stellate ganglion manifests as... Answer: Horner's
syndrome
◉ Symptoms of Horner's syndrome (4) Answer: Ptosis (eyelid
drooping), anhidrosis (no sweat), miosis (pupil constriction),
enophthalmos (sinking of eye into face)
,-"Very Horney PAM" - Vasodilation, horners, ptosis, anhidrosis,
miosis
◉ The adrenal gland is divided into 2 key areas and what do they
secrete: Answer: Medulla (inside): secretes catecholamines
Cortex (outside): secretes glucocorticoids, mineralocorticoids, and
androgens
◉ Preganglionic sympathetic nerves that synapse with the adrenal
medulla arise from... (area on spinal cord) Answer: Thoracic region
(T5-T9)
◉ Preganglionic fibers release acetylcholine directly onto what in
the adrenal medulla? What are these cells derived from? Answer: -
Chromaffin cells
-Derived from neural tissue
◉ SNS activity stimulates the chromaffin cells to release what?
Answer: Epi and NE directly into the blood stream
◉ Adrenal medulla is basically a ____ in direct contact with systemic
circulation. Any organ with ____ receptors (except ____) is activated by
____ released from the adrenal medulla. Answer: Sympathetic
ganglion
adrenergic receptors (except brain)
,catecholamines
◉ At rest, how much epi does the adrenal medulla secrete? Answer:
0.2mcg/kg/min
◉ At rest, how much norepi does the adrenal medulla secrete?
Answer: 0.05mcg/kg/min
◉ Catecholamines remain in the blood stream how much longer
than they do in the synaptic cleft? Why? Answer: 5-10 times longer
-Catecholamines in circulation must travel to the kidneys and liver
where they are metabolized by COMT and MAO
◉ What is the final metabolite of Epi and NE metabolism? Answer:
Vanillylmandelic Acid (VMA)
◉ What is pheochromocytoma?
Where do pheochromocytomas usually originate? Answer: -
Catecholamine secreting tumor (usually NE)
-Chromaffin tissue in the adrenal gland
◉ Clinical presentation of a pheochromocytoma?
What lab aid in diagnosis of pheochromocytoma? Answer: -
Excessive SNS activation (Headache, diaphoresis, and tachycardia)
, -Elevated VMA level in urine
◉ With a pheochromocytoma, should you block alpha or beta first?
Why? Answer: -Alpha before beta (A before B)
-Beta-2 blockade inhibits skeletal muscle vasodilation and increases
SVR
-Beta-1 blockade reduces inotropy and can precipitate CHF in the
setting of increased SVR
(unclamp before increasing HR)
◉ Commonly used nonselective alpha antagonists Answer:
Phenoxybenzamine and phentolamine
◉ Commonly used alpha-1 selective antagonists Answer: Doxazosin
and prazosin
◉ Conditions to prepare for after the pheochromocytoma is
removed Answer: Hypotension and hypoglycemia
-Tumor gone, catecholamines it secreted are gone too
◉ Effect of sympathetic stimulation on hepatocytes Answer: Causes
hepatocytes to release glucose and potassium into the systemic
circulation
