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Geriatric Neurologic Emergencies

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Presentation on theme: "Geriatric Neurologic Emergencies"— Presentation transcript:

1 Geriatric Neurologic Emergencies
Alan Lucerna, DO Emergency Department Kennedy University Hospitals - Stratford

2 Geriatric Neurologic Emergencies
This Care of the Aging Medical Patient in the Emergency Room (CAMPER) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3 Which of these tests is not part of the stroke evaluation in the ED?
CT with contrast Accucheck ECG Cardiac enzymes Coagulation panel Correct answer A. CT without contrast should be done.

4 When evaluating for potential thrombolysis, which of these criteria is an absolute contraindication to rtPA administration in a patient who is in the 3 hour window? Age less than 80 Platelet < 100, 000 Glucose of 200 INR 1.2 SBP 179 Correct answer B.

5 According to the recent published trials on the use of rtPA in patients presenting in the hour window, age above 80 is a contraindication. True False The correct answer is A.

6 Geriatric Neurologic Emergencies
Objective: To discuss the diagnosis, treatment, and unique features of common neurological emergencies as it pertains to the geriatric population This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

7 Trauma CVA SAH SDH Dizziness Meningitis/Epidural Abscess

8 Geriatric Trauma

9 Trauma Epidemiology Overall incidence of TBI in ER is 444 cases/100,000 persons in the US Incidence increases in the elderly and peaks at 1,026/100,000 in patients older than 85 Females> males ( younger patients 1.6 times likely to be male SDH far more common: 46% of TBI vs 28% in young cohort Epidural hematoma less common Elderly have more pedestrian accidents and falls

10 Falls Older than 65, annual incidence of 30%
Rate increased to 50% in octogenarians Multifactorial: - Normal aging: changes with vision, joints, propioception - Superimposed diseases (DM/ autonomic dysfunction) - Meds

11 “But, Doc, she fell from a standing position. It can’t be that bad….”

12 68 year old female; fall from standing; on coumadin, ASA, Plavix
Image Source: Kennedy Health Systems

13 Image Source: Kennedy Health Systems

14 81 year old SAH posterior sylvian fissure S/P fall
Image Source: Kennedy Health Systems

15 Image Source: Kennedy Health Systems

16 Falls When compared to younger patients, falls in the elderly are:
7 times more to be the predominant etiology of injury (48% vs 7%) 7 times more to be the cause of death (55% vs 7.5%)

17 Falls Same level falls resulted in 30% injuries in the elderly compared with 4% of a younger cohort Head and neck (47% vs 22%) Mortality of these “low falls” approaches 15%

18 Spinal Injuries The elderly have a different predominant mechanism and patterns of injury Increased upper cervical spine injury, particularly the odontoid Typically C4-7 most flexible and most likely to be injured in the young Senile DJD alter spine mechanics making upper cervical spine more mobile Photo: Microsoft Office Images #MP (http://office.microsoft.com/en-us/images/)

19 Spinal Injuries Lomoschitz and colleagues: 149 patients older than age 65, C2 injuries account for 40% of fx In lower cervical spine: C5/C6, 12% each Four in 10 had multilevel trauma: C1/2 or C5/6 Patients > 75 yrs more likely to have upper cervical spine injuries regardless of mechanism Risk factors: DJD, osteopenia Lucerna had a specific image of cervical spine injury with arrows pointing to fractures. Where did this come from? Does it need to be replaced?

20 Spinal Injuries Cervical plain films lack obvious prevertebral soft tissue swelling in 17% of upper cervical spine 40% of lower cervical spine Some experts advocate bypassing plain films However, 3 out of 4 elderly who have cervical spine injury have normal neurologic exam Therefore, low threshold for immobilization and imaging Lucerna had a specific image of cervical spine injury with arrows pointing to fractures. Where did this come from?

21 Pedestrian Injuries SAH- 26% SDH - 29% Mortality - 19.6%
Those transferred to trauma centers have enormous survival benefit ( 56% vs 8% in acute care hospital) However, elderly is less likely to be transported to trauma centers compared to younger patients ( 60% vs 82%) Image Source: Microsoft Clip Art

22 Traumatic Brain Injury
Overall, in-hospital mortality for isolated TBI was two fold higher, 30% vs 14% Age remained an independent risk factor for death even when pre-existing medical conditions and complications were removed Geriatric TBI patients who survive to discharge have poor cognitive and functional outcomes Lucerna had an image here with no image credit, so it can’t be used. Does this need an image or can it be left plain, as it appears here?

23 Stroke is a Medical Emergency
Emergency Dial 911 Image Source: Public domain image from US FHWA Manual on Uniform Traffic Control Devices. F.A.S.T. Stroke Identification Images: Used by permission. Image Source: Image Source: Used by permission.

24 Does the FACE look uneven?
Ask the person to smile. Does one ARM drift down? Ask the person to raise both arms. Does the person’s SPEECH sound strange? Ask the person to repeat a simple phrase, for example, “The sky is blue.” If you observe any of these signs, then it’s TIME to call 911. F.A.S.T. Stroke Identification Images: Used by permission. Image Source: Used by permission.

25 Epidemiology: USA 700,000 to 795,000 people suffer a new or recurrent stroke in the US each year Of these 625, 000 are ischemic By 2025, annual number of strokes will reach 1 million In 2003, nearly 200, 000 died from stroke It is the 3rd leading cause of death after heart disease and cancer

26 Kammersgaard LP, Jørgensen HS, Reith J, et al
Kammersgaard LP, Jørgensen HS, Reith J, et al. Short- and long-term prognosis for very old stroke patients: The Copenhagen Stroke Study. Age and Ageing 2004;33: Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33:

27 Copenhagen Study Very old (>85) was found to be associated with severe strokes, as was: Being female Having atrial fibrillation Pre-existing disability

28 ©Image used by permission.
Kammersgaard LP, Jørgensen HS, Reith J, et al. Age and Ageing 2004;33:

29 Epidemiology: World 3rd leading cause of death in industrialized Europe and leading cause of adult disability WHO estimates 15 million suffer a stroke worldwide per year This results in 5.7 million deaths and 5 million with disability.† Global incidence will only increase since people over 65 will be 10% of the world population by 2025 †http://www.medscape.org/viewarticle/719320

30 Feigin FL, Lawes CMM, Bennett DA, Anderson CS
Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Stroke epidemiology: A review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2003;2(1):43-53 ©Image used by permission. Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Lancet Neurol 2003;2(1):43-53.

31 Pathophysiology The brain: 2% of the body's mass
Requires 15-20% of the total resting cardiac output to provide the necessary glucose and oxygen for its metabolism Stroke: sudden disruption of blood flow to the brain with subsequent neurologic deficit

32 Pathophysiology: The Ischemic Cascade
Seconds to minutes of the loss of glucose and oxygen delivery to neurons, the cellular ischemic cascade begins Cessation of the normal cell electrophysiologic function Cytokine cascade = edema = cell death

33 Pathophysiology: Ischemic Penumbra
Zones of decreased or marginal perfusion The core: regions of the brain without significant flow; these cells are presumed to die within minutes of stroke onset Tissue in the penumbra can remain viable for several hours because of marginal tissue perfusion Currently studied pharmacologic interventions for preservation of neuronal tissue target this penumbra

34 Mechanisms of Stroke 80% Ischemic
Embolic: may either be of cardiac or arterial origin; sudden onset, several previous infarcts in neuroimaging Thrombotic: large-vessel strokes and small-vessel or lacunar strokes; situ occlusions on atherosclerotic lesions in the carotid, vertebrobasilar, and cerebral arteries, typically proximal to major branches Lacunar: 20% of all ischemic strokes, great majority are related to hypertension Watershed: border zone infarcts, develop from relative hypoperfusion in the most distal arterial territories

35 Rupture of the vessel in Subarachnoid space or intracerebral space
Intrinsic to the blood vessels of the brain Decreased perfusion pressure or increase blood viscosity Embolus from the heart or extracranial vessel Head image: Microsoft Images (MC by Fotolia) Circulatory System Image: PhotoDisc Health & Medicine Volume 18 (Image 18118) Internal Organ Image: Microsoft Images (MC by Fotolia) Image Source: Microsoft Images by Fotolia Image Source: PhotoDisc Health & Medicine Volume 18 . Used by permission. Image Source: Microsoft Images by Fotolia

36 Mortality/Morbidity Stroke is the leading cause of disability in the United States 26% of stroke survivors need assistance with daily living 30% need some type of assistance for walking 26% require admission to a long-term care facility. at least one third of stroke survivors have depression as well as many of their care providers

37 What is the cost? The direct costs (ie, treatment) and indirect costs (ie, lost productivity) of stroke in the United States are approximately $68.9 billion/year in 2009

38 Stroke Evaluation

39 EMS Evaluation and Transport
EMS Systems “must provide education/training to minimize delays to dispatch, assessment ,and transport of potential stroke victims” AHA.ASA EMS needs to Provide high priority dispatch Support cardiopulmonary function Perform rapid stroke assessment Define “time last seen normal” Notify receiving hospital of “stroke alert” Transport to Stroke Center if possible and prudent

40 EMS Stroke Assessment Cincinnati Prehospital Stroke Scale
Facial droop Arm weakness Speech abnormalities Los Angeles Prehospital Stroke Scale Age >45 History of seizures or epilepsy absent Symptoms duration, 24 hours At baseline not wheelchair bound or bedridden Blood glucose Obvious asymmetry of one following: facial smile/grimace, hand grip, or arm strength

41 Should all “Stroke” patients be transported to Primary Stroke Center ?
Better one year survivals, functional outcomes and quality of life in patients treated in Dedicated Stroke Center- studies done outside US, many randomized trials and meta analysis. “ When a dedicated stroke center is available within a reasonable transport interval stroke patients who require hospitalization should be admitted there” Class 1 evidence AHA

42 Case 77 yo female presents to the ER for an evaluation of right sided weakness and dysarthria. The patient states she was doing laundry when she noticed that she could not lift her right arm up. She arrived in the ER with VS 160/95, 89, 20, 98.6, 99% on RA. Her NIHSS is 16.

43 Single most important piece of historical information…
Image Source: Microsoft Images (# ) Single most important piece of historical information… Image Source: Microsoft Images

44 What is the time of onset?
Image Source: Microsoft Images MP What is the time of onset? Image Source: Microsoft Images

45 Myelinated Fibers Lost
TIME IS BRAIN Every 60 seconds of ischemia leads to irreversible damage of 1.9 million neurons. Estimated Pace of Neural Circuitry Loss in Typical Large Vessel, Supratentorial Acute Ischemic Stroke Neurons Lost Synapses Lost Myelinated Fibers Lost Accelerated Aging Per Stroke 1.2 billion 8.3 trillion 7140 km/4470 miles 36 years Per Hour 120 million 830 billion 714 km/447 miles 3.6 years Per Minute 1.9 million 14 billion 12 km/7.5 miles 3.1 weeks Per Second 32000 230 million 200 meters/218 yards 8.7 hours Quantitative estimates of the pace of neural circuitry loss in human ischemic stroke emphasize the time urgency of stroke care. The typical patient loses 1.9 million neurons each minute in which stroke is untreated. From: Saver JL. Stroke 2006;37(1):

46 TIME IS BRAIN If stroke ran a full course: 10 hours, look at what is lost: 1.2 billion neurons 8.3 trillions synapses 4,470 miles of myelinated fibers

47 Stroke Evaluation Sudden weakness of face, arm, leg; sudden confusion; sudden difficulty speaking or understanding speech; visual disturbances; trouble walking; dizziness; sudden severe headache History Time of onset? Single most important piece of information Sx’s now resolved, worse, or getting better Similar episodes before ? Family history of CVA, cerebral aneurysm?

48 Acute Stroke Syndromes
Motor and/or sensory deficit ( Foot > face, arm). Grasp, sucking reflex. Abulia, paratonic rigidity, gait apraxia. Embolic > atherothrombotic. Dominant hemisphere: aphasia, motor and sensory deficit (face, arm > leg > foot). Internal capsule: hemiplegia. Homonymous hemianopsia. Non-dominant hemisphere: neglect, anosognosia, motor and sensory deficit (face, arm > leg > foot). Homonymous hemianopsia. Public domain Circle of Willis image from Image Source: Homonymous hemianopsia; alexia without apraxia. Visual hallucinations, visual perseverations. Choreoathetosis, spontaneous pain (thalamus). CN III palsy, vertical eye movement paresis. Motor deficit ( cerebral peduncle, midbrain).

49 Acute Stroke Syndromes
Penetrating Blood Vessels Pure motor hemiparesis ( classic Lacunar) Pure sensory Pure sensory-motor Hemiparesis, homolateral ataxia Dysarthria/clumsy hand Vertebro-basilar: Cranial nerve palsy Crossed sensory deficits Diplopia. Dizziness, N/V, dysarthria Dysphagia, hiccup Limp, gait ataxia Motor deficit, coma B/L signs suggests basilar artery disease Image Source: Internal Carotid: Progressive or stuttering onset of MCA syndrome, Occasionally ACA syndrome as well if inadequate Collateral flow

50 Data from Gorelick PB, et al. Neurology 1986;36(11):1445-1450.

51 National Institutes of Health Stroke Scale (NIHSS)
National Institutes of Health Stroke Scale (NIHSS). Image courtesy of UpToDate. Used by permission. Image courtesy of UpToDate. Used by permission.

52 Percent of Favorable Outcome < 60 YO
Baseline NIH Score Percent of Favorable Outcome < 60 YO 0-9 42 10-14 18 >20 12 61-68 YO 37 25 69-75 YO 54 27 > 75 YO 36 15 5-20 6 Uptodate.com (NIHSS: National Institutes of Health Stroke Scale Adapted from NINDS t-PA Stroke Study Group, Stroke 1997; 28:2119)

53 Emergency Room Assessment
Ensuring Medical stability ( ABC’s, IV, O2, monitor) Reversing any conditions that may contribute to the problem Moving towards uncovering the basis the neurologic symptom ( history, CT scan) Screening for contraindication to thrombolysis is acute ischemic stroke Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.

54 Stroke Alert Algorithm
Assess VS, O2, monitor Fingerstick Glucose ECG NIH CBC/BMP/CE/Coags 2 IV’s (# 18) Head CT w/o Contrast Contact Neurologists Contraindications to tPA LFT UDS Etoh LP EEG UA, Blood Cx Type and Screen Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.

55 Patient Remains Candidate For Fibrinolytic Therapy? Any Hemorrhage on
Identify Signs of Possible Stroke Identify signs of Possible Stroke Critical EMS Assessments and Actions Immediate General Assessment and Stabilization Immediate Neurologic Assessment by Stroke Team or Designee Hemorrhage on CT Scan? Patient Remains Candidate For Fibrinolytic Therapy? Begin Stroke Pathway… Probable Acute Ischemic Stroke; Consider Fibrinolytic Therapy No Hemorrhage Consult Neurologist Or Neurosurgeon; consider transfer if not available Hemorrhage Review Risks/Benefits with Patient And Family… Candidate Administer Aspirin Not Candidate Hemorrhage OR No Hemorrhage: NO Hemorrhage: Hemorrhage: Critical EMS Assessments and Actions Support ABC; give oxygen if needed Perform prehospital stroke assesment Establish time when patient last known normal (Note: therapies may be available beyond 3 hrs. from onset) Transport: Consider bringing a witness, family member or caregiver Alert hospital Check glucose if possible NOT Candidate for Fibrinolytic Therapy: Candidate for Fibrinolytic Therapy: Immediate General Assessment and Stabilization Assess ABCs, vital signs provide oxygen if hypoxemic Obtain IV access and blood samples Check glucose; treat if indicated Perform neurologic screening assessment Activate stroke team order emergent CT scan of brain Obtain 12-lead ECG Immediate Neurologic Assessment by Stroke Team or Designee Review patient history Establish symptom onset Perform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale) Begin Stroke Pathway Admit to stroke unit if available Monitor BP; treat if indicated Monitor neurologic status; emergent CT if deterioration Monitor blood glucose; treat if needed Initiate supportive therapy; treat co-morbidities Consult Neurologist Or Neurosurgeon; consider transfer if not available Review Risks/Benefits with Patient and Family: If acceptable – Give tPa No anticoagulants or antiplatelet treatment for 24 hours Probable Acute Ischemic Stroke; Consider Fibrinolytic Therapy Check for fibrinolytic exclusions Repeat neurologic exam: are deficits rapidly improving to normal? Patient Remains Candidate For Fibrinolytic Therapy? Any Hemorrhage on CT Scan? Administer Aspirin

56 Early Signs of Stroke on CT
Hypoattenuation involving one-third or more of the middle cerebral artery (MCA) territory Obscuration of the lentiform nucleus [blue arrow] Cortical sulcal effacement Focal parenchymal hypoattenuation Loss of the insular ribbon or obscuration of the Sylvian fissure Image Source: the Radiology Assistant (www.radiologyassistant.nl) Tomura N, et al. Radiology 1988;40(10): Lentiform nucleus image source: the Radiology Assistant. The images and illustrations on the Radiology Assistant site may be reproduced for educational purposes with due credit being given to the original author and the Radiology Assistant. Original image from Tomura N, Uemura K, Inugami A, et al. Eraly CT finding in cerebral infarction: Obscuration of the lentiform nucleus. Radiology 1988;168(10): Hyperattenuation of large vessel (e.g., “hyperdense MCA sign”) Loss of gray-white matter differentiation in the basal ganglia

57 2 hours after symptoms Image Source: Kennedy Health Systems

58 S/P tPA, 16 hours after initial symptoms
Image Source: Kennedy Health Systems

59 21 hours Image Source: Kennedy Health Systems

60 Day 5 Image Source: Kennedy Health Systems

61 Early Signs of Stroke on CT
Hypoattenuation involving one-third or more of the middle cerebral artery (MCA) territory Obscuration of the lentiform nucleus Cortical sulcal effacement Focal parenchymal hypoattenuation Loss of the insular ribbon or obscuration of the Sylvian fissure Hyperattenuation of large vessel (e.g., "hyperdense MCA sign") Loss of gray-white matter differentiation in the basal ganglia Early CT signs of infarction implies a worse prognosis The presence of these signs was associated with an increased risk of poor functional outcome Analysis from the NINDS trial found that early CT signs of infarction were not independently associated with increased risk of adverse outcome after IV alteplase treatment Patients treated with alteplase did better whether or not they had early CT signs Albers GW, et al. Chest 2008;133(6_suppl):630S-669S. Oliveira-Filho J, Koroshetz WJ. Accessed 9/20/2010.

62 Medical Therapy of Stroke American Heart Association
TPA in Acute Ischemic Stroke is Level 1 Care!!! The Decision may no longer be yours!!!

63 TPA For Acute Ischemic Stroke
Patient Selection Must present within 4.5 hours of sx’s CT excludes ICH Review History for contraindications Treatment of patients with minor neuro deficits or rapidly improving deficits is not recommended

64 TPA For Acute Ischemic Stroke
Contraindications: Evidence of ICH Suspicion of Subarachnoid hemorrhage pretreatment Recent (within 3 months) intracranial ,or intraspinal surgery Any history of intracranial hemorrhage in past Uncontrolled Hypertension Seizure at the onset of stroke

65 TPA For Acute Ischemic Stroke
Contraindications: Active internal bleeding Brain tumor, AVM, or aneurysm Known bleeding diathesis Current warfarin use; INR> 1.7, or PT >15 seconds Heparin within 48 hours Elevated PTT Platelets < 100,000

66 Image courtesy of UpToDate. Used by permission.

67 TPA For Acute Ischemic Stroke
Warnings Patients with severe neurologic deficits at presentation( NIHSS>22) are high risk for ICH Patients with major early infarct signs on Pretreatment CT with cerebral edema, mass effect, or midline shift

68 rtPA Expansion To 4.5 Hours
European Cooperative Acute Stroke Study (ECASS)-3 28% given tPA at hours of symptom onset had modest improvement at 6 months Eligibility criteria is the same as the 3 hour time period However, there are exclusions: patients. older than 80 yrs old 2. Taking anticoagulants with INR 1.7 3. Baseline NIHSS >25 The European Cooperative Acute Stroke Study 3 (ECASS 3) trial was performed to confirm or disconfirm the finding from the pooled analysis of benefit of IV tPA therapy in the 3- to 4.5-hour window. In ECASS 3, 821 patients were randomized to IV tPA or placebo. Major symptomatic hemorrhages occurred in 2.4% of the tPA group versus 0.2% of the placebo group, with no increase in mortality. Patients treated with tPA had a substantially better chance of functional independence with minimal or no disability 3 months after treatment. The proportion of patients with minimal or no disability increased from 45% with placebo to 52% with tPA, a 7% absolute improvement. The number needed to treat for 1 more patient to have a normal or near normal outcome was 14, and the number needed to treat for 1 more patient to have an improved outcome was 8. Overall, for every 100 patients treated within the 3- to 4.5-hour window, 16 had a better outcome as a result and 3 had a worse outcome.2 del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Stroke 2009;40(8):

69 TPA For Acute Ischemic Stroke
Protocol Monitor bp q 15 min. Bp , 185/110 qualifies, BP> 185/110 not remaining below this threshold with treatment- no TPA Dosing: 0.9 mg/kg maximum 90 mg 10% of total dose given as IV bolus over one minute Remaining 90% infused over one hour

70 TPA For Acute Ischemic Stroke
Protocol Monitor closely vital signs and neurologic status Maintain Bp < 185/110 No anticoagulant or antiplatelet therapy for 24 hours Avoid hypotension Mental status change, new neuro deficits during treatment, suspect ICH Discontinue therapy and do emergent CT brain

71 Image Source: http://commons. wikimedia
Image Source: Photo by Mydriatic. Used by permission. rtPA and Stroke Mimics

72 Stroke Mimics Hypoglycemia Seizures with post-ictal Todd’s paralysis
CNS infections Systemic Infections Toxic metabolic diseases ( Renal failure/TTP, hyponatremia, hepatic disease, drugs) Intracranial mass lesions (chronic SDH, tumors) Head trauma Complex migraines Functional deficit ( conversion disorder)

73 Stroke Mimics Studies showed no hemorrhagic complications in these patients Chernyshev OY, Martin-Schild S, Albright KC, et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010;74(17): Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: Frequency, clinical characteristics, and outcome. Stroke 2009;40(4): Scott PA, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: Characteristics and outcomes. Ann Emerg Med 2003;42(5):

74 ICH During Therapy With TPA
Discontinue TPA Repeat CT Repeat CBC, PT,PTT, fibrinogen, D-dimer Consider FFP Cryoprecipitate Platelet infusion Stat Neurosurgical consult

75 Medical Therapy of Stroke Considerations
Oxygenation and Airway control Fever control Blood Sugars Seizure control Hypertension control Anti coagulant therapy ? Rapidly progressing strokes( Brainstem) Class 1 evidence AHA

76 Medical Therapy of Stroke
Oxygen and Airway control Give supplemental oxygen to hypoxic patients No clear evidence for oxygen for non-hypoxic patients Insufficient data on hyperbaric oxygen

77 Medical Therapy of Stroke
Temperature control Treat fever with antipyretics Induced hypothermia unproven Sugar control Treat hypoglycemia promptly Hyperglycemia treatment recommended ASA/AHA recommends treatment of of bld sugar >140 to 185 mg/dL ESI recommends treatment for glycose above 180 mg/dL Treat with fluids and insulin Avoid Dextrose containing fluids Monitor closely: don’t over treat Fever may contribute to brain injury in patients with an acute stroke. This concept has been demonstrated in animal models in which ischemic injury is increased in the presence of elevated temperature. Hyperthermia may act via several mechanisms to worsen cerebral ischemia [27]:�Enhanced release of neurotransmitters�Exaggerated oxygen radical production�More extensive blood-brain barrier breakdown�Increased numbers of potentially damaging ischemic depolarizations in the focal ischemic penumbra�Impaired recovery of energy metabolism and enhanced inhibition of protein kinases�Worsening of cytoskeletal proteolysis

78 Medical Therapy of Stroke
Hypertension control Treatment cautiously advised for sustained BP greater/equal to 185/110 BP> 220/120 = Not lytic candidate. Search for end-organ damage: Aortic Dissection, MI, CHF, Renal Failure, Encephalopathy Treat as hypertensive emergency, Labetelol, Nicardipine, Nitroprusside BP >185/110- Candidate for lytic therapy Treat with Labetolol IV mg Nitropaste 1-2 inches Nicardipine 5mg/hr IV increase 2.5 mg/hr q 5 mins to max 15 mg/hr Monitor closely: don’t over treat

79 Medical Therapy of Stroke
Seizure Control No prophylactic anticonvulsants recommended Treat seizures with Benzodiazopines Prevent further seizures Witnessed seizure at stroke onset is Contraindication to Thrombolytic therapy

80 Medical Therapy of Stroke
Anti- Coagulant Therapy Never the decision of ED physician May be indicated for A. Fib, Prosthetic heart valves, CHF, Brain stem stroke with progression Never used at time zero with TPA Call Neurologist at Stroke Center early !!!

81 Medical Therapy of Stroke
Head position: Flat vs 30 degrees Neurology 2005; 64: Wojner-Alexander and colleagues used transcranial Doppler on MCA blood flow on 20 patients with AIS Lowering HOB from 30 to 0 degrees increased blood flow velocities, on average 20% from 30 to 15 degrees 3 patients showed improved neurologic function Wojner-Alexander,AW, et al. Neurology 2005; 64(8):

82 Medical Therapy of Stroke
Head position: 30 degrees and neutral Elevated intracranial pressure (e.g., with large ischemic stroke, intracerebral hemorrhage, space-occupying lesion, or other cause of elevated intracranial pressure) Aspiration (e.g., those with dysphagia and/or diminished consciousness) Cardiopulmonary decompensation or low pox Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.

83 If it’s good for acne…. Hayakawa K, Mishima K, Hazekawa M, et al. Stroke 2008;39(3):

84 Spontaneous ICH Incidence: 10-20 cases per 100, 000
Associated with advancing age: chronic HTN, amyloid angiopathy One month mortality 35% to 52% Treatment: ABCD, BP and ICP monitoring, reversal of coagulopathy, seizure prophylaxis Mannitol/hyperventilation for IICP Oliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.

85 Intraparenchymal bleed
Image Source: Kennedy Health Systems

86 A Few Words on SDH

87 Chronic SDH Frequently misdiagnosed Male predominance
7 cases per 100, 000 among patients older than 70 yrs of age Contributing factors: prone to falls, antiplatelets, anticoagulants, structural brain lesions CSF Shunting : 8% of patients with shunts due to NPH

88 Chronic SDH Presentation less likely to be classical (HA, visual changes, vomiting) Seizures Focal signs Subtle cognitive deficits ( confusion, personality changes, memory loss, impaired judgment EP must consider this when evaluating an elderly person who has mental status change or sudden progression of neurologic or psychiatric disease

89 Image Source: Kennedy Health Systems

90 Aneurysmal SAH 78 per 100, 000 among aged 70-88
Average age at presentation is 50 yo Advanced age is an independent risk factor for death and severe disability Good outcome in 3 months is 25% in >70 yo ( 73% in <40 yo) Rebleeding rates are also higher 16.4 ( older than 70) More likely to develop intraventircular hemorrhage, hydrocephalus, vasospasm

91 Age & Aneurysmal SAH Poor outcomes in patients who have aneurysmal SAH are related to advanced age, as the Glasgow Outcome Scale (GOS) ratings show here. Data from: Kulchycki LK, Edlow JA. Emerg Med Clin N Am 2006;24(2):

92 Aneurysmal SAH Of course, ABCD
BP control: MAP 130 or less or SBP 140 or less Nicardipine or Labetalol No nitroprusside: dilates cerebral vasculature, increase ICP, impairs auto regulation, excesive hypotension patients may require multiple CT’s to evaluate changes is mental status EP’s role: detection by CT/LP and expedited disposition. Involve the neurosurgeon early International Subarachnoid Aneurysm Trial (ISAT): coiling superior to clipping

93 Dizziness

94 Dizziness One of the most common presenting complaints in adults older than 75 YO Words to describe: fatigue, near syncope, disequilibrium, vertigo Vertigo, or illusory sense of motion Peripheral: acute onset, severe, assoc with n/v, tinnitus, hearing loss

95 Dizziness Vertigo is concerning in the elderly
H&P is not infallible in distinguishing central vs peripheral Vestibular nuclei infarction from basilar artery occlusion can be indistinguishable from vestibular neuritis by exam Norrving conducted a small study: 24 patients 50 to 75 yo with isolated acute vertigo 25% were discovered to have cerebellar ischemia Some of these events are cardio embolic Unless the cause is clearly benign, maintain a low threshold for imaging and neurologic consultation Norrving B, et al. Acta Neurologica Scandinavica 1995;91(1):43-48.

96 Dizziness Peripheral Vertigo Causes: Motion Sickness BPPV Otitis Media
Vestibular Neuritis Ménière's disease Toxiclabyrinthitis/ Ototoxic Meds

97 Dizziness Central Vertigo Causes: Etoh Temporal lobe seizures Migraine
Head trauma VBI Posterior fossa mass

98 Dizziness Central Vertigo needs emergent treatment
Vascular risk factors and abrupt onset headache increase likelihood of stroke Assess S/S posterior circulatory involvement: diplopia, dysarthria, ataxia, long tract problems REMEMBER: peripheral vertigo: have difficulty walking Cerebellar stroke: CANNOT WALK AT ALL GAIT testing is MANDATORY

99 Dizziness Vertigo Treatment:
Steroids may improve outcome in patients with vestibular neuritis Modified Epley Maneuver Meclizine Benzo’s Anti-emetic

100 Epley Maneuver Epley maneuver illustration from Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician 2005;71(6): ,

101 CNS Infection

102 Factors Affecting Geriatric Immunity
Immunosenescence: decline of immune cells assoc with normal aging Malnutrition Presenting complaints are often nonspecific: confusion and falls, blunted fever response, at times even hypothermic

103 Meningitis Largest spike in incidence occur in infants and older than age 60 yrs Geriatric cases 2-9 cases per 100, 000 Diagnostic delays are common Complications and in house mortality are at increased rate Classic triad: fever, nuchal rigidity, altered mental status has 46% sensitivity More than 99% has at least one, absence of all 3 in ruling out the diagnosis

104 Meningitis Nuchal rigidity particularly unhelpful
Neck stiffness found in only 57% of elderly with meningitis But also in 35% without CNS infection Rigidity maybe from Parkinson’s, osteoarthritis, cervical spondylosis 12% of healthy elderly display positive Kernig sign 18% have positive Brudzinski 40-58% of the elderly who have meningitis present with concomitant infections

105 Causative Bacteria Meningitis in Patients Older than 50
S pneumoniae N meningitidis L monocytogenes Aerobic gram-negative bacilli

106 Epidural Abscess Diagnostic delay occur in up to 75% of patients
The elderly often visit the ER for DJD related back pain More than 85% do not have the classic triad: spinal pain, fever, neurologic deficits Lack of fever and leukocytosis does not rule it out MRI is the gold standard along with use of inflammatory markers like ESR as a screening tool for patients who have lower pretest probability Pt suspected of epidural abscess must be transferred to centers capable of neurosurgery Antibiotics prior to transfer Patients with cervical abscess may need intubation

107 References Albers GW, Amarenco P, Easton JD, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6_suppl):630S-669S. Chen R, Balami JS, Esiri MM, et al. Ischemic stroke in the elderly: An overview of evidence. Medscape Education. April 5, Accessed January 3, 2013. Chernyshev OY, Martin-Schild S, Albright KC, et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010;74(17): del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke 2009;40(8): Feigin FL, Lawes CMM, Bennett DA, Anderson CS. Stroke epidemiology: A review of population-based studies of incidence, prevalence, and case-fatality in the late 20th century. Lancet Neurol 2003;2(1):43-53. Gorelick PB, Hier DB, Caplan LR, Langenberg P. Headache in acute cerebrovascular disease. Neurology 1986;36(11):

108 References Hayakawa K, Mishima K, Hazekawa M, et al. Delayed treatment with minocycline ameliorates neurologic impairment through activated microglia expressing a high-mobility group box1-inhibiting mechanism. Stroke 2008;39(3): Jauch EC, Kissela B, Stettler B. Acute management of stroke. Medscape Reference. August 10, Accessed December 12, 2011. Kammersgaard LP, Jørgensen HS, Reith J, et al. Short- and long-term prognosis for very old stroke patients: The Copenhagen Stroke Study. Age and Ageing 2004;33: Kulchycki LK, Edlow JA. Geriatric neurologic emergencies. Emerg Med Clin N Am 2006;24(2): Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: Epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. Am J Roentgenol 2002;178(3): Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the elderly: Vestibular or vascular disease? Acta Neurologica Scandinavica 1995;91(1):43-48. Oliveira-Filho J, Koroshetz WJ. Initial assessment and management of acute stroke. Accessed September 20, 2010.

109 References Saver JL, Kalafut M. Thrombolytic therapy in stroke. Medscape Reference. March 29, Accessed May 11, 2011. Saver JL. Time is brain – quantified. Stroke 2006;37(1):263:266. Scott PA, Silbergleit R. Misdiagnosis of stroke in tissue plasminogen activator-treated patients: Characteristics and outcomes. Ann Emerg Med 2003;42(5): Winkler DT, Fluri F, Fuhr P, et al. Thrombolysis in stroke mimics: Frequency, clinical characteristics, and outcome. Stroke 2009;40(4): Ruo-Li C, Balami JS, Esiri EM, Chen LK, Buchan AAM,. Ischemic Stroke in the Elderly: An Overview of Evidence. [ online ].


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