IM25.{4,9} | Geriatric Vascular Events and Stroke — Summary & Reflection

KEY TAKEAWAYS

Stroke epidemiology in elderly: doubles per decade after 55; hypertension = single most modifiable risk factor; AF = most important cardiac cause (5-fold stroke risk; CHA₂DS₂-VASc guides anticoagulation).

Stroke mechanisms: large vessel atherothrombosis (antiplatelet + statin + risk factors), cardioembolic (anticoagulation — DOAC preferred in non-valvular AF), lacunar small vessel (aggressive BP control + antiplatelet), cryptogenic (investigate for occult AF/PFO).

Atypical presentation in elderly: confusion, unexplained falls, dysphagia — always consider stroke. Wallenberg syndrome: crossed sensory signs + Horner + dysphagia + ipsilateral ataxia (PICA territory).

Acute management: NCCT first (exclude haemorrhage) → IV alteplase within 4.5 hours (not if haemorrhage, INR therapeutic, major surgery <3 months) → mechanical thrombectomy for LVO within 24 hours. BP: pre-tPA <185/110; post-tPA <180/105; no reperfusion — allow up to 220/120 for 24–48 hours.

Secondary prevention: TIA → ABCD² score → dual antiplatelet (aspirin + clopidogrel) for 21 days → address mechanism; AF → CHA₂DS₂-VASc ≥2 (men) / ≥3 (women) → DOAC; carotid stenosis ≥70% → CEA within 2 weeks.

Rehabilitation: early mobilisation, physiotherapy, speech therapy (dysphagia/aphasia), OT; post-stroke depression (SSRIs); caregiver support.

REFLECT

Return to the opening hook and Mr Govindswamy's acute stroke presentation. The registrar's instinct to lower the blood pressure was understandable — a reading of 178/102 mmHg looks dangerous in routine clinical practice. But in the acute stroke setting, that same blood pressure is sustaining perfusion to the ischaemic penumbra. Medicine's knowledge changes clinical instinct — and this case is a perfect example. Reflect on how the concepts of homeostenosis and the impaired autoregulation of the injured brain change not just what you know, but how you respond at the bedside. If you had a 4.5-hour window to treat and the CT showed no haemorrhage, what would your next three actions be, in order, and why?