Presentation on theme: "Geriatric Neurologic Emergencies"— Presentation transcript:
1Geriatric Neurologic Emergencies Alan Lucerna, DOEmergency DepartmentKennedy University Hospitals - Stratford
2Geriatric 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.
3Which of these tests is not part of the stroke evaluation in the ED? CT with contrastAccucheckECGCardiac enzymesCoagulation panelCorrect answer A. CT without contrast should be done.
4When 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 80Platelet < 100, 000Glucose of 200INR 1.2SBP 179Correct answer B.
5According to the recent published trials on the use of rtPA in patients presenting in the hour window, age above 80 is a contraindication.TrueFalseThe correct answer is A.
6Geriatric Neurologic Emergencies Objective:To discuss the diagnosis, treatment, and unique features of common neurological emergencies as it pertains to the geriatric populationThis lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.
9Trauma EpidemiologyOverall incidence of TBI in ER is 444 cases/100,000 persons in the USIncidence increases in the elderly and peaks at 1,026/100,000 in patients older than 85Females> males ( younger patients 1.6 times likely to be maleSDH far more common: 46% of TBI vs 28% in young cohortEpidural hematoma less commonElderly have more pedestrian accidents and falls
10Falls Older than 65, annual incidence of 30% Rate increased to 50% in octogenariansMultifactorial:- 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….”
1268 year old female; fall from standing; on coumadin, ASA, Plavix Image Source: Kennedy Health Systems
16Falls 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%)
17FallsSame level falls resulted in 30% injuries in the elderly compared with 4% of a younger cohortHead and neck (47% vs 22%)Mortality of these “low falls” approaches 15%
18Spinal InjuriesThe elderly have a different predominant mechanism and patterns of injuryIncreased upper cervical spine injury, particularly the odontoidTypically C4-7 most flexible and most likely to be injured in the youngSenile DJD alter spine mechanics making upper cervical spine more mobilePhoto: Microsoft Office Images #MP (http://office.microsoft.com/en-us/images/)
19Spinal InjuriesLomoschitz and colleagues: 149 patients older than age 65, C2 injuries account for 40% of fxIn lower cervical spine: C5/C6, 12% eachFour in 10 had multilevel trauma: C1/2 or C5/6Patients > 75 yrs more likely to have upper cervical spine injuries regardless of mechanismRisk factors: DJD, osteopeniaLucerna had a specific image of cervical spine injury with arrows pointing to fractures. Where did this come from? Does it need to be replaced?
20Spinal InjuriesCervical plain films lack obvious prevertebral soft tissue swelling in 17% of upper cervical spine40% of lower cervical spineSome experts advocate bypassing plain filmsHowever, 3 out of 4 elderly who have cervical spine injury have normal neurologic examTherefore, low threshold for immobilization and imagingLucerna had a specific image of cervical spine injury with arrows pointing to fractures. Where did this come from?
21Pedestrian 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
22Traumatic 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 removedGeriatric TBI patients who survive to discharge have poor cognitive and functional outcomesLucerna 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?
23Stroke 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.
24Does 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.
25Epidemiology: USA700,000 to 795,000 people suffer a new or recurrent stroke in the US each yearOf these 625, 000 are ischemicBy 2025, annual number of strokes will reach 1 millionIn 2003, nearly 200, 000 died from strokeIt is the 3rd leading cause of death after heart disease and cancer
26Kammersgaard 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:
27Copenhagen StudyVery old (>85) was found to be associated with severe strokes, as was:Being femaleHaving atrial fibrillationPre-existing disability
29Epidemiology: World3rd leading cause of death in industrialized Europe and leading cause of adult disabilityWHO estimates 15 million suffer a stroke worldwide per yearThis 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
31Pathophysiology 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 metabolismStroke: sudden disruption of blood flow to the brain with subsequent neurologic deficit
32Pathophysiology: The Ischemic Cascade Seconds to minutes of the loss of glucose and oxygen delivery to neurons, the cellular ischemic cascade beginsCessation of the normal cell electrophysiologic functionCytokine cascade = edema = cell death
33Pathophysiology: Ischemic Penumbra Zones of decreased or marginal perfusionThe core: regions of the brain without significant flow; these cells are presumed to die within minutes of stroke onsetTissue in the penumbra can remain viable for several hours because of marginal tissue perfusionCurrently studied pharmacologic interventions for preservation of neuronal tissue target this penumbra
34Mechanisms of Stroke 80% Ischemic Embolic: may either be of cardiac or arterial origin; sudden onset, several previous infarcts in neuroimagingThrombotic: 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 branchesLacunar: 20% of all ischemic strokes, great majority are related to hypertensionWatershed: border zone infarcts, develop from relative hypoperfusion in the most distal arterial territories
35Rupture of the vessel in Subarachnoid space or intracerebral space Intrinsic to the blood vessels of the brainDecreased perfusion pressureor increase blood viscosityEmbolus from the heart orextracranial vesselHead 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 FotoliaImage Source: PhotoDisc Health & Medicine Volume 18 .Used by permission.Image Source: Microsoft Images by Fotolia
36Mortality/MorbidityStroke is the leading cause of disability in the United States26% of stroke survivors need assistance with daily living30% need some type of assistance for walking26% 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
37What 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
39EMS Evaluation and Transport EMS Systems “must provide education/training to minimize delays to dispatch, assessment ,and transport of potential stroke victims” AHA.ASAEMS needs toProvide high priority dispatchSupport cardiopulmonary functionPerform rapid stroke assessmentDefine “time last seen normal”Notify receiving hospital of “stroke alert”Transport to Stroke Center if possible and prudent
40EMS Stroke Assessment Cincinnati Prehospital Stroke Scale Facial droopArm weaknessSpeech abnormalitiesLos Angeles Prehospital Stroke ScaleAge >45History of seizures or epilepsy absentSymptoms duration, 24 hoursAt baseline not wheelchair bound or bedriddenBlood glucoseObvious asymmetry of one following: facial smile/grimace, hand grip, or arm strength
41Should 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
42Case77 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.
43Single most important piece of historical information… Image Source: Microsoft Images (# )Single most important piece of historical information…Image Source: Microsoft Images
44What is the time of onset? Image Source: Microsoft Images MPWhat is the time of onset?Image Source: Microsoft Images
45Myelinated Fibers Lost TIME IS BRAINEvery 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 StrokeNeurons LostSynapses LostMyelinated Fibers LostAccelerated AgingPer Stroke1.2 billion8.3 trillion7140 km/4470 miles36 yearsPer Hour120 million830 billion714 km/447 miles3.6 yearsPer Minute1.9 million14 billion12 km/7.5 miles3.1 weeksPer Second32000230 million200 meters/218 yards8.7 hoursQuantitative 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):
46TIME IS BRAINIf stroke ran a full course: 10 hours, look at what is lost:1.2 billion neurons8.3 trillions synapses4,470 miles of myelinated fibers
47Stroke EvaluationSudden weakness of face, arm, leg; sudden confusion; sudden difficulty speaking or understanding speech; visual disturbances; trouble walking; dizziness; sudden severe headacheHistoryTime of onset? Single most important piece of informationSx’s now resolved, worse, or getting betterSimilar episodes before ?Family history of CVA, cerebral aneurysm?
48Acute Stroke Syndromes Motor and/or sensory deficit ( Foot > face, arm).Grasp, sucking reflex.Abulia, paratonic rigidity, gait apraxia.Embolic > atherothrombotic.Dominant hemisphere: aphasia, motor andsensory 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 fromImage 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).
49Acute Stroke Syndromes Penetrating Blood VesselsPure motor hemiparesis ( classic Lacunar)Pure sensoryPure sensory-motorHemiparesis, homolateral ataxiaDysarthria/clumsy handVertebro-basilar:Cranial nerve palsyCrossed sensory deficitsDiplopia. Dizziness, N/V, dysarthriaDysphagia, hiccupLimp, gait ataxiaMotor deficit, comaB/L signs suggests basilar artery diseaseImage Source:Internal Carotid:Progressive or stuttering onset of MCA syndrome,Occasionally ACA syndrome as well if inadequateCollateral flow
50Data from Gorelick PB, et al. Neurology 1986;36(11):1445-1450.
51National 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.
52Percent of Favorable Outcome < 60 YO Baseline NIH ScorePercent of Favorable Outcome< 60 YO0-94210-1418>201261-68 YO372569-75 YO5427> 75 YO36155-206Uptodate.com (NIHSS: National Institutes of Health Stroke Scale Adapted from NINDS t-PA Stroke Study Group, Stroke 1997; 28:2119)
53Emergency Room Assessment Ensuring Medical stability ( ABC’s, IV, O2, monitor)Reversing any conditions that may contribute to the problemMoving towards uncovering the basis the neurologic symptom ( history, CT scan)Screening for contraindication to thrombolysis is acute ischemic strokeOliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.
54Stroke Alert Algorithm Assess VS, O2, monitorFingerstick GlucoseECGNIHCBC/BMP/CE/Coags2 IV’s (# 18)Head CT w/o ContrastContact NeurologistsContraindications to tPALFTUDSEtohLPEEGUA, Blood CxType and ScreenOliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.
55Patient Remains Candidate For Fibrinolytic Therapy? Any Hemorrhage on Identify Signs ofPossible StrokeIdentify signs of Possible StrokeCritical EMS Assessments and ActionsImmediate General Assessment and StabilizationImmediate Neurologic Assessment by Stroke Team or DesigneeHemorrhage on CT Scan?Patient Remains CandidateFor Fibrinolytic Therapy?Begin Stroke Pathway…Probable Acute Ischemic Stroke;Consider Fibrinolytic TherapyNo HemorrhageConsult NeurologistOr Neurosurgeon;consider transferif not availableHemorrhageReview Risks/Benefits with PatientAnd Family…CandidateAdminister AspirinNot CandidateHemorrhage ORNo Hemorrhage:NO Hemorrhage:Hemorrhage:Critical EMS Assessments and ActionsSupport ABC; give oxygen if neededPerform prehospital stroke assesmentEstablish time when patient last known normal (Note: therapies may be available beyond 3 hrs. from onset)Transport: Consider bringing a witness, family member or caregiverAlert hospitalCheck glucose if possibleNOT Candidate for Fibrinolytic Therapy:Candidate for Fibrinolytic Therapy:Immediate General Assessment and StabilizationAssess ABCs, vital signsprovide oxygen if hypoxemicObtain IV access and blood samplesCheck glucose; treat if indicatedPerform neurologic screening assessmentActivate stroke teamorder emergent CT scan of brainObtain 12-lead ECGImmediate Neurologic Assessment by Stroke Team or DesigneeReview patient historyEstablish symptom onsetPerform neurologic examination (NIH Stroke Scale or Canadian Neurologic Scale)Begin Stroke PathwayAdmit to stroke unit if availableMonitor BP; treat if indicatedMonitor neurologic status; emergent CT if deteriorationMonitor blood glucose; treat if neededInitiate supportive therapy; treat co-morbiditiesConsult NeurologistOr Neurosurgeon;consider transferif not availableReview Risks/Benefits with Patient and Family: If acceptable –Give tPaNo anticoagulants or antiplatelet treatment for 24 hoursProbable Acute Ischemic Stroke;Consider Fibrinolytic TherapyCheck for fibrinolytic exclusionsRepeat neurologic exam: are deficits rapidly improving to normal?Patient Remains CandidateFor Fibrinolytic Therapy?Any Hemorrhage onCT Scan?Administer Aspirin
56Early Signs of Stroke on CT Hypoattenuation involving one-third or more of the middle cerebral artery (MCA) territoryObscuration of the lentiform nucleus [blue arrow]Cortical sulcal effacementFocal parenchymal hypoattenuationLoss of the insular ribbon or obscuration of the Sylvian fissureImage 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
572 hours after symptomsImage Source: Kennedy Health Systems
58S/P tPA, 16 hours after initial symptoms Image Source: Kennedy Health Systems
61Early Signs of Stroke on CT Hypoattenuation involving one-third or more of the middle cerebral artery (MCA) territoryObscuration of the lentiform nucleusCortical sulcal effacementFocal parenchymal hypoattenuationLoss of the insular ribbon or obscuration of the Sylvian fissureHyperattenuation of large vessel (e.g., "hyperdense MCA sign")Loss of gray-white matter differentiation in the basal gangliaEarly CT signs of infarction implies a worse prognosisThe presence of these signs was associated with an increased risk of poor functional outcomeAnalysis from the NINDS trial found that early CT signs of infarction were not independently associated with increased risk of adverse outcome after IV alteplase treatmentPatients treated with alteplase did better whether or not they had early CT signsAlbers GW, et al. Chest 2008;133(6_suppl):630S-669S.Oliveira-Filho J, Koroshetz WJ. Accessed 9/20/2010.
62Medical Therapy of Stroke American Heart Association TPA in Acute Ischemic Stroke is Level 1 Care!!! The Decision may no longer be yours!!!
63TPA For Acute Ischemic Stroke Patient SelectionMust present within 4.5 hours of sx’sCT excludes ICHReview History for contraindicationsTreatment of patients with minor neuro deficits or rapidly improving deficits is not recommended
64TPA For Acute Ischemic Stroke Contraindications:Evidence of ICHSuspicion of Subarachnoid hemorrhage pretreatmentRecent (within 3 months) intracranial ,or intraspinal surgeryAny history of intracranial hemorrhage in pastUncontrolled HypertensionSeizure at the onset of stroke
65TPA For Acute Ischemic Stroke Contraindications:Active internal bleedingBrain tumor, AVM, or aneurysmKnown bleeding diathesisCurrent warfarin use; INR> 1.7, or PT >15 secondsHeparin within 48 hoursElevated PTTPlatelets < 100,000
67TPA For Acute Ischemic Stroke WarningsPatients with severe neurologic deficits at presentation( NIHSS>22) are high risk for ICHPatients with major early infarct signs on Pretreatment CT with cerebral edema, mass effect, or midline shift
68rtPA Expansion To 4.5 Hours European Cooperative Acute Stroke Study (ECASS)-328% given tPA at hours of symptom onset had modest improvement at 6 monthsEligibility criteria is the same as the 3 hour time periodHowever, there are exclusions: patients. older than 80 yrs old2. Taking anticoagulants with INR 1.73. Baseline NIHSS >25The 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.2del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. Stroke 2009;40(8):
69TPA For Acute Ischemic Stroke ProtocolMonitor bp q 15 min. Bp , 185/110 qualifies,BP> 185/110 not remaining below this threshold with treatment- no TPADosing: 0.9 mg/kg maximum 90 mg10% of total dose given as IV bolus over one minuteRemaining 90% infused over one hour
70TPA For Acute Ischemic Stroke ProtocolMonitor closely vital signs and neurologic statusMaintain Bp < 185/110No anticoagulant or antiplatelet therapy for 24 hoursAvoid hypotensionMental status change, new neuro deficits during treatment, suspect ICHDiscontinue therapy and do emergent CT brain
71Image Source: http://commons. wikimedia Image Source: Photo by Mydriatic. Used by permission.rtPA and Stroke Mimics
73Stroke MimicsStudies showed no hemorrhagic complications in these patientsChernyshev 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):
74ICH During Therapy With TPA Discontinue TPARepeat CTRepeat CBC, PT,PTT, fibrinogen, D-dimerConsiderFFPCryoprecipitatePlatelet infusionStat Neurosurgical consult
75Medical Therapy of Stroke Considerations Oxygenation and Airway controlFever controlBlood SugarsSeizure controlHypertension controlAnti coagulant therapy ?Rapidly progressing strokes( Brainstem)Class 1 evidence AHA
76Medical Therapy of Stroke Oxygen and Airway controlGive supplemental oxygen to hypoxic patientsNo clear evidence for oxygen for non-hypoxic patientsInsufficient data on hyperbaric oxygen
77Medical Therapy of Stroke Temperature controlTreat fever with antipyreticsInduced hypothermia unprovenSugar controlTreat hypoglycemia promptlyHyperglycemia treatment recommendedASA/AHA recommends treatment of of bld sugar >140 to 185 mg/dLESI recommends treatment for glycose above 180 mg/dLTreat with fluids and insulinAvoid Dextrose containing fluidsMonitor closely: don’t over treatFever 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 :�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
78Medical Therapy of Stroke Hypertension controlTreatment cautiously advised for sustained BP greater/equal to 185/110BP> 220/120 = Not lytic candidate. Search for end-organ damage: Aortic Dissection, MI, CHF, Renal Failure, EncephalopathyTreat as hypertensive emergency, Labetelol, Nicardipine, NitroprussideBP >185/110- Candidate for lytic therapyTreat with Labetolol IV mgNitropaste 1-2 inchesNicardipine 5mg/hr IV increase 2.5 mg/hr q 5 mins to max 15 mg/hrMonitor closely: don’t over treat
79Medical Therapy of Stroke Seizure ControlNo prophylactic anticonvulsants recommendedTreat seizures with BenzodiazopinesPrevent further seizuresWitnessed seizure at stroke onset is Contraindication to Thrombolytic therapy
80Medical Therapy of Stroke Anti- Coagulant TherapyNever the decision of ED physicianMay be indicated for A. Fib, Prosthetic heart valves, CHF, Brain stem stroke with progressionNever used at time zero with TPACall Neurologist at Stroke Center early !!!
81Medical Therapy of Stroke Head position: Flat vs 30 degreesNeurology 2005; 64:Wojner-Alexander and colleagues used transcranial Doppler on MCA blood flow on 20 patients with AISLowering HOB from 30 to 0 degrees increased blood flow velocities, on average 20% from 30 to 15 degrees3 patients showed improved neurologic functionWojner-Alexander,AW, et al. Neurology 2005; 64(8):
82Medical Therapy of Stroke Head position: 30 degrees and neutralElevated 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 poxOliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.
83If it’s good for acne….Hayakawa K, Mishima K, Hazekawa M, et al. Stroke 2008;39(3):
84Spontaneous ICH Incidence: 10-20 cases per 100, 000 Associated with advancing age: chronic HTN, amyloid angiopathyOne month mortality 35% to 52%Treatment: ABCD, BP and ICP monitoring, reversal of coagulopathy, seizure prophylaxisMannitol/hyperventilation for IICPOliveira-Filho J, Koroshetz WJ. Accessed September 20, 2010.
85Intraparenchymal bleed Image Source: Kennedy Health Systems
87Chronic SDH Frequently misdiagnosed Male predominance 7 cases per 100, 000 among patients older than 70 yrs of ageContributing factors: prone to falls, antiplatelets, anticoagulants, structural brain lesionsCSF Shunting : 8% of patients with shunts due to NPH
88Chronic SDHPresentation less likely to be classical (HA, visual changes, vomiting)SeizuresFocal signsSubtle cognitive deficits ( confusion, personality changes, memory loss, impaired judgmentEP must consider this when evaluating an elderly person who has mental status change or sudden progression of neurologic or psychiatric disease
90Aneurysmal SAH 78 per 100, 000 among aged 70-88 Average age at presentation is 50 yoAdvanced age is an independent risk factor for death and severe disabilityGood 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
91Age & Aneurysmal SAHPoor 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):
92Aneurysmal SAH Of course, ABCD BP control: MAP 130 or less or SBP 140 or lessNicardipine or LabetalolNo nitroprusside: dilates cerebral vasculature, increase ICP, impairs auto regulation, excesive hypotensionpatients may require multiple CT’s to evaluate changes is mental statusEP’s role: detection by CT/LP and expedited disposition. Involve the neurosurgeon earlyInternational Subarachnoid Aneurysm Trial (ISAT): coiling superior to clipping
94DizzinessOne of the most common presenting complaints in adults older than 75 YOWords to describe: fatigue, near syncope, disequilibrium, vertigoVertigo, or illusory sense of motionPeripheral: acute onset, severe, assoc with n/v, tinnitus, hearing loss
95Dizziness Vertigo is concerning in the elderly H&P is not infallible in distinguishing central vs peripheralVestibular nuclei infarction from basilar artery occlusion can be indistinguishable from vestibular neuritis by examNorrving conducted a small study:24 patients 50 to 75 yo with isolated acute vertigo25% were discovered to have cerebellar ischemiaSome of these events are cardio embolicUnless the cause is clearly benign, maintain a low threshold for imaging and neurologic consultationNorrving B, et al. Acta Neurologica Scandinavica 1995;91(1):43-48.
97Dizziness Central Vertigo Causes: Etoh Temporal lobe seizures Migraine Head traumaVBIPosterior fossa mass
98Dizziness Central Vertigo needs emergent treatment Vascular risk factors and abrupt onset headache increase likelihood of strokeAssess S/S posterior circulatory involvement: diplopia, dysarthria, ataxia, long tract problemsREMEMBER: peripheral vertigo: have difficulty walkingCerebellar stroke: CANNOT WALK AT ALLGAIT testing is MANDATORY
99Dizziness Vertigo Treatment: Steroids may improve outcome in patients with vestibular neuritisModified Epley ManeuverMeclizineBenzo’sAnti-emetic
100Epley ManeuverEpley maneuver illustration from Swartz R, Longwell P. Treatment of vertigo. Am Fam Physician 2005;71(6): ,
102Factors Affecting Geriatric Immunity Immunosenescence: decline of immune cells assoc with normal agingMalnutritionPresenting complaints are often nonspecific: confusion and falls, blunted fever response, at times even hypothermic
103MeningitisLargest spike in incidence occur in infants and older than age 60 yrsGeriatric cases 2-9 cases per 100, 000Diagnostic delays are commonComplications and in house mortality are at increased rateClassic triad: fever, nuchal rigidity, altered mental status has 46% sensitivityMore than 99% has at least one, absence of all 3 in ruling out the diagnosis
104Meningitis Nuchal rigidity particularly unhelpful Neck stiffness found in only 57% of elderly with meningitisBut also in 35% without CNS infectionRigidity maybe from Parkinson’s, osteoarthritis, cervical spondylosis12% of healthy elderly display positive Kernig sign18% have positive Brudzinski40-58% of the elderly who have meningitis present with concomitant infections
105Causative Bacteria Meningitis in Patients Older than 50 S pneumoniaeN meningitidisL monocytogenesAerobic gram-negative bacilli
106Epidural Abscess Diagnostic delay occur in up to 75% of patients The elderly often visit the ER for DJD related back painMore than 85% do not have the classic triad: spinal pain, fever, neurologic deficitsLack of fever and leukocytosis does not rule it outMRI is the gold standard along with use of inflammatory markers like ESR as a screening tool for patients who have lower pretest probabilityPt suspected of epidural abscess must be transferred to centers capable of neurosurgeryAntibiotics prior to transferPatients with cervical abscess may need intubation
107ReferencesAlbers 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):
108ReferencesHayakawa 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.
109ReferencesSaver 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 ].