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Cerebrovascular disease can be devastating for patients and their families, but much can be done to attenuate cerebral damage and reduce disability. Active intervention is in three phases: acute therapy, rehabilitation and secondary prevention. Thrombolysis within 4.5 hours of symptom onset substantially reduces morbidity from ischaemic stroke with no overall impact on mortality. Administration requires the use of clear protocols to rapidly triage, transport and investigate patients. Computed tomography remains an appropriate imaging technique in the early assessment of most stroke patients. An organized approach to stroke care in a specialist environment reduces disability and saves lives. Such care has many components and it is not known which specific elements confer benefit. Adoption of a ‘care bundle’ approach including the active management of pyrexia and hyperglycaemia, and early screening for swallowing difficulties, is beneficial. Secondary prevention should be considered in all patients presenting with stroke and transient ischaemic attack. Validated tools estimate recurrence risk in the individual. Assessment of the carotid arteries is urgent as the efficacy of surgical endarterectomy falls with time. Anticoagulant therapy in the elderly population with atrial fibrillation is safer than is often assumed.

Clarithromycin is an antibiotic of the macrolide family, which is commonly used in the treatment of respiratory tract infections. We report a woman aged 77 years with bronchiectasis who was prescribed oral clarithromycin for lower respiratory tract infection. She developed akathisia after 2 doses. On withdrawing the antibiotic, her symptoms resolved rapidly after 7 days.