MSGM Clinical Case Discussion December 2025

Title: “A Fall, A Slur, A Spin — And A Stroke Waiting to Happen”

Prepared by: Dr Amanda Goh Mae Ching

Supervisor: Dr Kejal A/P Hasmukharay

Location: Pusat Perubatan Universiti Malaya

Mr T, 81-year-old man

UNDERLYING

 Type 2 diabetes mellitus (DM)

 Hypertension

 Dyslipidaemia

DRUG HISTORY:

T Metformin 1g BD

T Linagliptin 5mg OD

T Aspirin 100mg OD

T Atorvastatin 20mg ON

T Perindopril 6mg OD

T Bisacodyl 10mg OD

Syrup Lactulose 15ml ON

PREMORBID CONDITION:

Clinical Frailty Score: 4

bADL - Independent - Able to shower/ dress / toilet needs and eat on his own	iADL - Independent - Able to drive, manage finance and use smartphone
Cognitive - Daughter noticed that he has been increasingly forgetful past 3 months - Misplacing things, forget to turn off switches and light incense for prayers (his daily routine for many years)	Mood and Behaviour - Normal
Continence - Dual continent - No constipation/ nocturia	Mobility / Fall - Ambulating unaided - No recent history of fall prior to June 2025
Diet - Takes a balance diet with good portion of vegetables and meat - No recent loss of weight	Sensory impairment - No hearing/ visual impairment

SOCIAL HISTORY

Married with 4 children

Retired teacher

Living with his wife and youngest daughter in a double-storey terrace house at Petaling Jaya – room on the top floor with an ensuite bathroom

PRESENTATION

Presented with complaint of 1-week duration of persistent dizziness described as spinning sensation associated with multiple episodes of vomiting and unsteadiness when ambulating which had led to a fall onto the floor in sitting position on his way to the toilet one day prior to presentation. Post fall there was no loss of consciousness, but his family noticed he had slurred speech and right sided weakness which lasted for less than an hour. He also had tinnitus and intermittent diplopia. He denied any other visual disturbances, headache, otalgia, hearing impairment, numbness, facial asymmetry, photophobia, phonophobia, neck stiffness, chest pain, palpitations or fever. He was compliant to his antiplatelet and other medications. Home monitoring BP and capillary blood glucose range between 130-150/60-80mmHg and 8-12mmol/L respectively.

PHYSICAL EXAMINATION

GCS: E4V5M6, orientated with place/person and time, not in respiratory distress with respiratory rate of 15 breaths/min, good peripheral perfusion, no carotid bruit, fair hydration. No facial asymmetry/ slurred speech/ ptosis.

+ bidirectional nystagmus over right eye.

BP: 198/100mmHg

PR: 88 beats/minute, regular

T: 36.6 degrees Celcius

SpO2: 98% under room air

Capillary blood glucose: 15.1 mmol/L

Cardiovascular: S1S2 normal with no murmur

Respiratory: Normal breath sound

Abdominal: soft, no tenderness, no hepatosplenomegaly/ mass palpable, no ascites, bowel sound present

Neurological examination: + right sided past pointing with no dysdiadochokinesia, unable to assess gait as patient complaint of dizziness, power on all 4 limbs 5/5 with normal tone, reflex and sensation. Plantar down going bilaterally, no clonus. No neck stiffness.

Other cranial nerve examinations were normal.

MMSE: 27/30 (repeat phrase: 0/1, writing: 0/1, drawing: 0/1)

MOCA: 25/30 (Executive function: 4/5, Language- repeat: 0/2, delayed recall: 3/5)

INVESTIGATIONS

Renal Profile:

Na	141 mmol/L
K	3.9 mmol/L
Urea	6.7 mmol/L
Creatinine	95 umol/L

Liver Function Test

Total protein	78g/L
Albumin	46g/L
Total bilirubin	28umol/L
ALP	94U/L
AST	28U/L
ALT	20U/L
GGT	20U/L

Electrolytes

Corrected Calcium	2.46 mmol/L
Mg	0.73 mmol/L
Phosphate	0.85 mmol/L

Complete Blood Count

WBC	19.4 10⁹/L (neutrophil predominant)
Hb	14.7 g/L
Platelet	284 10⁹/L

Lipid profile

Total cholesterol	3.2 mmol/L
Triglyceride	1.3 mmol/L
LDL	1.6 mmol/L

Troponin I: 15 ng/L

C reactive protein: 8 mg/L

HbA1c: 8.3%

UFEME: no abnormalities

CXR:

ECG: Sinus rhythm with heart rate 90bpm, no axis deviation, normal QRS complex, no ST segment or T wave abnormalities.

CT brain (Non-contrast) in ED at presentation:

No acute intracranial bleed.

Well defined hypodensities at the left centrum semiovale, right lentiform nucleus, anterior limb of both internal capsule, left occipital lobe, left cerebellar hemisphere and right middle cerebellar penduncle in keeping with chronic infarcts.

Periventricular hypodensitites in keeping with deep white matter ischemia.

Prominent ventricles, basal cisterns and sulci in keeping with age related cerebral atrophy.

Impression: Multifocal chronic infracts. No acute intracranial bleed.

MRIMRA/MRV Brain Contrasted on day 2 of admission:

Area of T1 hypo-, T2/FLAIR hyperintensities at both cerebellum and right cerebellar peduncle with restricted diffusion on DWI/ADC, in keeping with acute infarct.

Foci of T1 hypo-, T2/FLAIR hyperintensities at the left occipital lobe and left pons with no restricted diffusion in keeping with chronic infarcts.

On post contrast imaging, no focal enhancing brain parenchymal lesion or abnormal leptomeningeal enhancement.

Bilateral symmetrical periventricular and deep white matter T2/FLAIR hyperintensities, some start to from confluent in keeping with small vessels ischaemia [FAZEKAS 2].

Diffuse volume loss of both cerebral hemispheres and widening of sulci [GCA 2].

No acute intracranial bleed.

No hydrocephalus.

MRA:

Heavily calcified V3 and V4 segment of both vertebral arteries (L>R) with narrowing of both vertebral arteries (L>R) and some loss of normal flow void signal within, extending into the proximal basilar artery.

Intracranial segment of the ICAs are patent.

Both MCAs, ACAs and Acom are patent.

Both PCAs, both Pcoms, both SCAs, and right PICA are visualised.

Both AICAs and left PICA is not visualised.

No aneurysm or vascular malformation.

Impression:

1. Acute bilateral cerebellar and right cerebellar peduncle infarcts with bilateral distal vertebral and proximal basilar artery stenosis.

2. Multifocal chronic infarct with background of small vessels disease and generalized cerebral atrophy.

FINAL DIAGNOSIS:

1. Bilateral cerebellar stroke secondary to vertebral and basilar artery stenosis

2. Recurrent syncope secondary to vertebrobasilar insufficiency

3. Uncontrolled type 2 diabetes mellitus

4. Mild cognitive impairment – likely vascular in origin

PATIENT PROGRESS:

Neuromedical team was consulted regarding the potential role of endovascular stenting; however, they advised that it was not indicated and recommended 21 days of dual antiplatelet therapy. The patient was discharged in stable condition after a 14-day hospitalization, having undergone inpatient rehabilitation to improve gait and balance, along with optimization of diabetes management.

He was able to ambulate with a walking frame under supervision at the time of discharge. At his falls clinic follow-up four weeks later, he had no further episodes of presyncope, syncope, or falls and was walking well at home with the aid of a walking frame.

Latest medications:

T Aspirin 100mg OD for 21 days

T Clopidogrel 75mg OD

T Pantoprazole 40mg OD

T Atorvastatin 20mg OD

T Linagliptin 5mg OD

T Metformin 1g BD

SC Toujeo 18unit ON

Syrup lactulose 15mls ON

DISCUSSION

1. What are the key clinical features that help differentiate this patient’s recurrent syncope as secondary to vertebrobasilar insufficiency rather than cardiac syncope or seizure-related causes?

2. Given Mr T’s presentation with recurrent posterior circulation ischemic events (recurrent syncope/presyncope, TIAs, and new bilateral cerebellar infarcts) with MRI/MRA findings of significant bilateral distal vertebral and proximal basilar artery stenosis, what are the indications, benefits, and potential risks of considering endovascular intervention (e.g., angioplasty and/or stenting) in this patient?

3. Considering Mr T’s recent bilateral cerebellar infarcts, mild cognitive impairment, recurrent syncope, and decline in function, which components of the Comprehensive Geriatric Assessment are most essential in planning his inpatient and post-discharge rehabilitation, and how would you prioritize strategies to minimize his risk of falls?

4. How should his cardiovascular risk factors (diabetes, hypertension, dyslipidaemia) and antithrombotic therapy be optimized in the context of vertebrobasilar stenosis, recurrent TIAs, and small-vessel disease, while balancing geriatric considerations such as polypharmacy, cognition, and safety at home?