Cerebrovascular disease in older adults

Stroke is highly prevalent and disproportionately affects older adults. With almost 800,000 strokes in the United States annually, approximately 75% occur in patients over 65 years of age and 20% in patients older than 85 years. Forecasting suggests the incidence of stroke among older adults will continue to increase. 1–3 Stroke is caused by disruption of the circulation of blood to the brain and can be ischemic due to occlusion of an artery or hemorrhagic due to rupture of an artery. Ischemia accounts for ~85% of stroke while hemorrhage accounts for ~15%. 3 Elucidating etiology of a stroke is critical for optimal management. Ischemic stroke etiology can be classified by the TOAST criteria, which includes cardioembolism, large artery atherosclerosis, small vessel disease, cryptogenic (includes embolic stroke of underdetermined source), and other (e.g., hypercoagulable state). 4 Stroke prevention is paramount. Over 80% of strokes can be prevented through management of modifiable risk factors. 5 High blood pressure is the most significant modifiable risk factor, and management of diabetes, high cholesterol, and healthy lifestyle factors are essential to stroke prevention. 6 Thrombolysis and mechanical thrombectomy are the cornerstone of hyperacute stroke therapy and have demonstrated benefit in the older adult population 7,8 High-risk transient ischemic attacks and certain acute minor ischemic strokes may benefit from short-term dual antiplatelet therapy. 9–11 Direct oral anticoagulants are now widely prescribed and should be first-line for patients with nonvalvular atrial fibrillation and high thromboembolic risk or prior stroke regardless of age. 5