Q1. A stroke causing leg weakness greater than arm weakness most likely involves which artery? A. Middle cerebral B. Anterior cerebral C. Posterior cerebral D. Basilar ANSWER: B — anterior cerebral. Why: the ACA supplies the medial hemisphere, where the leg area of the motor homunculus lies. A: MCA affects face and arm more than leg. C: PCA causes visual field loss. LEARNING POINT: derive it from the homunculus rather than memorising a list.

Q2. What is the FIRST investigation in suspected acute stroke, after checking glucose? A. MRI brain with contrast B. Non-contrast CT head C. Carotid Doppler D. Lumbar puncture ANSWER: B — non-contrast CT head. Why: it rapidly identifies haemorrhage, which is the decision that determines whether treatment thins the blood or stops the bleeding. A: MRI is more sensitive for early infarct but slower and less available acutely. LEARNING POINT: the CT is there to rule out blood, not to prove ischaemia.

Q3. A 70-year-old on gliclazide is found with acute right hemiparesis and dysphasia. The FIRST action is: A. Immediate thrombolysis B. Check capillary blood glucose C. Urgent MRI D. Give aspirin ANSWER: B — check the glucose. Why: hypoglycaemia mimics stroke precisely and reverses within minutes of treatment. A sulfonylurea makes it substantially more likely. A: dangerous before imaging and before excluding mimics. D: premature before haemorrhage is excluded. LEARNING POINT: glucose is in every stroke protocol for exactly this reason.

Q4. A patient with a dense hemiparesis of 45 minutes has a CT reported as normal. The correct interpretation is: A. No stroke has occurred B. Haemorrhage is excluded; this supports ischaemic stroke and thrombolysis assessment C. The scan must be repeated immediately D. The patient has had a TIA ANSWER: B. Why: early ischaemic infarction is frequently invisible on CT for several hours. The scan's job was to exclude haemorrhage so that reperfusion can be considered. A: the classic misreading. D: a TIA implies resolved symptoms; this deficit is dense and ongoing. LEARNING POINT: a normal CT is the green light, not the all-clear.

Q5. A 66-year-old had 15 minutes of arm weakness that has fully resolved. ECG shows atrial fibrillation. The most appropriate secondary prevention is: A. Aspirin alone B. Anticoagulation C. No treatment as symptoms resolved D. Antibiotics ANSWER: B — anticoagulation. Why: AF causes left atrial stasis and thrombus, which embolises. Anticoagulation is substantially more effective than antiplatelet therapy against that mechanism. A: less effective for a cardioembolic source. C: TIA carries the highest stroke risk in the days that follow. LEARNING POINT: identify the SOURCE — it changes the drug.

Q6. A patient has LEFT facial weakness with RIGHT arm and leg weakness. This localises to: A. Left cerebral hemisphere B. Right cerebral hemisphere C. Brainstem D. Spinal cord ANSWER: C — brainstem. Why: cranial nerve nuclei lie in the brainstem and supply the ipsilateral face, while the corticospinal tract crosses lower down. Only a lesion between the two produces crossed signs. A, B: a hemispheric lesion affects face and limbs on the SAME (contralateral) side. LEARNING POINT: crossed signs are a brainstem signature, and posterior circulation strokes are easily mistaken for vestibular disease.

Q7. In acute ISCHAEMIC stroke not undergoing thrombolysis, a blood pressure of 190/100 is usually managed by: A. Rapid aggressive reduction to normal B. Permissive hypertension, avoiding aggressive lowering C. Immediate intravenous nitrates D. Withholding all antihypertensives permanently ANSWER: B — permissive hypertension. Why: the ischaemic penumbra is perfused through collaterals at the edge of viability. Dropping the systemic pressure reduces that perfusion and can extend the infarct. A, C: risk enlarging the infarct. D: overstated — pressure is treated later, in the secondary prevention phase. LEARNING POINT: the opposite applies in haemorrhagic stroke, where lowering pressure limits haematoma expansion. Same number, opposite management, decided by the CT.