True statements regarding the long-term prognosis for death and disability in a patient who has had a stroke include which of the following? (Mark all
... [Show More] that are true.)
Early recovery of neurologic function is a sign of a good prognosis
The severity of the stroke as measured by the National Institutes of Health Stroke Scale can be used to predict long-term prognosis
In general, lacunar strokes cause more severe disability than ischemic strokes of the major cerebral arteries
The risk of recurrence of stroke is higher in the second year after a stroke than in the first year
Patients who have two strokes in the same arterial territory will typically recover more quickly the second time
Patients with poor function prior to the stroke are less likely to make a complete recovery to their pre-stroke state
A, B, F
The National Institutes of Health Stroke Scale (NIHSS) score predicts the long-term outcome for patients with stroke. The NIHSS score at 6 days is a more accurate predictor than the score in the first 24 hours (SOR B). Consistent markers of better long-term recovery include younger age, less severe initial symptoms, early recovery from symptoms, and good social support (SOR B). Lacunar infarcts are more likely to be followed by either complete recovery or minimal disability (SOR B).The risk of recurrence is highest immediately after a stroke and falls throughout the first year, reaching a plateau thereafter that is still higher than that of the general population (SOR B). Multiple strokes in the same area tend to create more severe disability than the first stroke (SOR B). Poor functional ability prior to the stroke is a poor prognostic factor for recovery (SOR B).
A 74-year-old male has an acute ischemic stroke. He has a history of hypertension adequately controlled with medication. CT does not indicate any hemorrhagic component.Which one of the following is true about early anticoagulation with heparin or low molecular weight heparin in this situation?
Urgent anticoagulation is recommended to prevent recurrent stroke
Urgent anticoagulation is recommended to prevent neurologic worsening
Urgent anticoagulation is recommended to improve neurologic outcomes
Urgent anticoagulation should be avoided in stroke
Initiation of anticoagulant therapy within 24 hours of treatment with intravenously administered rtPA is recommended
D
Research has not shown a benefit from urgent anticoagulation in preventing recurrent stroke or neurologic deterioration (SOR A), or for improving outcomes after acute ischemic strokes. Initiation of anticoagulation within 24 hours of treatment with intravenous rtPA is associated with increased risks of bleeding complications (SOR B). Urgent anticoagulation is not indicated in moderate to severe strokes, due to an increased risk of serious intracranial hemorrhagic complications (SOR A).
A 67-year-old male suffers a stroke. Which of the following factors would be likely to compromise his nutrition and hydration status following the stroke? (Mark all that are true.)
Depression
Sensory or perceptual deficits
Swallowing difficulties
Unilateral lower extremity weakness
Altered consciousness
ALL OF THE ABOVE
Nutrition and hydration can be affected by a number of factors following a stroke. Physical problems that can affect the patient's ability to eat and drink include altered consciousness, dysphagia, sensory deficits, and reduced mobility. Depression can reduce the patient's interest in food. Patients should be evaluated for nutrition and hydration status as soon as possible after admisssion, and intake and body weight should be monitored regularly (SOR C). A variety of methods should be used as necessary to maintain adequate intake of food and fluids.
Well documented measures to prevent an initial stroke include modification of which of the following, by either treating or eliminating the condition? (Mark all that are true.)
Cigarette smoking
Obesity
Migraine headaches
Atrial fibrillation
Hypertension
A, B, D, E
Risk factors for a first stroke include both modifiable and nonmodifiable risk factors. Well documented nonmodifiable risk factors include age, gender, low birth weight, and genetic factors. Modifiable risk factors that have been well documented include cigarette smoking, poor diet, physical inactivity, postmenopausal hormone therapy, obesity, and body fat distribution (SOR A). Other well-documented modifiable risk factors include medical conditions such as hypertension, atrial fibrillation, other cardiac conditions, dyslipidemia, carotid artery stenosis, and sickle cell disease (SOR A).Some modifiable risk factors have been linked to an increased risk for stroke, but the link is not well established. Medical conditions in this category include sleep apnea, metabolic syndrome, migraine, hyperhomocysteinemia, hypercoagulability, inflammation, and infection (SOR B).
True statements regarding the epidemiology of stroke and TIA in the United States include which of the following? (Mark all that are true.)
Cerebrovascular disease ranks among the top five causes of death
Each year more men than women have a stroke
More than 10 million people in the United States have had a silent stroke
Approximately 15% of all strokes are heralded by a TIA
Approximately half of all patients who experience a TIA fail to report it to their health care providers
A, C, D, E
In the United States, someone suffers a stroke approximately every 40 seconds and someone dies from a stroke every 3-4 minutes. Given the tremendous morbidity and mortality of stroke, the American Heart Association and American Stroke Association publish yearly stroke statistics to educate health care providers and the general public about key epidemiologic factors. Cerebrovascular diseases rank fourth among all causes of death, behind heart disease, cancer, and lung disease (SOR A). Every year approximately 55,000 more women than men have a stroke (SOR A). An estimated 13 million people in the United States have had a silent stroke (SOR A). Approximately 15% of all strokes are heralded by a TIA (SOR A). Approximately half of all patients who experience a TIA fail to report it to their health care providers (SOR A).
A 67-year-old female had a cerebrovascular accident 1 week ago, and now has spasticity in her right upper extremity. True statements regarding treatment of her spasticity and prevention of contractures include which of the following? (Mark all that are true.)
Tizanidine (Zanaflex) can be used to treat painful spasticity
Benzodiazepine therapy is recommended for the treatment of spasticity and prevention of contractures
Constraint-induced therapy for 90% of waking hours can improve functional use of the affected arm and reduce disability
Positioning, passive stretching, and range-of-motion exercises should be performed several times daily
Splinting, serial casting, and surgical correction can be considered for contractures interfering with function
A, C, D, E
Patients with muscle spasticity are at high risk of developing contractures following stroke. Contractures in turn increase the risk of poor hygiene, skin breakdown, pain, and loss of function. Early intervention is of the utmost importance and should be performed in a stepwise fashion beginning with positioning and passive range-of-motion exercises and proceeding to constraint-induced therapy. Pharmacotherapy may be required and the judicious use of agents such as tizanidine, dantrolene, and baclofen is important to avoid excessive sedation, which may interfere with the rehabilitation process. More severe, painful, or debilitating spasticity and contractures may require more invasive treatment such as botulinum toxin administration, intrathecal baclofen, orphenol/alcohol neurolysis. Neurosurgical procedures such as selective dorsal rhizotomy may be required in selected cases. Tizanidine has been used specifically for chronic stroke patients with painful spasticity (SOR B). Benzodiazepine therapy may have a deleterious effect on post-stroke recovery. The effectiveness of constraint-induced therapy and the use of a restraining mitt has been demonstrated in a randomized, controlled trial (SOR A). Positioning, passive stretching, and range-of-motion exercises have also been shown to provide relief in randomized, controlled trials (SOR A). There is some evidence from clinical trials that splinting, serial casting, and surgical correction may be helpful (SOR C).
True statements regarding the use of warfarin (Coumadin) for primary prevention of ischemic stroke in patients with sinus rhythm include which of the following? (Mark all that are true.)
Warfarin should be considered for stroke prevention in patients with elevated high-sensitivity C-reactive protein levels, particularly if they have three or more cardiovascular risk factors
Warfarin may be considered in patients with severe left ventricular dysfunction with or without heart failure
Warfarin should be used for stroke prevention in essentially all patients in the first 3 weeks after a myocardial infarction
It is reasonable to prescribe warfarin for patients with left ventricular dysfunction and extensive regional wall-motion abnormalities following an ST-segment-elevation myocardial infarction
B, D
No evidence supports the use of C-reactive protein (CRP) screening as a marker of vascular risk, much less the use of warfarin in patients with elevated CRP (SOR B). Warfarin may be considered in patients with severe left ventricular dysfunction, with or without heart failure (SOR C). There is no convincing evidence to support the use of warfarin for stroke prevention in all patients following a myocardial infarction (SOR C). Warfarin can be prescribed to patients with left ventricular dysfunction and extensive regional wall-motion abnormalities or a left ventricle thrombus on an imaging study following an ST-segment-elevation myocardial infarction (SOR A).
An 81-year-old male is brought to the emergency department by his wife 1 hour after the onset of right-sided weakness. She also reports that 2 months ago the patient suffered a severe concussion from a bicycling accident and was hospitalized overnight. The patient has known coronary artery disease and takes aspirin, 81 mg daily. He had a total right knee replacement 1 month ago, using spinal anesthesia. CT of the head shows no hemorrhage. His blood pressure is now 174/104 mm Hg and it has been 2½ hours since the onset of symptoms.Which one of the following would be a contraindication to the use of intravenous alteplase (Activase) in this patient?
His use of aspirin
His elevated blood pressure
His history of recent surgery
His history of a recent lumbar puncture
The length of time since the stroke
His history of head trauma
F
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 an antiplatelet drug 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. Intravenous 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 <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated.
True statements regarding alcohol use and stroke risk include which of the following? (Mark all that are true.)
To decrease stroke risk, alcohol intake should not exceed 2 drinks per day for men and 1 drink per day for nonpregnant women
Nondrinkers should be advised to drink 1-2 alcoholic beverages per day to decrease their stroke risk
Heavy drinkers with a history of an ischemic stroke or TIA should eliminate or reduce their consumption of alcohol to decrease their risk of stroke
Chronic alcoholism and heavy alcohol intake have been shown to increase only hemorrhagic stroke risk
A, C
The American Heart Association/American Stroke Association 2014 guideline on stroke prevention in patients with a previous stroke or TIA lists elimination or reduction of alcohol consumption in heavy drinkers as one of the primary goals of secondary stroke prevention. While the effects of alcohol on stroke risk are controversial, the negative effects of heavy alcohol consumption (>5 drinks/day) are well documented (relative risk 1.69 when compared with nondrinkers) (evidence level 1A). Heavy alcohol use increases the risk for all forms of stroke.A protective effect has been seen in patients who consume alcohol in moderation (≤2 drinks/day for men and ≤1 drink/day for women) (evidence level IIB, SOR C).However, this is not a reason to encourage patients to begin or increase alcohol consumption (SOR C).
In patients with a previous history of ischemic stroke or transient ischemic attack, American Heart Association guidelines favor which one of the following for secondary stroke prevention?
A target systolic blood pressure goal of <130 mm Hg in patients with a lacunar stroke
A target blood pressure goal of <140/90 mm Hg in patients with a history of a TIA or nonlacunar stroke
A target blood pressure goal of <130/80 mm Hg in patients without premorbid hypertension
Use of either a thiazide diuretic or a nondihydropyridine calcium channel blocker as first-line therapy
A
Among patients with a recent stroke or TIA, the prevalence of premorbid hypertension is approximately 70%. In these patients, studies demonstrate a 30% reduction in recurrent stroke risk with blood pressure-lowering therapies. Blood pressure-lowering treatment is recommended for both prevention of recurrent stroke and prevention of other vascular events in persons who have had an ischemic stroke or TIA and are beyond the hyperacute period (SOR A). American Heart Association (AHA) guidelines currently favor treatment with a thiazide diuretic, ACE inhibitor, or ARB, or combination treatment consisting of a thiazide diuretic plus an ACE inhibitor in patients with a history of stroke or TIA.The 2017 American College of Cardiology/AHA hypertension guidelines recommend a target systolic blood pressure goal of <130 mm Hg following a lacunar stroke in adults, and a target blood pressure of <130/80 mm Hg following a stroke or TIA in patients with premorbid hypertension. For patients without premorbid hypertension who have a blood pressure >140/90 mm Hg in the post-stroke period, the AHA recommends a target blood pressure of <130/80 mm Hg. However, in adults who have an ischemic stroke or TIA, have a systolic blood pressure <140 mm Hg and a diastolic blood pressure <90 mm Hg, and have not previously been treated for hypertension, the AHA concluded that the usefulness of initiating antihypertensive treatment ais not well established.
True statements regarding stroke in patients with sickle cell disease include which of the following? (Mark all that are true.)
All children with sickle cell disease should be screened for increased stroke risk with transcranial Doppler studies
In children with sickle cell disease at increased risk of stroke, prophylactic transfusions reduce the risk
Children with sickle cell disease who do not have a stroke over the course of 3 years while receiving prophylactic transfusion therapy can safely discontinue the treatment
Routine transfusion therapy for children with sickle cell disease should be discontinued after 5 years to prevent complications of iron overload
Subclinical brain ischemia in children with sickle cell disease can cause learning and behavioral difficulties
A,B, E
In children with sickle cell disease and abnormal cerebrovascular blood flow documented by transcranial Doppler examination, prophylactic transfusion therapy reduces their stroke risk from 10% to <1% per year (SOR A). The Stroke Prevention Trial in Sickle Cell Anemia (STOP II) tested whether transfusion for primary stroke prevention could be stopped after at least 30 months in children who had not had a stroke and in whom the transcranial Doppler flow abnormalities had been reversed. This trial was stopped early by the safety committee because of excessive events in the non-transfusion group (SOR B).Iron overload is a complication of transfusion therapy and measures should be taken to reduce its manifestations. This does not, however, create a contraindication to continued therapy (SOR B). About 20% of children with sickle cell disease are found to have "silent infarcts" on MRI, and these are associated with deterioration of cognitive function, affecting learning and behavior (SOR B). The risks and benefits of prophylactic transfusion based on silent MRI lesions are being tested in an ongoing clinical trial.
Modalities shown to be beneficial in the rehabilitation of muscle weakness following a stroke include which of the following? (Mark all that are true.)
Muscle strengthening
Functional electrical stimulation
Treadmill training with partial body weight support in patients with gait dysfunction
Hyperbaric oxygen
A,B,C
The Department of Veterans' Affairs and Department of Defense have developed guidelines for post-stroke rehabilitation that have been endorsed by the American Heart Association and the American Stroke Association. These guidelines recommend muscle strengthening for stroke patients with muscle weakness, based on the relationship between muscle strength, function, and fall prevention (SOR C). Research has shown that training improves muscle strength and function in patients who have completed rehabilitation.The number of studies to evaluate functional electrical stimulation is small, but based on the results the guidelines do recommend its use (SOR B). A Cochrane review concluded that it does lead to reductions in glenohumeral subluxation. Other studies have looked at effects on wrist and knee extension, ankle dorsiflexion, and gait in patients with hemiplegia.Treadmill training with partial body weight support to unload the lower extremities has proven to be superior to treadmill training with the patient supporting his or her full body weight. For this reason, treadmill training with partial support of body weight is recommended as an adjunct to conventional therapy in patients with mild-to-moderate dysfunction and resulting impairment of gait (SOR B).Hyperbaric oxygen therapy for cerebral ischemia has been evaluated in a number of human and animal studies; however, there is presently no consensus regarding its efficacy. Recent randomized, controlled human studies have not shown a benefit from this therapy, although all were limited by small sample size. Important differences between animal and human studies suggest that hyperbaric oxygen might be effective within the first few hours after a stroke. There is no evidence that it would be efficacious during the rehabilitation period.
Cardiac conditions that increase the risk of stroke include which of the following? (Mark all that are true.)
Endocarditis
Mitral stenosis
Patent foramen ovale
A tissue mitral valve prosthesis 1 year postoperatively
A mechanical mitral valve prosthesis 1 year postoperatively
A, B, C, E
Endocarditis may lead to production of emboli (SOR A). Mitral stenosis increases stroke risk because increasing the size of the left atrium, especially if associated with atrial fibrillation, increases the risk of embolism (SOR A). Patent foramen ovale may be a cause of cryptogenic stroke (SOR A). Mechanical mitral valves do not become covered by endothelium, and long-term anticoagulation is necessary to prevent stroke and other complications (SOR A). A tissue prosthesis becomes covered with endothelium within months and does not pose a risk for stroke (SOR A).
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
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
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
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 videofluoroscopy 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
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).
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
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 preexisting 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
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
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 <185 mm Hg and their diastolic BP is <110 mm Hg before IV fibrinolytic therapy is initiated.
A 63-year-old male presents to your office because he thinks he has had a stroke. You have treated him for hypertension for several years, but he has no other chronic medical problems. On examination you note slurred speech and impaired fine motor coordination of his left hand. The examination is otherwise normal.These findings are most consistent with which type of infarct?
Brain stem
Cerebellar
Lacunar
Left middle cerebral artery
Occipital lobe
C
The dysarthria/clumsy hand syndrome is characteristic of a lacunar (small vessel) infarct (SOR B). MRI studies of affected patients often show the infarct localized to the internal capsule or putamen. Hypertension is a major risk factor. The prognosis is generally good. Infarcts of the left hemisphere generally produce right hemiparesis, right sensory defects, and aphasia. Brain stem infarcts usually produce dysarthria, nystagmus, and disconjugate gaze. Cerebellar infarcts often result in an ataxic gait and ipsilateral limb ataxia. Occipital lobe infarcts can produce visual field defects, visual hallucinations, and color anomia.
Under Medicare guidelines, which of the following would disqualify a patient from stroke rehabilitation at an inpatient rehabilitation center? (Mark all that are true.)
Angina pectoris with low-level exercise
A therapy program limited to speech therapy, for both speech and swallowing difficulties
Fatigue after 4 hours of physical therapy
Significant dementia with no likelihood of improvement with intensive therapy
A predicted length of rehabilitation of less than 2 weeks
A, B, D
Medicare guidelines require that a patient be able to tolerate 3 hours of therapy daily to be eligible for inpatient rehabilitation. Medicare guidelines also state that the patient should be medically stable, and require therapy from multiple therapy disciplines, one of which must be physical or occupational therapy. Also, the patient must be realistically able to improve his or her situation with the therapy provided. The guidelines do not specify a time limit.
A 68-year-old female has an acute ischemic stroke. CT of the head shows no bleeding or masses. Two days later she is stable but has a brief focal seizure that resolves spontaneously.Which one of the following would be most appropriate at this point?
Observation only
An EEG
Diazepam (Valium)
Levetiracetam (Keppra)
Phenytoin (Dilantin)
A
Seizures occur in 3%-23% of stroke victims after the stroke. Early-onset focal seizures (<2 weeks post stroke) rarely recur, making anticonvulsant treatment unnecessary after the first seizure (SOR B). Early-onset seizures in this group do not adversely affect prognosis. Recurrent seizures should be treated. [Show Less]