What is the best course of treatment for an older adult with a history of comorbidities, including previous strokes, heart conditions, or bleeding disorders, presenting with symptoms of a stroke, such as sudden weakness, numbness, or difficulty speaking?

Acute Stroke Management in Older Adults with Comorbidities

Immediate Emergency Response

For an older adult presenting with sudden weakness, numbness, or difficulty speaking, immediately activate emergency medical services and transport to a facility with advanced stroke care capabilities (CT/MRI on site, thrombolysis/thrombectomy available) within minutes—time is brain tissue, and treatment windows are measured in hours, not days. 1, 2, 3

Recognition and Triage

• Use the FAST method (Face drooping, Arm weakness, Speech difficulty, Time of onset) to rapidly identify stroke symptoms 2, 4
• Document the exact time symptoms began—this is critical for determining eligibility for thrombolytic therapy, which must be administered within 3 hours of symptom onset 4, 5, 6
• Patients presenting within 48 hours with unilateral weakness, speech disturbance, or aphasia are at VERY HIGH risk for recurrent stroke and require immediate emergency department evaluation 1, 3

Risk Stratification by Timing

The Canadian Stroke Best Practice guidelines provide clear time-based triage:

• Within 48 hours: Very high risk—immediate ED transfer, imaging within 24 hours 1, 3
• 48 hours to 2 weeks: High risk—comprehensive evaluation within 24 hours by stroke specialist 1
• Beyond 2 weeks: Lower urgency—evaluation within one month 1

Essential Immediate Investigations

Within 24 Hours for High-Risk Patients

• Urgent brain imaging (CT or MRI) to differentiate ischemic from hemorrhagic stroke 1, 3
• Noninvasive vascular imaging (CTA or MRA from aortic arch to vertex) to identify large vessel occlusion and carotid stenosis 1, 3
• 12-lead ECG without delay to evaluate for atrial fibrillation or other cardiac sources of embolism 1, 3
• Laboratory investigations including glucose, coagulation studies (especially relevant given bleeding disorder history) 1

Acute Management Priorities

Airway, Breathing, and Circulation

• Administer supplementary oxygen if oxygen saturation <94% to prevent hypoxemia, which worsens stroke prognosis 2, 4, 6
• Maintain airway control to prevent aspiration, particularly in patients with dysphagia 7
• Ensure adequate oxygenation and ventilation as hypoxemia negatively impacts stroke outcome 6

Blood Pressure Management

Critical caveat: Blood pressure management in acute stroke is nuanced and depends on whether thrombolytic therapy is planned:

• Without thrombolysis: The American Stroke Association recommends blood pressure reduction only if systolic >220 mmHg or diastolic >120 mmHg 7
• With thrombolysis planned: Blood pressure must be reduced to systolic <180 mmHg and diastolic <105 mmHg before treatment 7
• Avoid precipitous drops in diastolic pressure, as cerebral autoregulation may be dysfunctional in ischemic brain and blood pressure stabilization is associated with better outcomes 7, 6

Glucose Control

• Treat glucose levels >8 mmol/L (>144 mg/dL), as hyperglycemia predicts poor prognosis even after correcting for age and stroke severity 6
• Insulin therapy in critically ill stroke patients is safe and associated with lower mortality and complication rates 6

Temperature Management

• Control body temperature and treat hyperthermia early, as elevated temperature has a negative effect on stroke outcome 6

Thrombolytic Therapy Considerations

Eligibility and Timing

• Intravenous tissue plasminogen activator (tPA) has clinical benefits for acute ischemic stroke but must be administered within 3 hours of symptom onset 4, 5, 6
• Fibrinolytic therapy administered within the first hours significantly improves outcomes 4

Special Considerations for Comorbidities

Important caveat for patients with bleeding disorders or previous hemorrhagic stroke: The presence of bleeding disorders substantially increases the risk of intracranial hemorrhage with thrombolytic therapy 8. While the FDA label for tPA does not provide absolute contraindications for all bleeding disorders, careful risk-benefit assessment is essential, and these patients may not be candidates for thrombolysis 8.

• History of previous hemorrhagic stroke is typically a contraindication to thrombolytic therapy
• Active bleeding disorders require careful evaluation before considering tPA 8
• Patients on anticoagulation require coagulation studies before thrombolysis decisions 9

Secondary Prevention and Carotid Intervention

For Patients with Carotid Stenosis

Once acute management is complete and the patient is stabilized:

• Carotid endarterectomy should be performed for 70-99% symptomatic stenosis (NASCET criteria) by a specialist surgeon with low perioperative mortality/morbidity 1
• For 50-69% symptomatic stenosis, consider endarterectomy in select patients based on age, gender, and comorbidities 1
• Timing is critical: perform carotid endarterectomy as soon as possible after the event, ideally within 2 weeks 1
• Carotid angioplasty and stenting may be considered for patients who meet criteria for endarterectomy but are deemed unfit due to medical comorbidities (significant heart/lung disease, age >80 years) 1

Stroke Unit Care

All acute stroke patients should be managed in a dedicated stroke unit where evidence-based care can be delivered by a specialist, multidisciplinary team in an organized, coordinated fashion 1. Stroke unit care has been consistently shown to improve outcomes compared to general medical ward care 1.

Key Components

• Specialist multidisciplinary team with stroke expertise 1
• Organized, coordinated care with routine outcome auditing 1
• Early rehabilitation initiated during acute hospitalization 1
• Prevention of complications including aspiration, deep vein thrombosis, and pressure ulcers 1

Special Considerations for Older Adults with Multiple Comorbidities

Hypercoagulable States

• Screening for hypercoagulable states is generally not advocated for all stroke patients, but consider in younger patients or those with cryptogenic stroke and family history of thrombosis 9
• The yield is typically low in older, unselected stroke patients 9
• For documented hypercoagulable states, treatment typically involves long-term or indefinite warfarin, though clinical trial data supporting this approach is limited 9

Posterior Circulation Symptoms

Patients presenting with vertigo, ataxia, diplopia, or dysarthria may have posterior circulation stroke (including medullary or pontine involvement), which places them in the highest risk category 1, 2, 3. These symptoms combined with weakness indicate very high risk and demand immediate evaluation 3.

Critical Time Windows

The concept of "time is brain" cannot be overstated:

• Every minute of delay results in progressive, irreversible loss of brain tissue 10, 7
• The risk of recurrent stroke is highest in the first 48 hours and first week after symptom onset 3
• Approximately 54% of U.S. stroke deaths occur outside of a hospital, emphasizing the need for immediate emergency response 5
• For hemorrhagic stroke, immediate surgery is crucial to prevent rebleeding that results in serious impairment or death in 40-60% of cases 5