USMLE Step 2 CK Neurology Questions: Acute Ischemic Stroke, Subarachnoid Hemorrhage and Giant Cell Arteritis

by

Neurology emergencies on USMLE Step 2 CK test time-sensitive decisions: when to give thrombolytics, which test to order after a normal CT, and when to treat before the diagnosis is confirmed. Try these three questions.

Question 1: Sudden weakness and trouble speaking

A 67-year-old man is brought to the emergency department 2 hours after the sudden onset of right arm and leg weakness and difficulty speaking. Blood pressure is 168/95 mm Hg. Fingerstick glucose is 110 mg/dL. Noncontrast CT of the head shows no hemorrhage. He takes no anticoagulants and has no recent surgery, bleeding or prior intracranial hemorrhage. Which of the following is the most appropriate next step in treatment?

A. Aspirin 325 mg and observation
B. Intravenous heparin infusion
C. Lower the blood pressure below 140/90 mm Hg before any other treatment
D. MRI of the brain before treatment
E. Intravenous thrombolytic therapy (alteplase or tenecteplase)

Correct answer: E. Intravenous thrombolytic therapy (alteplase or tenecteplase)

This patient has an acute ischemic stroke within 4.5 hours of symptom onset, with no hemorrhage on CT, normal glucose and no contraindications. He should receive IV thrombolysis. His blood pressure is already below the required threshold of 185/110 mm Hg. CT angiography should also be done to look for a large vessel occlusion, which may qualify him for mechanical thrombectomy. Aspirin is delayed for 24 hours after thrombolysis.

Why the other options are wrong:

  • Aspirin and observation is for patients who are not candidates for thrombolysis.
  • Heparin is not used in acute ischemic stroke and increases the risk of bleeding.
  • Aggressive blood pressure lowering is unnecessary; the target before thrombolysis is below 185/110.
  • MRI before treatment delays therapy; noncontrast CT is enough to exclude hemorrhage.

Question 2: The “worst headache of my life” with a normal CT

A 45-year-old woman comes to the emergency department because of a sudden, severe headache that began 10 hours ago while she was exercising. She describes it as the worst headache of her life and reached maximal intensity within a minute. She has neck stiffness. Neurologic examination is otherwise normal. Noncontrast CT of the head shows no abnormalities. Which of the following is the most appropriate next step?

A. Discharge with analgesics
B. Lumbar puncture
C. Electroencephalography
D. Subcutaneous sumatriptan
E. Repeat CT of the head in 1 week

Correct answer: B. Lumbar puncture

A thunderclap headache suggests subarachnoid hemorrhage (SAH), usually from a ruptured berry aneurysm. Noncontrast CT is very sensitive in the first 6 hours but becomes less sensitive afterward. When the CT is negative and onset was more than 6 hours ago, perform a lumbar puncture to look for xanthochromia or red blood cells that do not clear from tube 1 to tube 4. If positive, perform CT or catheter angiography to find the aneurysm.

Why the other options are wrong:

  • Discharge risks missing a life-threatening rebleed.
  • EEG is used for seizures, not to diagnose SAH.
  • Sumatriptan treats migraine; it should not be given before SAH is ruled out.
  • Waiting a week delays the diagnosis; rebleeding risk is highest early.

Question 3: New headache and jaw pain while chewing in an older woman

A 72-year-old woman has had a new headache over her right temple for 3 weeks. Her scalp is tender when she combs her hair, and her jaw aches while chewing. She also has morning stiffness in her shoulders and hips. Visual acuity is normal. The right temporal artery is tender and has a decreased pulse. ESR is 92 mm/h. Which of the following is the most appropriate next step?

A. Temporal artery biopsy, with treatment only after the result
B. MRI of the brain
C. Naproxen
D. High-dose oral prednisone, started now
E. Low-dose prednisone (10–15 mg daily)

Correct answer: D. High-dose oral prednisone, started now

This is giant cell (temporal) arteritis: age over 50, new headache, jaw claudication, scalp tenderness, a tender temporal artery and a very high ESR. It is often associated with polymyalgia rheumatica (shoulder and hip stiffness). The feared complication is permanent vision loss from ischemic optic neuropathy. Start high-dose glucocorticoids immediately, before the biopsy results. Temporal artery biopsy should still be done, ideally within 1–2 weeks, and remains diagnostic despite steroids. If there are visual symptoms, give IV methylprednisolone.

Why the other options are wrong:

  • Waiting for the biopsy risks irreversible blindness.
  • MRI of the brain does not diagnose GCA and delays treatment.
  • NSAIDs do not treat the vasculitis or prevent vision loss.
  • Low-dose prednisone is the treatment for polymyalgia rheumatica alone, not GCA.

Key takeaways

  • Ischemic stroke within 4.5 hours, no hemorrhage, BP below 185/110: IV thrombolysis; check for large vessel occlusion for thrombectomy.
  • Thunderclap headache with negative CT after 6 hours: lumbar puncture for xanthochromia.
  • Giant cell arteritis: start high-dose steroids immediately, then confirm with biopsy.

More USMLE practice questions

Repeated USMLE Questions Step 2 CK Review Vol 1 book cover

Want 100+ more clinical questions like these?

Get Repeated USMLE Questions Step 2 CK Review Vol 1 by Dr. Ray Makar

Buy on Amazon →

As an Amazon Associate, I earn from qualifying purchases.

Written and reviewed by Dr. Ray Makar, MD, dermatologist with 20 years of clinical practice. Last reviewed: October 2026. For exam preparation only, not medical advice.

FREE USMLE PDFs

Get 80 free practice questions

Four free sampler PDFs by Dr. Ray Makar: Step 1 (Pathology & Pharmacology) and Step 2 CK (Medicine, Surgery & Pediatrics), in both Review style and USMLE style, with answers and explanations. Also useful for NEET-PG, INI-CET and FMGE.

Download the free PDFs See the full books →

Leave a Comment